TB Nurse Network Meeting
Wednesday, July 24, 201810:00-11:30 AM ET
Conference call in number: 1-888-557-8511Access Code: 254-487-3 #
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Agenda
Announcements• Upcoming events & webinars
Questions From A TB Survivor• Have you supplemented TB treatment with probiotics?
Discussion• TB Nursing Certification, Fall 2018• Re-establishment of MIACET• Billing for TB Services: Survey Results
Announcements
Next meeting Wednesday, October 17th, 2018• Topic: TBD. Suggestions? Contact [email protected]
Sunstrum Seminar• Off for the summer, seminars will begin again in September 2018
TTT TST Workshop Webinars• Interested in taking the Train the Trainer for the TST Workshop?
Rutgers Global TB Institute: TB Nurse Case Management Webinars• Looking for a nurse to present on August 24th (Friday)
• Any case that you feel presented some challenges with nursing case management that others could learn from. Can be ongoing or past.
• Also looking for 2019 presenters• Dates can be set by presenter
SNTC Webinar Series Coming Soon
Title When TB is the Least of Their Worries...
AboutThis webinar series examines the many challenges patients may encounter in conjunction with tuberculosis. This series helps healthcare professionals identify these challenges and provide strategies for support and intervention.
Schedule
• Corrections - August 23, 2018 | 12:00 PM ET• Opioids - September 13, 2018 | 12:00 PM ET• Homelessness - October 2018• Immigrants - November 2018• Refugees - December 2018• Additional Topics - Spring 2019
Format Webinars
Audience Physicians, nurses, and health professionals working with patients with TB and LTBI.
CE Continuing education credits have been applied for.
Tri-State TB Intensive Workshop
• Date: September 25-27, 2018• Time: 8:30 AM – 4:30 PM• Location: 1980 West Broad Street, Columbus, Ohio, 43224• Brochure is here:
https://www.michigan.gov/documents/mdhhs/Save_the_date_620193_7.pdf• More information: Amy Lewis [email protected]
Day 1: LTBI Focus• Diagnosis and treatment of LTBI• Use of TST vs IGRA• Strategies to improve treatment completion and patient education• B1/B2 immigrants
Days 2-3: TB Disease Focus• Epidemiology, transmission & path, chest radiography, lab methods for diagnosis,
treatment, managing adverse drug reactions, extra-pulmonary TB, drug resistant TB, role of TB nurse case management, TB and diabetes, substance abuse, case studies.
www.Michigan.gov/TB Training & Education Educational Events & Presentations
TB Publications
Late-onset paradoxical reactions 10 years after treatment for tuberculous meningitis in an HIV-negative patient: a case report.• Paradoxical reactions (PRs) during TB treatment are well-established. However, little is
known about PRs presenting as a new lesion after the completion of treatment, especially in TB meningitis cases.
• A 27-year-old female, with history of completing treatment for TB meningitis 10 years ago, was admitted to a hospital due to headache and worsening of pre-existing visual disturbance.
• MRI revealed new tuberculomas in the left sylvian fissure. Repeatedly negative PCR and culture suggested this was not a relapse of TB meningitis
• Diagnosed with late-onset post-treatment PRs and treated with oral corticosteroids, tapered off over 1 year. Eventually, the symptoms were relieved, and the tuberculomas disappeared.
• Clinicians should consider the possibility of PRs long after the completion of TB meningitis treatment.
TB Publications
Detection of Mycobacterium tuberculosis in urine by Xpert MTB/RIF Ultra: a useful adjunctive diagnostic tool in HIV-associated tuberculosis.• "In January 2017, the World Health Organization recommended the Xpert® MTB/RIF
Ultra assay (Ultra) for tuberculosis (TB) diagnosis. Ultra offers improved analytical sensitivity when compared with the initial Xpert® MTB/RIF (Xpert) assay for the detection of Mycobacterium tuberculosis.
• We present a case from Uganda demonstrating Ultra positivity in urine from an HIV-infected patient presenting with altered mental status and urinary incontinence, and no other signs of active pulmonary or extrapulmonary TB. This represents the first published instance of a diagnosis of extrapulmonary TB made on the basis of a positive urine Ultra assay. The use of Ultra on urine may be a useful addition to the diagnostic armamentarium for disseminated TB in persons with HIV co-infection. The diagnostic accuracy of urine Ultra should be characterized further via prospective studies.”
Questions From A TB Survivor
Have you supplemented TB treatment with probiotics?
1. What are the known digestive health effects of TB treatment?2. Does anyone prescribe probiotic supplements during TB treatment?3. What are the effects of TB treatment on gut microbiota?
2018 TB Nursing Certification Course
• Date: Tentatively 10/15 – 10/16/18• Okemos, MI• Audience: Public health nurses, target those newer to the field of TB• Content…
o Should we eventually update and stick to the Michigan TB Case Management course? Or keep the content more flexible, based on request?
o Virginia example:• 2 trainings a year, 1 for new nurses and 1 for experienced nurses
www.Michigan.gov/TB Training & Education Educational Events & Presentations
Re-establishing the Michigan Advisory Committee for the Elimination of TB (MIACET)
• MIACET was formed in 1992 by a group of representatives from both private and public agencies with the goal of developing strategies and recommendations for the elimination of tuberculosis in Michigan. The 2012 MIACET Guidelines can be found here.
• Mission Statement: MIACET promotes effective management of persons in Michigan who are affected by tuberculosis and works toward statewide tuberculosis elimination.
• Vision Statement: The vision of MIACET is the elimination of tuberculosis in Michigan.
Possible Projects:• TB billing• Updating the Michigan TB Program Manual and the Michigan TB Tool Kit• Consensus on TB testing recommendations, specifically when to re-test and which result to
take as true, from the 2017 CID/IDSA/ATS TB diagnosis publication• LTBI:
• 3HP and SAT recommendations• Creating and strengthening surveillance for LHDs• Outreach to private providers for testing and treatment (LTBI toolkit like Pennsylvania’s)
Email Helen if interested in joining: [email protected]
Billing for TB Services: Survey Results
Background:• Some MI HDs incur expenses for TB testing and treatment services (TB disease and LTBI) that can
be billed to Medicaid• There are no recommendations or best practices for billing for TB services and Medicaid does
not have official stance on using codes for these services
Proposal: Survey HDs to• Understand why some HDs are not billing for TB services, and• Assess how other HDs bill and successfully get reimbursed for TB services
Results:• Ran from: 1/31/18 - 3/5/18• 59 people responded from 30 MI HDs (27 public health nurses, 32 finance)
• What PMS (practice management system) do you use? Insight (52%)
• What types of payments and/or insurance does your HD accept? Medicaid (100%), cash payments (93%), commercial/private insurance (77%), etc.o Average payer-mix: Medicaid Managed Care (37%), Commercial insurance (24%), Medicaid
(traditional) (20%), etc.
• What insurance companies do you contract with?
• What billable services does your HD offer? Immunizations (100%), hearing and vision screening (93%), STI testing and treatment (87%), lead testing (83%), etc.
General Billing Questions
What TB services are offered at your HD?
Does your HD currently bill for TB services?
70%
30%
Yes
Service % replied
TB Testing 97%
In-Person DOT 77%
LTBI treatment 73%
TB disease treatment 63%
Medical consult (nurse) 63%
Medical consult (physician) 60%
eDOT 30%
Sputum induction 17%
No answer 3%
Those who don’t bill: Indicate the reason(s) your HD does not bill for TB services
Reason % replied
We do not see enough TB cases/LTBI to justify billingeach 50%
We do not bill for communicable diseases
We send these patients to outside organizations for services, who then bill the patient 38%
Poor reimbursement rates
each 25%Do not know which codes to use / Staff are not trained in coding and billing
No funding to provide staff training to code
Other
Most of our clients do not have insurance
each 13%Not enough staff time available for coding & billing / follow-up on unpaid bills
Difficulty getting on private carrier’s insurance lists
No answer
Those who don’t bill: How are these costs usually covered?
• Subsidized by local funds (75%), cash payers (fee-for-service paid by clients) (13%), no answer (13%)
Those who don’t bill: If you could bill for TB services, what services would you bill for?
Service type % replied
TB testing 78%
In-person DOTeach 67%
LTBI treatment
Physician consultation (LTBI & active TB)each 56%
eDOT
Nurse consultation (LTBI & active TB) 44%
Chest x-ray 22%
Labs
each 11%Translation line
Sputum induction
Those who bill: Who does your HD currently bill for TB services?
100%
73%
14%5%
0%
20%
40%
60%
80%
100%
Medicaid(traditional) &Managed care
Commercial (private)insurance
Medicare Local employers
Comments• “Reimbursement rates are very poor for private insurance carriers, we do a lot of private pay TB
tests as well as Contractor Billing for TB tests.”• “We don't bill for nursing services. We may bill for TST, but do not provide IGRA testing currently.
We will encourage those covered by insurance to use the PCP for medication management, and provide meds for those not covered using general fund or bill the county directly for services including diagnostics and/or meds.”
Those who bill: What are the most pressing challenges your HD encounters when billing for TB services?
Service type % replied
Poor reimbursement rates 52%
None 24%
Difficulty getting on private carrier’s insurance lists 19%
Managing multiple Medicaid Managed Care contractseach 14%
Most of our clients do not have insurance
Difficulty working with Commercial and Medicaid health plans
each 10%Not enough staff time available for coding & billing / follow-up on unpaid bills
Inadequate or difficult billing software
Do not know which codes to use / Staff are not trained in coding and billing
Checking and entering eligibility information
each 5%No funding to provide staff training to code
We do not have a “referring provider” or we are not the primary care provider
No answer
Comments• “We currently only bill for TST placement and venous draws for QFT. We are currently getting denials for TST because we do not
have a "Referring Provider" or we are not the primary care provider”• “We only bill for TSTs and that is done through out immunizations program. In the next few months we will start billing for T-spots.”• “Inability to bill for nursing time”
Those who bill: What type of TB services does your HD bill for?
Service type % replied
TB testing 100%
LTBI treatment
each 14%Physician consultation (LTBI & active TB)
In-person DOT
Chest x-ray
each 5%Nurse consultation (LTBI & active TB)
eDOT
No answer
Those who bill: Billing Codes Overview
TB TESTING CHEST X-RAY
Code* TST QFT T-SPOT VenipunctureNon-specific
reaction to PPD w/o active TB
Encounter for screening for respiratory TB
Outpatient new or established
patientFront Lateral
86580
86480
86481
36415
ICD-10 R76.11
ICD-10 R11.1
99201-99215
71010†
71020†
Always reimbursed
Sometimes reimbursed
Never reimbursed
Key
*Codes are CPT unless otherwise stated†These codes were deleted 1/1/18, should now use codes 71045-71048 (http://www.m3meridian.com/resources/insights/cpt-2018-summary-changes/)
Those who bill: Billing Codes Overview
CPT Code TB Testing LTBI Txt Physician consult for TB disease
Physician consult for LTBI
Nurse consult for LTBI
Nurse in-person DOT eDOT
99201-99215
99201-99205
99211-99215
99201
99202
99203
99204
99211
99212
99213
99214
99215
99384-99386
99394-99396
36415
Always reimbursed
Sometimes reimbursed
Never reimbursed
Key
Thank you!
Meeting notes and presentations will be sent to everyone on the TB Nurse Network list and posted on our website.
Next TBNN meetingWednesday, October 17th, 2018
10-11:30 AM ET
Please contact Helen McGuirk with questions, comments, or suggestions for presentations and content: