Family PACT STI Related Benefits Michael S. Policar, MD, MPH UCSF School of Medicine March 3, 2010

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5. 5 Evaluation and Sign-in At the conclusion of session complete: Evaluation Form Sign-in Sheet Please fax these items to 510-625-9307 Forms can be sent to you by calling 1-877- FAMPACT or emailing familypact@jba-cht.com The evaluation and continuing education forms were available prior to the start of this session for download. Now that the session has started, the forms are no longer available on webex. If you have already downloaded them, you can use those to complete and fax back to us. Those who are listening today without web access can get forms by calling 1-877-FAMPACT.The evaluation and continuing education forms were available prior to the start of this session for download. Now that the session has started, the forms are no longer available on webex. If you have already downloaded them, you can use those to complete and fax back to us. Those who are listening today without web access can get forms by calling 1-877-FAMPACT.

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8. 8 Family PACT Secondary Benefits: STI Services Family PACT program structure Primary benefits: family planning, screening tests (GC, CT, syphilis, HIV, Pap, screening mammogram) Secondary benefits: other reproductive health conditions Diagnosis and treatment of STIs Urinary tract infections (UTIs) in women Management of cervical abnormalities

9. 9 Secondary Diagnosis Codes Used on claims for STIs, UTIs, cervical abnormalities Procedures (CPT) and supplies (ZM modifier) Clinic dispensed or administered antibiotics Certain laboratory tests, for example… Herpes cultures, wet mounts, biopsies Screening tests are included under S-code Available for men and women Standard ICD-9 codes Note the addition of presumptive diagnosis codes based on symptoms or exposure The secondary diagnosis codes are used for treatment of identified STIs and vaginitis. Many STI screening tests are included as the core screening services under a primary diagnosis code. This includes HIV, gonorrhea, chlamydia and syphilis screening tests. Some STIs and vaginal infections are not routinely screened for. If you wish to run a viral culture for suspected herpes, a wet mount for vaginitis, or do a biopsy of an atypical wart you must use a Secondary Diagnosis. Note that some tests are further limited by gender and/or certain diagnosis codes. The secondary diagnosis codes are used for treatment of identified STIs and vaginitis. Many STI screening tests are included as the core screening services under a primary diagnosis code. This includes HIV, gonorrhea, chlamydia and syphilis screening tests. Some STIs and vaginal infections are not routinely screened for. If you wish to run a viral culture for suspected herpes, a wet mount for vaginitis, or do a biopsy of an atypical wart you must use a Secondary Diagnosis. Note that some tests are further limited by gender and/or certain diagnosis codes.

10. 10 Chlamydia Benefits Overview of Clinical and Preventive Services: Secondary Diagnosis Each STI has a (Secondary Diagnosis) Client must be method user for STI treatment: This Program is not an STI Program LOOK At Chlamydia Grid: Far left is ICD-9 Code choices that include options for females and males. Four new choices are now included: one for presumptive treatment of the client whose partner has tested positive; and three for the client with symptoms that you wish to treat now while awaiting results from the screening test. Lab Section has most lab tests that are used in practice or available at public health labs. Most screening tests are covered under the primary diagnoses and remember are listed at the bottom of each grid page. Note that gram stain as a diagnostic test is limited to male clients and it requires a secondary diagnosis code for the claim to pay, regardless of the result of the test. Notice that this is the first place you have seen antibiotics listed in the medications column. The CDC recommended antibiotic treatment for each STI is included in the medication column. Benefits Overview of Clinical and Preventive Services: Secondary Diagnosis Each STI has a (Secondary Diagnosis) Client must be method user for STI treatment: This Program is not an STI Program LOOK At Chlamydia Grid: Far left is ICD-9 Code choices that include options for females and males. Four new choices are now included: one for presumptive treatment of the client whose partner has tested positive; and three for the client with symptoms that you wish to treat now while awaiting results from the screening test. Lab Section has most lab tests that are used in practice or available at public health labs. Most screening tests are covered under the primary diagnoses and remember are listed at the bottom of each grid page. Note that gram stain as a diagnostic test is limited to male clients and it requires a secondary diagnosis code for the claim to pay, regardless of the result of the test. Notice that this is the first place you have seen antibiotics listed in the medications column. The CDC recommended antibiotic treatment for each STI is included in the medication column.

11. 11 Gonorrhea Benefits Overview of Clinical and Preventive Services: Secondary Diagnosis Benefits Overview of Clinical and Preventive Services: Secondary Diagnosis

12. 12 Genital Herpes Just like with the wet mount, herpes culture is not a routine screening test. Use this diagnosis when testing suspicious lesions. Several choices are available depending upon the laboratory used. Reflex typing is not covered. Drug choices have changed. Cultures for clients that may report an exposure and do not have symptoms are not covered.Just like with the wet mount, herpes culture is not a routine screening test. Use this diagnosis when testing suspicious lesions. Several choices are available depending upon the laboratory used. Reflex typing is not covered. Drug choices have changed. Cultures for clients that may report an exposure and do not have symptoms are not covered.

13. 13 Pelvic Inflammatory Disease 614.2 may be the correct diagnosis when the clinician is unsure about PID until test results are obtained. 614.2 may be the correct diagnosis when the clinician is unsure about PID until test results are obtained.

14. 14 Syphilis Mention of the reflex test result from screening tests as something new that will be coming back from the lab based on a confirmed positive screen and it should not be separately ordered with a presumptive diagnosis.Mention of the reflex test result from screening tests as something new that will be coming back from the lab based on a confirmed positive screen and it should not be separately ordered with a presumptive diagnosis.

15. 15 Trichomoniasis Secondary diagnosis code is required for these diagnostic tests. These tests pay with either the definitive diagnosis or the more general symptom-based code 616.10 for vaginitis/vulvitis/BV. Secondary diagnosis code is required for these diagnostic tests. These tests pay with either the definitive diagnosis or the more general symptom-based code 616.10 for vaginitis/vulvitis/BV.

16. 16 Vulvovaginitis Note that wet mounts are not a routine screening test but are done when a client has symptoms or findings on exam. If you did a wet mount but found only normal leukorrhea, use the ICD-9 for nonspecific vaginitis to gain access to the test and be reimbursed.Note that wet mounts are not a routine screening test but are done when a client has symptoms or findings on exam. If you did a wet mount but found only normal leukorrhea, use the ICD-9 for nonspecific vaginitis to gain access to the test and be reimbursed.

17. 17 Genital Warts Note that the supplies used for destruction of lesions include the chemical agent or liquid nitrogen. TCA/BCA, liquid nitrogen or Podophyllin should not be separately billed.Note that the supplies used for destruction of lesions include the chemical agent or liquid nitrogen. TCA/BCA, liquid nitrogen or Podophyllin should not be separately billed.

18. 18 Cervical Abnormalities Benefits Overview of Clinical and Preventive Services Dysplasia Note that colposcopy services are restricted to ages 15 years through 55 years. Look at dysplasia grid – this page is broken out into five slides. This is the first row across the chart. Annual screening pap is covered under primary diagnosis Repeat paps, HPV testing and treatments require a Secondary Diagnosis code Note that there are procedures and supplies for dysplasia treatment. Non-physician medical practitioners may perform and bill for any of the procedures for which they are trained. Just as with STI treatment, women must be regulating their fertility and have a method S-code Benefits Overview of Clinical and Preventive Services Dysplasia Note that colposcopy services are restricted to ages 15 years through 55 years. Look at dysplasia grid – this page is broken out into five slides. This is the first row across the chart. Annual screening pap is covered under primary diagnosis Repeat paps, HPV testing and treatments require a Secondary Diagnosis code Note that there are procedures and supplies for dysplasia treatment. Non-physician medical practitioners may perform and bill for any of the procedures for which they are trained. Just as with STI treatment, women must be regulating their fertility and have a method S-code

19. 19 Colposcopy (Footnote 18)

20. 20 Cervical Abnormalities Benefits Overview of Clinical and Preventive Services Dysplasia Look at dysplasia grid - Benefits Overview of Clinical and Preventive Services Dysplasia Look at dysplasia grid -

21. 21 Cervical Abnormalities Benefits Overview of Clinical and Preventive Services Dysplasia Look at dysplasia grid - Benefits Overview of Clinical and Preventive Services Dysplasia Look at dysplasia grid -

22. 22 All Clinical Practice Alerts issued since August 2005 can be found on the Family PACT website at familypact.org as indicated on this slide. Check www.familypact.org often for new Clinical Practice Alerts that become available. All Clinical Practice Alerts issued since August 2005 can be found on the Family PACT website at familypact.org as indicated on this slide. Check www.familypact.org often for new Clinical Practice Alerts that become available.

23. 23 Urinary Tract Infections in Women A detailed history is necessary to differentiate lower UTIs from pyelonephritis The diagnosis or treatment of a lower UTI does not routinely require a urine culture. Limit to those With a recent history of recurrent UTI Who fail antibiotic treatment Preferred treatments for UTIs are TMP-SMX or ciprofloxacin given as a three-day regimen Nitrofurantoin should not be prescribed unless the other alternatives are unacceptable choices

24. 24 Urinary Tract Infections in Women 1st line: TMP-SMX (DS) BID for 3 days 2nd line: Ciprofloxacin 250 mg BID for 3 days Concerns about the development of quinolone resistant strains of uropathogens 3rd line: Cephalexin 500 mg BID or 250 QID for seven days. Disadvantages include Increasing rates of cephalosporin resistance Lower completion rates than three day therapies

25. 25 Urinary Tract Infections in Women 4th line: Nitrofurantoin 100 mg BID for seven days While used frequently in pregnant women with UTIs, it has no safety advantage if non-pregnant Lower completion rates than 3 day therapies Nitrofurantoin rarely can induce hemolytic anemia in patients with G6PD and use should be avoided in these patients Cost is 5-7 times higher other regimens

26. 26 Urinary Tract Infections in Women How should UTI visits in women be coded? Restricted to female clients All claims for UTI services must contain a primary diagnosis (S-code) and a secondary diagnosis code If diagnosis of UTI, use code 595.0 (acute cystitis) If a UTI is presumptively treated, code for the presenting symptom 599.71 Gross hematuria 788.1 Dysuria 788.41 Urinary frequency 789.09 Abdominal pain, other specified site

27. 27 Routine STI Screening Screening based upon population based characteristics, not individual behaviors Cervical chlamydia Annually in sexually active women thru 25 yo Cervical gonorrhea Annually in sexually active women thru 25 yo Only if practice-site prevalence (PSP) is at least 1%, as determined by your clinical lab’s review of test results Now let’s move on to STI Screening. Because a majority of women with gonorrhea (GC) and Chlamydia trachomatis (Ct) infections have no symptoms or signs, screening is essential for detecting infection. Early diagnosis and prompt management are intended to prevent complications including PID, tubal infertility, ectopic pregnancy, and chronic pelvic pain. Routinely screen all sexually active females 25 years of age and younger annually for CT Routinely screen all sexually active females 25 years of age and younger annually for gonorrhea, unless the prevalence of GC in your client population is known to be less than one percent. [read rest of slide]Now let’s move on to STI Screening. Because a majority of women with gonorrhea (GC) and Chlamydia trachomatis (Ct) infections have no symptoms or signs, screening is essential for detecting infection. Early diagnosis and prompt management are intended to prevent complications including PID, tubal infertility, ectopic pregnancy, and chronic pelvic pain. Routinely screen all sexually active females 25 years of age and younger annually for CT Routinely screen all sexually active females 25 years of age and younger annually for gonorrhea, unless the prevalence of GC in your client population is known to be less than one percent. [read rest of slide]

28. 28 Targeted GC and Ct Screening… Only if Risk Factors Are Present Ct screening in women > 26 years old GC screening in women of any age, PSP <1% History of gonorrhea, chlamydia, or PID in the past 2 years More than 1 sexual partner in the past year New sexual partner within 90 days Reason to believe that the client’s sexual partner has other partners According to guidelines of the California Sexually Transmitted Disease (STD) Control Branch, the criteria for targeted GC and CT screening are: A history of GC, Ct, or PID in the past two year; More than one sex partner in the past 12 months Having a sexual partner(s) who may have had other partners during the year; African-American women, especially in urban areas, between the ages of 26 to 30 have been identified as a group that is at higher risk of GC infections.According to guidelines of the California Sexually Transmitted Disease (STD) Control Branch, the criteria for targeted GC and CT screening are: A history of GC, Ct, or PID in the past two year; More than one sex partner in the past 12 months Having a sexual partner(s) who may have had other partners during the year; African-American women, especially in urban areas, between the ages of 26 to 30 have been identified as a group that is at higher risk of GC infections.

29. 29 GC+Ct Screening Recommendations Nucleic acid amplification test (NAAT) preferred Urine, vaginal swab, and cervical samples are all highly and equally accurate Sample the endocervix only if client is having a pelvic exam for another reason GC culture is done in some labs because of high specificity, but has more false negatives In asymptomatic heterosexual women and men who engage in oral or anal sex, CDC and Family PACT do not recommend pharyngeal or anal GC or Ct tests As mentioned previously, the Nucleic acid amplification test (NAAT) is preferred. NAATs can be performed on urine, cervical, vaginal, or urethral specimens. Unless a pelvic exam is being done for other reasons, a urine sample or vaginal swab should be collected. Tests for both pathogens can be performed on a single sample. The second choice is a nucleic acid probe. It is less expensive than amplification tests, but it is also less accurate. Other tests are considered suboptimal and outdated and if used it is necessary to confirm positive screens.As mentioned previously, the Nucleic acid amplification test (NAAT) is preferred. NAATs can be performed on urine, cervical, vaginal, or urethral specimens. Unless a pelvic exam is being done for other reasons, a urine sample or vaginal swab should be collected. Tests for both pathogens can be performed on a single sample. The second choice is a nucleic acid probe. It is less expensive than amplification tests, but it is also less accurate. Other tests are considered suboptimal and outdated and if used it is necessary to confirm positive screens.

30. 30 Screening and Testing Post-Treatment Test of Cure Not necessary after use of CDC recommended or alterative regimens Consider if compliance is in question, symptoms persist, or re-infection is suspected Still recommended after chlamydia treatment in pregnant women Avoid non-culture tests < 3 weeks of treatment, as dead organisms may be found

31. 31 Screening and Testing Post-Treatment Re-testing: women treated for chlamydia or GC should be re-tested in 3 months Past Ct infection is strong predictor of subsequent infection High likelihood of repeat infection by untreated partner or new partner Short time to repeat positive test

32. 32 Retesting for Ct and GCImproving Clinic Practice Initial patient counseling Stress importance of retest Advance appointment at the time of initial treatment System to contact regarding retest (Advanced Patient permission) Tickler system, with follow-up if no return visit Reminders by mail (self-addressed letter or card) Reminder phone calls, e-mails, or text messages Opportunistic testing Flag chart Test at any subsequent visit (3-12 months)

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34. 34 Partner Management Strategies Expedited Partner Treatment (EPT) Patient brings partner to provider site (“BYOP”) Patient-delivered partner therapy (PDPT) Provide patient with drugs intended for partner(s) (not a Family PACT benefit) Write prescription in the partner’s name Prescribe extra doses of medication in the index patient’s name (not a Family PACT benefit)

35. 35 Patient-Delivered Partner Therapy PDPT studies show that partners are more likely both to be notified and treated for their presumed infections Studies included only heterosexual men, women No data re: syphilis or GC/Ct among MSM Written materials should accompany medication and mention concern about PID in females First line management is still clinical evaluation

36. 36 2006 CDC Criteria for Acute PID “Minimal criteria” Lower abdominal pain AND Cervical motion tenderness OR Uterine tenderness OR Bilateral adnexal tenderness If more severe clinical signs– at least 1 of:

37. 37 Acute PID: Hospitalization* Uncertain diagnosis; especially if appendicitis or ectopic pregnancy cannot be excluded Adnexal or pelvic mass consistent with pelvic abscess Pelvic infection in a pregnant woman HIV infection; other immune deficiency state Severe nausea and vomiting or allergy that preclude oral therapy Failure to respond to treatment within 72 hours Hospitalization of adolescents based same criteria *Not a Family PACT benefit

38. 38 Outpatient PID TreatmentCDC 2006

39. 39 QRNG and Treatment of PID

40. 40 Prescription Drug Coverage Pharmacy benefit changes in 2010 enforce Family PACT’ s limited formulary TARs are required for a few specified drugs listed in the PPBI to manage complications Drug substitutions are not allowed Prescriptions written with extra doses or for longer courses than those listed in the Family PACT PPBI will deny at the pharmacy See: http://www.familypact.org/en/Providers/policies-procedures-and-billing-instructions.aspx

41. 41 Contact Information www.familypact.org www.medi-cal.ca.gov HP/TSC (800) 541-5555 Office of Family Planning (916) 650-0414 fampact@cdph.ca.gov

42. 42 Questions & Answers

43. 43 File Transfer

44. 44 Evaluation and Sign-in At the conclusion of session complete: Evaluation Form Sign-in Sheet Please fax these items to 510-625-9307 Forms can be sent to you by calling 1-877- FAMPACT or emailing familypact@jba-cht.com Thank you! The evaluation and continuing education forms were available prior to the start of this session for download. Now that the session has started, the forms are no longer available on webex. If you have already downloaded them, you can use those to complete and fax back to us. Those who are listening today without web access can get forms by calling 1-877-FAMPACT.The evaluation and continuing education forms were available prior to the start of this session for download. Now that the session has started, the forms are no longer available on webex. If you have already downloaded them, you can use those to complete and fax back to us. Those who are listening today without web access can get forms by calling 1-877-FAMPACT.