Provider Update

Volume 21, Issue 6 

November/December 2004

Program of All-Inclusive Care for the Elderly Training Packet Correction
Medicare Plus Choice Claims and Cover Sheets Billing Primary Insurance Carriers
ICD-CM Codes Modifications to HIPAA Contingency Plan
2004 CPT Codes Billing Mother and Baby Claims
Provider Participation Dental Claims Are Being Misrouted
CommunityCARE Referrals and Authorizations Extension of Outpatient Physician Visits
LADUR Education Article

Program of All-Inclusive Care for the Elderly 

The Program of All Inclusive Care for the Elderly (PACE) is a capitated model of care which coordinates and provides all needed preventive, primary, acute and long term care services so that older individuals may choose to continue living in the community with appropriate supports. PACE programs generally consist of an adult day health center where primary care physician services and other services are also available. The PACE organization includes a network of providers similar to a managed care organization and will only pay providers in its network for authorized services. Emergency services may be provided outside of the PACE network, but services must be authorized and paid by the PACE provider. Any provider treating a PACE enrollee on an emergency basis should contact the PACE provider immediately so coordination and authorization may be initiated. Medicare and Medicaid will not reimburse any other provider for covered services when the enrollee is linked to a PACE provider. 

Unlike other Medicaid services, each PACE site must be approved by the Centers for Medicare and Medicaid Services (CMS). In order to obtain this approval, the potential PACE provider must submit a comprehensive provider application to CMS outlining its operations and specifying the geographic area and number of individuals to be served. This application must be developed in coordination with the Medicaid agency and community stakeholders. Once this provider application is approved by CMS, an additional three-way agreement between Medicare, Medicaid and the PACE provider must be submitted and approved. Each PACE site may only serve the specific geographic area and number of individuals as denoted in the approved three-way agreement. 

PACE enrollees will be identified when the Medicaid eligibility card is swiped or Medicaid eligibility is verified by telephone or via the web and e-MEVS. A provider will be instructed to contact the PACE provider for authorization of services as PACE, not Medicaid, is responsible for authorization and payment for services rendered to PACE enrollees. The Medicaid claims processing system, including Pharmacy Point of Sale system, will be modified to deny payment of claims submitted for PACE enrollees. 

Medicaid enrollees in PACE must be age 55 years old or older, are determined by Medicaid to meet a nursing home level of care requirements, live in the PACE provider service areas Orleans (zip codes 70112, 70113, 70115, 70116, 70117, 70118, 70119, 70122, 70124, 70125, 70126, 70127, 70128, 70129, 70130) or St. Bernard Parishes (zip codes 70032 or 70043). Participation in PACE is strictly voluntary and enrollees may disenroll at any time and return to Medicaid fee-for-service at the beginning of the next or second subsequent month if Medicaid eligibility requirements continue to be met. Enrollment/disenrollment in PACE is always at the first of a month and enrollees will be identified in Medicaid eligibility systems as PACE enrollees. 

PACE programs are required to provide all Medicare and Medicaid covered services including: 

Physicians services Transportation
Inpatient and outpatient hospital services Social work
Nursing facility care services Rehabilitation therapies
Medical specialty services Personal care services
Drugs & biologicals Nutritional therapy
Lab, X-rays, and diagnostic procedures Recreational therapy
Durable Medical Equipment, prosthetics, orthotics Adult day health care

Medicaid and/or Medicare will reimburse PACE a monthly capitated payment. 

PACE Greater New Orleans (GNO) is Louisiana's first PACE site and is expected to be operational in late spring of 2005. Providers should remember to always verify eligibility on each visit to assure that a Medicaid recipient is eligible for fee-for-service payment. If a Medicaid recipient is enrolled in PACE, PACE GNO may be contacted at (504) 945-1531 to request authorization and payment of services provided to PACE enrollees. 

Medicare Plus Choice Claims

Unisys began processing Medicare Plus Choice claims effective December 1, 2004. All recipients participating in Medicare Plus Choice must have both Medicare Part A and Medicare Part B.

The Managed Care Plans currently participating in this program are: Ochsner (Ochsner 65), Tenet (Tenet 65 and Tenet PPO) and Sterling (Sterling Option One). These plans have been added to the Medicaid Third Party Resource File for the appropriate recipients with six-digit alpha-numeric carrier codes that begin with the letter "H," and with a trailing zero. 

When possible these plans will electronically transmit the Medicare claims directly to Medicaid, just as Medicare carriers electronically transmit Medicare crossover claims. These claims will be processed just as claims crossing directly from a Medicare carrier are processed. If claims do not cross electronically from the carriers within 30-45 days from the Medicare plan EOB date, providers must submit paper claims with the Medicare plan EOB attached to each claim. Timely filing guidelines applicable for Medicare crossover claims apply for Medicare Plus Choice claims. 

NOTE: Sterling Option One will not electronically transmit claims to Unisys. Providers in the Sterling Option One network must submit claims hard copy to Unisys.

When it is necessary for providers to submit claims hard copy, the appropriate carrier code must be entered on each hard copy claim form in order for the claim to process correctly. The carrier codes are as follows:

Ochsner 65 H19510 Tenet 65 H19610
Tenet PPO H19010 Sterling Option One H50060

In addition, a Medicare Plus Choice institutional or professional cover sheet MUST be completed for each claim and attached to the top of the claim and EOB. These cover sheets are available on the Louisiana Medicaid website for easy download and appear in this newsletter for provider use. Claims received without this cover sheet will be rejected.

Hard copy claims submitted without the plan EOB and without a six-digit carrier code beginning with an "H" and end with a zero will deny 275 (Medicare eligible). Both the EOB and the correct carrier code are required for these claims to process properly.

Providers may not submit these claims electronically. Electronic submissions directly from providers will deny for error edit 966 (submit hard copy claim).

The calculated reimbursement methodology currently used for pricing Medicare claims will be used to price these claims. Thus, claims may price and pay a zero payment if the plan payment exceeds the Medicaid allowable for the service.



ICD-CM Codes

The 2005 ICD-CM codes have been loaded on our files and may be billed with the effective date of service October 1, 2004.

2004 CPT Codes

The 2004 CPT Codes have been loaded to our files and may be billed with the effective date of service October 1, 2004. Providers may now submit claims for Medicaid covered 2004 codes.

The 2004 Professional Fee Schedule can be found on the website.

Provider Participation

All providers are reminded that the indication of agreement to participate in the Medicaid Program includes the following:

Although this is a voluntary program, providers should note that their signature on a claim form serves as their agreement to abide by all the policies and regulations of Louisiana Medicaid. This signature also certifies that, to the best of the providers� knowledge, the information contained on the claim form is true, accurate, and complete.

Please note that this agreement extends to providers who submit claims electronically for payment. 

CommunityCARE Referrals and Authorizations

CommunityCARE referrals and authorizations may no longer be requeted or issued via the U.S. Postal Service. Hospital to PCP post-authorizations shall be requested and issued (or denied when appropriate) via fax or Electronic Referral Authorization System (eRA). When referring a CommunityCARE recipient for specialty care, the PCP may elect to send the referral/authorization with the recipient, or fax it to the other physician. Any questions regarding this policy should be directed to the CommunityCARE Program Office at (225) 342-4810.

Training Packet Correction

All of the Fall 2004 provider training packets contained an incorrect telephone number under the listing, �Additional Number for Provider Assistance.� The correct telephone number for the KIDMED Recipient Hotline is 800-259-4444. 

Billing Primary Insurance Carriers

Effective December 13, 2004, when a claim is denied for other insurance coverage, all identified insurance coverage effective on the date of service will appear on the TPL report (TPL denied claims notification list - CP-O-25) that accompanies the weekly remittance advice indicating the claim denial. We believe this change will assist you with billing primary insurance carriers (Medicare and private insurance) prior to billing Medicaid for services.

Modifications to Louisiana Medicaid HIPAA Contingency Plan

Attention Hardcopy Submitters: 
Effective March 1, 2005, all hardcopy claims that are eligible for the 837 HIPAA mandated transaction submission will be held at least 21 days prior to final adjudication. All claims received for dental, long-term care, case management and non-emergency transportation services and claims requiring attachments will not be delayed by this process. We encourage you to begin submitting electronic claims in the mandated 837 formats prior to this implementation to ensure that payments will not be delayed. If you have questions, please call Provider Relations at 800-473-2783 or 225-924-5040.

Attention EMC Proprietary Submitters: 
LA Medicaid has started our Phase-In of Proprietary EMC submitters to the X12N 837 HIPAA mandated transactions. Below is a listing of the programs and the deadline dates for accepting proprietary EMC Claims. Once the deadline has passed for a particular program, those EMC proprietary files will be returned to the submitter unprocessed. Therefore we encourage you to move to the mandated HIPAA 837 as soon as possible. If you have not chosen a Vendor, Billing Agent, or Clearinghouse (VBC), go to to find a VBC that has already been approved to submit the 837 HIPAA mandated transactions. If you have a question or need additional information regarding electronic billing please call 225-237-3318.

Phase-In Deadlines by Program
� October 31, 2004 - Hospital Inpatient/Outpatient/Hemodialysis 
� January 1, 2005 - DME/Ambulance
� March 31, 2005 - Professional - includes Physicians, Ambulatory Surgical Centers, Physician Services, Lab & X-Ray, Prenatal Clinics, TB Clinics, STD Clinics, EPSDT Health Services, Mental Health Clinics, Mental Health Rehab, Rehab Centers, Vision,Opthalmologist/ Optometrists, Rural Health Centers, FQHCs, & Waiver
� June 1, 2005 - Long Term Care, Dental

Billing Mother and Baby Claims

The proposed effective date for the change to split mother/baby claims for processing has been delayed until February 1, 2005. Providers are asked to begin splitting claims effective with dates of service February 1, 2005. The system edit will be an educational edit during the months of February and March, informing providers that the claim must be split. The edit will become a denial edit beginning April 1, 2005. At that time these claims must be submitted with a valid Medicaid recipient ID number for both the mother�s claim and the baby�s claim, or the claims will deny. Please take the necessary steps to ensure that you are obtaining valid recipient ID numbers for both mother and baby prior to submitting these claims.

Dental Claims Are Being Misrouted

It has come to our attention that dental claims are being misrouted due to errors that can easily be 
prevented. Adhering to the following reminders will help prevent delays in payment and/or prior authorization review:

Claims for Payment

If a claim is being submitted for payment, please mark �Statement of Actual Services� in Block 1 of the 2002 or 2002,2004 American Dental Association (ADA) Claim Form.

Providers are reminded that claims for payment are to be submitted to the following address:

P.O. Box 91022
Baton Rouge, LA 70821

Claims for payment that are sent to Unisys should never include radiographs. Claims for payment that are submitted with radiograph attachments will cause a delay in payment.

Unisys will return to the provider all claims received that are marked as �Request for Predetermination/Preauthorization.�

Dental Prior Authorization Requests

If a claim is being submitted for prior authorization, please mark �Request for Predetermination/Preauthorization� in Block 1 of the 2002 or 2002,2004 ADA Claim Form.

Providers are reminded that dental prior authorization requests are to be submitted to the following address:

LSU School of Dentistry
Dental Medicaid Unit
1100 Florida Ave, Box F5-510
New Orleans, LA 70119

Radiographs should only be submitted with request for prior authorization.

The LSu School of Dentistry, Dental Medicaid Unit will return to the provider all claims received that are marked as �Statement of Actual Services.�

Extension of Outpatient Physician Visits 

Local Medicaid offices are NOT the place to send Medicaid patients who need to request additional outpatient physician visits because they have used all of their 12 annual visits. Only providers can request additional visits and this may be done only after the patient has been seen. Please assure that your office staff knows that the local Medicaid offices have no authority to request additional office visits and Medicaid recipients should not be sent there. Please use the following procedures to request additional office visits.

In order for Louisiana Medicaid to reimburse outpatient physician visits beyond the maximum 12 allowed visits per State Fiscal Year, the physician must request an extension from the UNISYS Prior Authorization Unit. Extensions will be granted only for emergencies, life-threatening conditions, and life-sustaining treatments. Providers will need to attach documentation to the 158-A Extension Form substantiating the diagnosis justifying the office visit. All extensions of outpatient visits must be requested AFTER the service has been rendered. The attached documentation may be clinical notes, patient history, pathology or laboratory reports, or whatever else can support the diagnosis and services performed. The ICD-9-CM diagnosis code and the appropriate-level CPT code correlating to the diagnosis must also be entered on the 158-A Extension Form. Up to 11 additional visits may be requested on a single Form 158-A. Incomplete extension forms will be rejected. All questions about this process may be directed to the Prior Authorization Unit at 1-800-488-6334.

Extension forms are available from Unisys upon request at the address below. The physician should complete the top portion of the 158-A Extension Form and submit it to the Prior Authorization Unit for review at the following address:

Prior Authorization Unit
P. O. Box 14919
Baton Rouge, LA 70898-4919

Once a decision has been made, the Prior Authorization Unit will return the 158-A form to the provider. If the extension request is approved, the provider should submit the following documents to Provider Relations: 

(1) a hardcopy claim, 
(2) a cover letter of explanation, and
(3) a copy of the approved 158-A Extension Form.

These documents must be submitted to the following address:

Provider Relations Correspondence Unit
P. O. Box 91024
Baton Rouge, LA 70821

Louisiana Drug Utilization Review (LADUR) Education

Chronic obstructive pulmonary disease (COPD)

W. Greg Leader, Pharm.D.
Associate Dean and Director
School of Pharmacy - The University of Louisiana at Monroe


� COPD airflow limitation is usually progressive and is associated with an 
abnormal inflammatory response in the lungs to noxious agents.

� It is the fourth leading cause of death in the United States.

� In 2002, the treatment of COPD in the US was 
estimated to cost approximately $32.1 billion.

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response in the lungs to noxious agents. It is the fourth leading cause of death in the United States, with more than 10 million adults in the United States having physician diagnosed COPD, and morbidity and mortality associated with COPD is expected to increase in the next decade. This is particularly disturbing when one considers that exposure to tobacco smoke is the primary cause of COPD, accounting for 80-90% of the risk for disease development.

In 2002, the treatment of COPD in the US was estimated to cost approximately $32.1 billion. Of these costs, $18.1 billion was attributed to direct costs and $14.1 billion was attributed to indirect costs. In 1998, the World Health Organization and the National Heart Lung and Blood Institute held a consensus workshop that resulted in the 2001 publication of a report entitled the "Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for diagnosis management and prevention of chronic obstructive pulmonary disease." This publication was updated in 2003, and it is the purpose of this article to summarize the GOLD 2003 report. The report recommends four components to the management of COPD: 1) Assess and monitor disease, 2) Reduce Risk Factors, 3) Manage stable COPD, and 4) Manage exacerbations. 

Goals of Disease Management
The goals of the disease management process is to

1. Prevent disease progression
2. Relieve symptoms
3. Improve exercise tolerance
4. Improve health status
5. Prevent and treat complications
6. Prevent and treat exacerbations
7. Reduce mortality

Table 1.  Risk Factors for the Development of COPD

Host Factors


Genes (a1-antitrypsin deficiency)

Airway Hyperresponsiveness

Tobacco Smoke

Occupational Dusts and Chemicals

Outdoor and Indoor Air Pollution


Socioeconomic Factors

Component 1: Assess and Monitor Disease
As stated previously, COPD is characterized by a fixed limitation in airflow that may be partially reversible. In addition, it is characterized by an age related decline in pulmonary function that exceeds that of patients without COPD. The diagnosis should be considered in any patient with a history of exposure to risk factors (Table 1) and symptoms of cough, sputum production and /or shortness of breath. Chronic cough is usually the first symptom to develop and may or may not be associated with airflow limitation. Signs of airflow limitation are usually not present on physical exam until significant lung impairment has occurred. Because of this, patients with a suspected diagnosis of COPD should have the diagnosis confirmed by spirometry, and a post bronchodilator forced expiratory volume in 1 second (FEV1) < 80% predicted and an FEV1 to forced Vital Capacity ratio of < 70%. Based on the level of symptoms, severity of pulmonary function defects as measured by spirometry and the presence of complications, COPD may be classified into several severity classifications (Table 2). 

Table 2.  Classification of COPD Severity



  0:  At Risk

  • Normal spirometry
  • Chronic symptoms such as cough, sputum production

   I:  Mild COPD

  • FEV1/FVC < 70%
  • FEV1 > 80% predicted
  • With or without chronic symptoms (cough, sputum production)

  II:  Moderate COPD 

  • FEV1/FVC < 70%
  • 50% < FEV1 < 80% predicted
  • With or without chronic symptoms (cough, sputum production)

 III:  Severe COPD

  • FEV1/FVC < 70%
  • 30% < FEV1 < 50% predicted
  • With or without chronic symptoms (cough, sputum production)

IV:  Very Severe COPD

  • FEV1/FVC < 70%
  • FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

For those patients with Stage II COPD or greater, additional diagnostic tests may be warranted. Unless bullous disease is present, a chest X-ray is rarely diagnostic, but may be helpful in ruling out other diagnoses. When there is a doubt in the diagnosis, high resolution computed tomography may assist in the differential diagnosis. In patients with an FEV1 < 40% predicted or signs of respiratory or right sided heart failure, arterial blood gas measurements should be performed by arterial puncture. For patients who present with COPD at less than 45 years of age, it may be appropriate to test for a coexisting a1-antitrypsin deficiency.

Because COPD is a progressive disease, symptoms and pulmonary function should be monitored for complications and to determine when to adjust therapy. Follow-up office visits should include:

� A discussion of new or worsening symptoms
� Spirometry if there is substantial increases in symptoms
� Arterial blood gas measurements in patients with an FEV1 < 40% or signs of respiratory failure 
or right sided heart failure.
� A discussion of the current therapeutic regimen including drug dosages, inhaler technique, adverse 
effects and the effectiveness of the current regimen.

In addition, the frequency, severity and likely causes of exacerbations should be monitored and any increase in sputum volume or worsening dyspnea should be noted. Coexisting conditions such bronchial carcinoma, tuberculosis, sleep apnea, and left heart failure should be considered when symptoms are suggestive.

Component 2: Reduce Risk Factors
Smoking is the primary risk factor for the development of COPD. Smoking cessation is the most effective intervention to prevent COPD, and the only intervention shown to slow the accelerated decline in pulmonary function. Every smoker should be offered the opportunity to quit smoking at every visit to a health care provider. Table 3 outlines the 2000 Public Health Service Report entitled "Treating Tobacco Use and Dependence: A Clinical Practice Guideline." The provider is referred to this report for more in-depth information. In addition to the effectiveness of certain pharmacotherapeutic interventions, three types of counseling have been shown to be particularly effective: 1) practical counseling, 2) social support as a part of treatment, and 3) social support arranged outside of treatment. Pharmacotherapy should be recommended when counseling is not sufficient to help patients stop smoking.

Table 3. Strategies to help the patient willing to quit smoking

1.  Ask

Systematically identify all tobacco users at every visit.  Tobacco use for every patient at every clinic visit should be asked about and documented

2.  Advise

Strongly urge all tobacco users to quit using a clear, strong and personalized manner

3.  Assess

Determine the patient�s willingness to make an attempt to quit smoking by asking them if they are willing to quit smoking at this time (e.g. within the next 30 days)

4.  Assist

Assist the patient in quitting by helping them to develop a quit plan, providing practical counseling, providing intra-treatment social support, providing extra-treatment social support, recommending the use of approved pharmacotherapy except in special circumstances and providing supplementary materials

5.  Arrange

Schedule follow-up contact either in person or on the phone


Table 4.  Pharmacotherapy for Smoking Cessation




Nicotine Gum

Nicorette�, Generic

2mg, 4mg


Highly addicted:  4mg

Less addicted:  2mg

1-2 pieces every 1-2 hours for 1-6 weeks, then 1 piece every 2-4 hours for weeks 7-9, then 1 piece every 4-8 hours weeks 10-12.

Up to 12 weeks

Nicotine Lozenge


2mg, 4mg


Highly addicted:  4mg

Less addicted:  2mg

1 lozenge every 1-2 hours for 1-6 weeks, then 1 lozenge every 2-4 hours for weeks 7-9, then 1 lozenge every 4-8 hours weeks 10-12.

Up to 12 weeks

Nicotine Transdermal Patch

Nicotrol �

5, 10, and 15mg

16 hour release



Nicoderm CQ�

7, 14, and 21mg

24 hour release




Generic 1

7, 14, and 21mg

24 hour release




Generic 2

11 and 22mg

24 hour release


> 10 cigarettes/day:

15mg patch X 6 weeks, then 10mg patch X 2 weeks, then 5mg patch X 2 weeks.

Not recommended for those that smoke < 10 cigarettes/day


> 10 Cigarettes/day

21mg patch X 6 weeks, then 14mg patch X 2 weeks, then 7mg patch X 2 weeks

<10 Cigarettes/day

14mg patch X 6 weeks, then 7mg patch X 2 weeks


> 10 Cigarettes/day

21mg patch X 4 weeks, then 14mg patch X 2 weeks, then 7mg patch X 2 weeks

<10 Cigarettes/day

14mg patch X 6 weeks, then 7mg patch X 2 weeks


> 15 Cigarettes/day

22mg patch X 6 weeks

<15 Cigarettes/day

11mg patch X 6


10 weeks






10 Weeks



8 Weeks


8 Weeks



8 Weeks



6 Weeks


6 Weeks

Nicotine Nasal Spray

Nicotrol NS�

0.5mg nicotine in 50mcL spray


1-2 doses per hour (2 sprays = 1 dose, Initially use at lease 8 doses/day, do not use more than 5 doses/hour or 40 doses/day)  Gradually decrease dosage over 3-6 months.


3-6 months

Nicotine Oral Inhaler

Nicotrol Inhaler�

10mg cartridge delivers 4mg dose of nicotine


Usual dose is 6-16 cartridges/day.  Cartridge is depleted after 20 minutes of puffing.  Patient should initially use at least 6 cartridges/day

Up to 6 months

Bupropion SR


150mg sustained release tablet


150mg every morning for 3 days, then increase to 150mg twice a day allowing at least 8 hours between doses.  Patient should quit smoking 1-2 weeks after starting therapy.

8-12 weeks, up to 6 months for maintenance

If occupational exposure to noxious substances is being considered as a contributing factor, the contributing substance should be eliminated or exposure to the substance limited. If a patient is susceptible to indoor and/or outdoor pollution, exposure should also be limited. 

Figure 1. Summary of  COPD Stage Characteristics and Treatment


0:  At Risk

I:  Mild

II:  Moderate

III:  Severe

IV:  Very Severe


Chronic Symptoms

Exposure to Risk Factors

Normal Spirometry

FEV1/FVC < 70%

FEV1 > 80% predicted

With or without chronic symptoms (cough, sputum production)

FEV1/FVC < 70%

50% < FEV1 < 80% predicted

With or without chronic symptoms (cough, sputum production)

FEV1/FVC < 70%

30% < FEV1 < 50% predicted

With or without chronic symptoms (cough, sputum production)

FEV1/FVC < 70%

FEV1 < 30% predicted or  chronic respiratory failure or right heart failure


Avoidance of risk factors; influenza vaccine



Add short-acting bronchodilator when needed1




Add regular treatment with one or more long acting bronchodilators2

Add rehabilitation





Add inhaled corticosteroids if repeated exacerbations






Add long-term oxygen if chronic respiratory failure.  Consider surgical treatments

1 albuterol or ipratropium
2 formoterol, salmeterol, or tiotropium

Component 3: Manage Stable COPD
The overall approach to managing stable COPD should be characterized by a stepwise increase in treatment based on disease severity. The steps recommended by the GOLD report can be seen in Figure 1. Therapy should be individualized based on disease severity and the patient's response to various therapies. A management program should include patient education as well as pharmacologic treatment. 

Patient education is important to improve skills and the ability to cope with the illness and the patient's health status. It is also effective in assisting with smoking cessation, teaching the patient about advanced directives and end of life issues and improving the patient's response to acute exacerbations. Education should be tailored to the needs and environment of the patient. Characteristics of an education program and suggested topics are seen in Table 5.

Table 5.  Suggested Characteristics and Content of Patient Education Programs



Tailored to the needs of the patient

Tailored to the environment of the patient


Directed at improving quality of life

Simple to follow


Appropriate to the intellectual and social skills of the patient

Smoking cessation

Basic information COPD and the pathophysiology of the disease

General approach to therapy and specific aspects of medical treatment

Self-management skills

Strategies to help minimize dyspnea

Advice about when to seek help

Self-management  and decision making in exacerbations

Advanced directives and end of life issues

All patients should be vaccinated against the influenza virus on a yearly basis. Routine use of the polyvalent pneumococcal vaccine in all patients is not recommended; however, the vaccine should be given to those patients that have other indications (e.g., age > 65, immunosuppression).

None of the current pharmacologic agents have demonstrated the ability to slow the decline in lung function that characterizes the disease; however, medications are useful to prevent and control symptoms, decrease the frequency and severity of exacerbations, and improve health status and exercise tolerance. Bronchodilators are the primary agents used in the symptomatic management of COPD and should be administered by inhalation. Bronchodilators may be given on an as needed or on a regular basis to prevent or decrease symptoms. In addition, all bronchodilators will increase exercise capacity even if they do not produce a significant increase in FEV1. Because individual responses often vary, there is no clear advantage of one bronchodilator over another; however, long-acting inhaled bronchodilators are more convenient than short-acting bronchodilators, and they are recommended for patients who require regular bronchodilator therapy. Until recently, anticholinergic bronchodilators were only available in a short acting form (ipratropium), but recently, tiatropium, a long acting anticholinergic with a duration of action that exceeds 24 hours and an adverse effect profile similar to ipratropium, is available. Combining bronchodilators with different mechanisms and duration of action may increase the degree of bronchodilation and health status with the same or lesser risk of adverse effects; however increasing the dose of a single bronchodilator may provide similar benefit. The approach of combining bronchodilators tends to increase the cost of therapy, and if side effects are not a limiting factor, increasing the dose of a single agent may be preferred.

Regular treatment with inhaled corticosteroids does not decrease the disease related decline in pulmonary function. For symptomatic patients with an FEV1 <50% predicted (stage III and IV) and frequent exacerbations, regular use of inhaled corticosteroids has been demonstrated to decrease frequency of exacerbations. Despite the common practice of using a short course of oral corticosteroids to identify patients who might benefit from long-term corticosteroid therapy, current evidence indicates that response to a short course of oral corticosteroids is not predictive of the long-term response to inhaled corticosteroids.

In young patients with severe a1-antitrypsin deficiency and established emphysema, a1-antitrypsin augmentation therapy may be an option. This therapy is extremely expensive and is not recommended for patients with COPD that is not related to this hereditary defect. Other agents that are not generally recommended for the management of stable COPD include mucolytics, antioxidants, immunoregulators, vasodilators, respiratory stimulants and narcotics. Due to the protective role of cough, regular use of antitussives is not recommended. Chronic use of antibiotics is also not effective.

Table 6. Indications for Hospital Assessment or Admission for Exacerbations of COPD

Marked increase in intensity of symptoms, such as sudden development of resting dyspnea.

Severe background COPD.

Onset of new physical signs (e.g. cyanosis, peripheral edema).

Failure of exacerbations to respond to initial medical management.

Significant comorbidities.

Newly occurring arrhythmias.

Diagnostic uncertainty.

Older age.

Insufficient home support.

Table 7. Discharge Criteria for Patients with Exacerbations of COPD

Inhaled b2-agonists therapy is required no more frequently than every 4 hours.

Patient, if previously ambulatory, is able to walk across the room.

Patient is able to eat and sleep without frequent awakening by dyspnea.

Patient has been clinically stable for 12-24 hours.

Arterial blood gasses have been stable for 12-24 hours.

Patient (or home care giver) fully understands correct use of medications

Follow-up and home care arrangements have been completed (e.g., visiting nurse, oxygen delivery, meal provisions).

Patient family and physician are confident patient can manage successfully.

A comprehensive pulmonary rehabilitation program including exercise training, nutrition counseling, and education are effective when conducted in inpatient, outpatient, and home settings. The minimum duration of a successful program is two months, and it appears that the longer the program, the more effective the results.

The long-term administration of oxygen (> 15 hours a day) is the only therapy that has been shown to reduce mortality. Oxygen therapy is indicated in patients with stage IV COPD and a PaO2 < 55mm Hg or a PaO2 < 60 mm hg with evidence of pulmonary hypertension, congestive heart failure, or polycythemia. The goal of therapy should be to increase baseline PaO2 to at least 60mm Hg at rest. Routine mechanical ventilation does not appear to be beneficial.

Component 4: Manage Exacerbations
Exacerbation of symptoms in COPD often requires medical intervention and the mortality of patients requiring hospitalization is high. The most common causes are infection and air pollution, but often the cause is not readily apparent. The primary symptom of an exacerbation is increased breathlessness, which may be accompanied by wheezing, chest tightness, increased cough and sputum production, changes in the color and/or tenacity of the sputum, and fever. The severity of the exacerbation should be assessed using a complete medical history, lung function tests, arterial blood gas measurements, and other laboratory tests. A peak expiratory flow of < 100 L/minute or and FEV1 < 1.00 L indicates a severe exacerbation. A paO2 < 60 mm Hg and/or a SaO2 < 90% indicates respiratory failure, and an arterial pH < 7.30 indicates a life-threatening episode. Chest X-rays and ECGs may be beneficial in identifying alternative diagnoses that may mimic the symptoms of an acute exacerbation. White blood cell counts are usually not helpful, and because COPD patients are chronically colonized with bacteria, sputum gram-stains are often not informative.

The primary strategies for the treatment of acute exacerbations are the intensification of bronchodilator therapy, systemic corticosteroids, and antimicrobial therapy. In more severe exacerbations, supplemental oxygen therapy or mechanical ventilation are necessary. If there is no indication for hospitalization (Table 6), patients may be treated at home. Frequency and/or doses of inhaled bronchodilators should be increased, and if a patient is not already on an inhaled anticholinergic, one may be added. High dose nebulized bronchodilators may be used for short-term treatment of the exacerbation; however, nebulized therapy should not be continued for the management of stable COPD. If the patient's FEV1 is < 50% predicted, systemic corticosteroids should be considered. The recommended dose of prednisone is 40mf by mouth daily for 10 days. The role of bacterial infection as a cause of COPD exacerbation is controversial. It is suspected that approximately 50% of exacerbations are caused by infection with approximately half of these of bacterial origin. Antibiotics should be considered when patients with worsening dyspnea and cough also have increased sputum volume and purulence. The antibiotic chosen should reflect local resistance and sensitivity patterns for S. pneumonia, H. influenzae, and M. catarrhalis. Ampicillin, amoxicillin, doxycycline, and sulfamethoxazole/trimethoprim are often effective, and there is no evidence to indicate that new, more expensive antibiotics are more effective.

Oxygen therapy is the cornerstone for the treatment of hospitalized patients. The goal is to achieve a PaO2 > 60mm Hg or Sa02 > 90%. Arterial blood gases should be evaluated approximately 30 minutes after oxygen therapy is initiated to insure appropriate oxygenation without CO2 retention or acidosis. As with home treatment, bronchodilator therapy should be maximized. Although the role of aminophylline in the treatment of COPD exacerbations is controversial, the addition of oral theophylline or intravenous aminophylline may be considered. If these agents are used, close monitoring of serum theophylline concentrations is warranted to avoid adverse effects. The addition of oral or intravenous corticosteroids is recommended. Doses of 30-40mg of prednisone for 10-14 days are recommended. Therapy for longer than 2 weeks is not beneficial, and higher doses have a significant risk for adverse effects. As with home treatment, antibiotics should be used when patients with worsening dyspnea and cough also have increased sputum volume and purulence. Ventilatory support may also be necessary in severe cases. 

Criteria for discharge from the hospital are shown in Table 7. A follow-up assessment should be scheduled for 4-6 weeks after hospital discharge. The assessment should include the patient's ability to cope in their usual environment, measurement of FEV1, reassessment of inhaler technique, understanding of the recommended treatment option, and the need for long-term oxygen therapy and/or home nebulizer for patients with very severe COPD.

COPD can be a severe and debilitating disease. Smoking cessation is the only intervention known to slow the progression of the disease, and therapy is directed at the treatment of symptoms and the improvement of quality of life. Bronchodilators are the cornerstone of the management of stable disease, and therapy should be intensified in a step-wise fashion. Exacerbations are common, and are treated with increased bronchodilator therapy and corticosteroids. Antibiotics are only effective in patients with increased sputum volume and purulence.