Asthma Education
Effective 01/01/07, PrimeWest Health will reimburse for asthma education provided by Certified Asthma Educators ("CAEs") who are employed by PrimeWest Health participating providers. Education can be provided in an individual or group setting, and must meet program criteria in order to bill for such services.
Program Criteria The following criteria must be incorporated into an asthma self-management education program in order for the provider to bill for reimbursement.
- Instructors must be certified asthma educators. This can be accomplished through completing an asthma education certification course and passing a certified asthma educator exam.
- Basic facts about asthma
- Inhaler technique
- Written asthma action plan (which is provided by the treating physician). In the class setting, this component may be limited to discussing the importance of asking the physician for one.
- Home peak flow or other medical monitoring
- Environmental control measures
- Emphasis of need for regular follow-up visits
- Navigation of the health care system
- For class setting: Providers must hold a copy of the curriculum, materials, and each class attendance list to submit to PrimeWest Health upon request.
- For clinic setting: Providers must document the session in the chart.
- An asthma action plan (AAP) is written, discussed and documented in the patient's medical record; or the patient or parent can show his/her copy of an AAP to the class instructor.
- AAPs are filed or documented in charts. PrimeWest Health's Service Quality Program audits for them.
- A pre-test and post-test are recommended for outcome measurement.
Providers are responsible for measuring their own outcomes and are required to submit measurement outcomes to PrimeWest Health upon request.
Frequently Asked Questions
Will CAEs be credentialled with PrimeWest Health?
Ø No, CAEs will not be credentialled separately for asthma education. Some CAEs may be nurse practitioners or otherwise be credentialled separately with PrimeWest.
How will CAEs bill PrimeWest for members who receive education/take classes?
Ø Only a certified asthma educator who is working for a PrimeWest participating provider may bill for classes or individual sessions.
o Bill under the clinic's PrimeWest provider identifier.
o If the CAE is an NP or otherwise credentialled separately with PrimeWest, bill under their individual identifier.
o If the CAE is not credentialed separately with PrimeWest, bill under a supervising physician identifier plus the modifier "U7."
o Bill directly to PrimeWest Health under each participating member's PrimeWest Health identification number, which is found on the member's PrimeWest Health ID card. If you have questions or are unsure whether the member is currently enrolled, please verify eligibility.
o The asthma diagnosis must be listed on the claim and indicated in the service line.o Each class or session must be listed as a separate line, with "1" as the number of services (units) provided that day.
o Bill only once per session per member who is receiving education; parents/guardians who may learn along with a young PrimeWest Health member should not be billed separately. If there are multiple children in a family who are all taking a class together, bill for each child who has an asthma diagnosis.
o Sessions may be billed 10 times in the first year after diagnosis, and 3 times per year thereafter. Sessions may be mixed, in any given year, between individual and class sessions.
What CPT codes will CAEs use to bill for asthma education?
Ø CPT Code S9441
Ø Description: Asthma Education; non-physician provider, per session, per PrimeWest Health member.
Can a physician provide the asthma education and get reimbursed under this program?
Ø No. This program is designed to reimburse non-physician providers who are Certified Asthma Educators to provide structured education outside of the office visit. Codes for physicians to use for education they provide as part of an office visit already exist and are currently being billed.
Where is there more information about becoming a CAE?
Ø Contact the American Lung Association at 651-268-7593 or visit its Web site at www.alamn.org for information regarding its Asthma Educator Certification course.
Is asthma education reimbursement available for all PrimeWest members?
Ø Yes.
How will PrimeWest Health verify that the standards are met?
Ø PrimeWest Health will conduct random class materials/chart audits to ensure that providers are meeting the program criteria and meet certification requirements.