Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.

Evidence summary

Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.

Acupuncture and herbals provide some benefit

While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.³ In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.⁴

When it comes to herbal remedies, a good-quality systematic review⁵ of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.

• Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV₁) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
• Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV₁ by 30% at 3 months compared with 17% in controls (P<.05).
• Wenyang Tonglulo Mixture (WTM) improved FEV₁ by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
• Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
• Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
• Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).⁵

Other therapies didn’t quite make the grade

Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.

The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.⁶

Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.⁷

Manual therapy. A Cochrane review⁸ of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.

Mind-body therapy. A pilot RCT⁹ with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.

Recommendations from others

The New Zealand Guideline Group (NZGG)¹⁰ gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Stopped at a red light, Mr. O glances in the rearview mirror and sees headlights coming up fast. The sport utility vehicle behind him is not slowing down. He braces himself as the SUV plows into the back of his car, snapping his head back and forth violently.

As white smoke fills his eyes and lungs. Mr. O realizes he has been pushed into the intersection, and for a moment thinks about never seeing his wife and children again. As he hears tires screeching, his car is struck by a truck.

Mr. O does not die, as he feared, but 6 months later he is “just not ready” to return to work. The doctor who is treating his whiplash injury refers him for evaluation of lingering anxiety.

Posttraumatic stress disorder (PTSD) resulting from a motor vehicle accident (MVA) can have a persistent disabling effect. To help you effectively treat patients such as Mr. O, this article examines:

• common PTSD symptoms in accident survivors
• recommended diagnostic interviews and assessment tools
• techniques for using psychotherapy to overcome residual PTSD symptoms.

CASE CONTINUED: Lingering impairment

In the 6 months since the accident, Mr. O’s sleep is disrupted by pain and worry; when he can sleep, he frequently has nightmares about the accident. Mr. O feels anxious and irritable, and thoughts of that evening play over and over in his mind.

Mr. O doesn’t like to talk about the accident and has not resumed driving. He avoids all but required trips, such as to doctors’ appointments, which he endures with extreme anxiety. Whenever his wife drives without him, he insists that she immediately call him when she reaches her destination. At the same time, he feels emotionally distant from her and the children. He shows little interest in hobbies he’d previously enjoyed.

3 symptom clusters of PTSD

To meet DSM-IV-TR criteria for PTSD, a person must have experienced, witnessed, or been confronted by an event that involved actual or threatened death or serious injury, to which he responded with intense fear, helplessness, or horror.¹ PTSD’s 3 symptom clusters—reexperiencing, avoidance/numbing, and hyperarousal—encompass 17 core symptoms, and a patient must exhibit at least the minimum number of symptoms from each cluster (Table 1).

MVA survivors with PTSD often have intrusive memories and nightmares. They might avoid talking about the accident and resist or abstain from driving or traveling by car. They often fear and avoid people, places, activities, and reminders of the MVA that can trigger upsetting reactions, such as anxiety, tachycardia, and panic. They may be irritable, detached, or estranged from loved ones, or have difficulty sleeping or concentrating. These symptoms must persist for ≥30 days and cause clinically significant distress and impaired functioning for a person to meet the criteria for chronic PTSD.

Table 1

Patients experience 3 ‘clusters’ of PTSD symptoms

CASE CONTINUED: Reaching a diagnosis

Using a combination of interviews and self-report measures, the psychiatrist diagnoses Mr. O with chronic PTSD. Since the MVA, Mr. O has developed the required number of reexperiencing, avoidance/numbing, and hyperarousal symptoms. These symptoms have persisted for >30 days and significantly impair his functioning.

Use multiple assessment tools

To assess an MVA survivor for PTSD and related problems, we advocate using a combination of:

• unstructured clinical interviews
• structured clinical interviews
• self-report measures.

Also collect information from collateral sources, such as patients’ spouses or significant others, when appropriate and available.

In an unstructured interview, obtain:

• a thorough, detailed description of the MVA, including what occurred and the patient’s thoughts and feelings during and since the accident
• a description of physical injuries, medical treatments, and medication use.

This information can rule out physical causes of PTSD-like symptoms, such as a traumatic brain injury that results in concentration difficulties and irritability. Also assess the MVA’s effect on travel behavior because this information will help inform treatment.

Structured diagnostic interviews are straightforward and easy to administer with minimal training. We prefer the 30-question Clinician Administered PTSD Scale (CAPS) because evidence supports its reliability and validity.^2,3 Use the CAPS to rate intensity and frequency of the 17 core PTSD symptoms over the past week, month, or lifetime. The CAPS can be scored for a PTSD diagnosis and for symptom severity. This tool’s drawback is that it takes 30 to 60 minutes to administer and a few more minutes to score.

Self-report measures are quick to administer and score and provide valuable information about symptom presence and severity.⁴ We recommend the PTSD Checklist (PCL), a widely used measure that has been shown to reliably and validly assess MVA-related PTSD.^5,6 Consisting of 17 items corresponding to the DSM-IV-TR PTSD symptoms, the PCL takes about 5 minutes to complete and 1 or 2 minutes to score. A score ≥44 is a highly accurate indication of PTSD.⁶

Patients with MVA-related PTSD often have psychiatric comorbidities.⁷ The most frequently diagnosed are:

• major depressive disorder (in about one-half of persons with MVA-related PTSD)
• anxiety disorders, such as generalized anxiety disorder (in about one-third)
• chronic pain
• alcohol or other substance abuse.

We use the Structured Clinical Interview for DSM-IV (SCID) to diagnose comorbid conditions.⁸ If you do not have time to administer a structured clinical interview, we recommend using psychometrically sound self-report measures, such as the Beck Depression Inventory⁹ and the State Trait Anxiety Inventory.¹⁰

Length of time since the MVA gives a good indication of how likely PTSD is to remit without intervention. Longitudinal studies have found that within 1 year, PTSD will remit without intervention in nearly two-thirds of those diagnosed within 1 to 4 months of the MVA. PTSD that persists after 1 year is much less likely to resolve without treatment.¹¹ Other predictors of PTSD persistence include:

• lack of physical recovery
• major depression within the first 2 months of the MVA
• current major depression
• alcohol abuse before the MVA
• perceived vulnerability during the MVA
• poor family relationships after the MVA.¹¹

PTSD symptoms that initially do not meet diagnostic criteria (subsyndromal PTSD) can worsen in the first year postMVA and lead to a diagnosis of delayed-onset PTSD.¹² Having less social support and experiencing additional life stressors—such as another accident, worsening physical health, or change in job—can contribute to delayed-onset PTSD.

CASE CONTINUED: Overcoming fears with psychotherapy

As part of cognitive-behavioral therapy (CBT), the therapist teaches Mr. O a simple breathing exercise to reduce anxiety. He also leads Mr. O through a progression of imaginal and in vivo exposure exercises. The former involves having the patient think about provocative situations in a graded fashion, from easiest to most difficult, while in the psychiatrist’s office. The latter involves having Mr. O seek out red lights—first as a passenger in a vehicle, then as a driver with a passenger, and then while driving alone—until they no longer cause distress.

The American Psychiatric Association,¹³ Veterans Affairs/Department of Defense,¹⁴ International Society of Traumatic Stress Studies,¹⁵ and other organizations recommend CBT to treat PTSD.¹⁶ Randomized, controlled trials and other evidence support CBT’s efficacy for MVA-related PTSD.^11,17

Before implementing CBT, cultivate a strong therapeutic relationship with MVA survivors. The exercises may be acutely distressing, and you will be asking them to complete between-session practice tasks.

CBT for MVA-related PTSD can be delivered to individuals or groups,¹⁸ typically in 8 to 16 weekly or semi-weekly, 60- to 90-minute sessions. (Table 2) explains which elements of CBT address specific PTSD symptoms.¹¹

Therapy usually begins with psychoeducation about PTSD symptoms and expected reactions to trauma (the “flight, fight, or freeze” response) to normalize these reactions and place them within the cognitive-behavioral conceptualization. Teach your patients that avoiding memories and reminders of the trauma maintains PTSD and that they must overcome avoidance for treatment to be successful. Note that avoidance can be subtle, such as a patient going to a feared place but distracting himself while there.

CBT for PTSD often includes teaching an anxiety management skill (Box). Imaginal and in vivo exercises also are usually part of treatment.

In imaginal exposure, patients repeatedly and fully confront their frightening memories within session by recounting as much detail about the MVA as possible, including what they were sensing, feeling, and thinking. This description of the MVA can be recorded during the session or written outside of therapy and read aloud by the patient during sessions.

Either way, assign your patients to review the written or recorded account 2 to 3 times per day between sessions. Repeating this exercise results in habituation to these memories, and the thoughts will evoke progressively less distress.

In vivo exposure is designed to extinguish the conditioned associations patients formed during the MVA. Travel-related anxiety is the primary focus of in vivo exposure because almost all patients experience it.¹¹

This type of exposure therapy uses a fear hierarchy—a list of feared MVA reminders. Patients rate each reminder using a distress scale, such as the Subjective Units of Discomfort Scale (SUDS). Together the therapist and patient agree on a situation in the fear hierarchy that the patient feels able to confront in person without escaping. Patients confront the situation until their distress scale score declines by at least half, repeatedly addressing each item on the hierarchy until they have overcome the most frightening reminders. Consider recruiting patients’ family or friends to help complete these homework exercises.

Box

Cognitive therapy typically is conducted simultaneously with the other therapeutic components. Early in therapy, the clinician assesses patients’ beliefs related to the accident (such as “The world is very dangerous” or “I have no control over what happens on the road”) and their psychological experiences (“I will lose control of my emotions if I think about it”) and challenges the veracity of these assumptions by bringing up these distortions and statements as they occur within the treatment session. By using forms designed to identify thoughts and beliefs that produce anxiety, patients learn to monitor and challenge their maladaptive thoughts, in essence becoming their own cognitive therapists.

Scheduling pleasant events—assigning patients to participate in activities they previously enjoyed but have discontinued—has been used effectively to treat depression.¹⁹ For MVA survivors, this therapy is designed to target PTSD’s numbing symptoms by increasing patients’ social support and resilience.

Patients initially may need some cajoling, but once they begin pleasant activities they often find the experience reinforcing and mood-enhancing, which increases their future participation.

Although pharmacologic therapy for PTSD is beyond the scope of this article, antidepressants—including selective serotonin reuptake inhibitors (such as paroxetine and sertraline), tricyclics, and monoamine oxidase inhibitors—have been shown to effectively treat PTSD.²⁰ For some patients, a combination of medication and psychotherapy may be best.

Patients with MVA-related PTSD often present other problems, including chronic pain, sleep problems, and generalized anxiety. How—and even if—to address these problems in therapy for PTSD is a matter of clinical judgment. Some evidence suggests that CBT can help improve comorbid conditions.^7,21

Table 2

Cognitive-behavioral therapy: What’s effective for MVA-related PTSD

CASE CONTINUED: Getting back on the road

After 4 months of CBT, Mr. O’s symptoms have resolved to the point where he is able to drive and return to work. When confronted with situations that had been problematic, Mr. O uses the CBT tools he learned to monitor thoughts and reactions that previously led to distress. With each change and improvement he feels a growing sense of confidence.

Related resources

• National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
• Hickling EJ, Blanchard EB. Overcoming the trauma of your motor vehicle accident: a cognitive behavioral treatment program, therapist guide. New York: Oxford University Press; 2006.
• Follette VM, Ruzek JI, Abueg FR. Cognitive-behavioral therapies for trauma, 2nd ed. New York: Guilford Press; 1998.

Drug brand names

• Paroxetine • Paxil
• Sertraline • Zoloft

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).