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The Denton County Health Department has confirmed a second case of measles, with history of exposure to a previous, imported case reported in April 2013. This new case was fully vaccinated against measles and demonstrated an atypical presentation of the illness, developing a rash but no fever, cough, coryza or conjunctivitis. The case has been confirmed by positive IgM results.
For more information and guidance for physicians, please see the Health Alert issued by DSHS.
On April 7, 2013 a one year old unvaccinated male resident of Harris County with history of recent international travel was diagnosed with measles, confirmed via laboratory testing. Onset of symptoms was March 25 with rash onset on March 30. During his infectious period he had visited several healthcare providers. Follow-up tracking of staff, patients and others who were potentially exposed during those visits has resulted in identification of several symptomatic contacts who are being closely followed. Further transmission in the Houston/Harris County area may occur.
Healthcare providers are requested to aid in this investigation by considering measles when evaluating febrile rash illnesses and by reporting suspected measles cases promptly to their local health department. By Texas statute, measles is to be reported immediately upon suspicion.
The symptoms of concern are:
- Fever over 101
- Generalized maculopapular rash, usually beginning on the face and spreading to the trunk
- Cough
- Coryza
- Conjunctivitis
If a patient presents with these symptoms, take the following steps:
- Isolate the patient. In a hospital setting, negative air pressure rooms are recommended.
- All visitors and staff working with the patient should use airborne precautions.
- Obtain diagnostic specimens.
- Report the patient to the health department.
Testing for confirmation may include the following:
- Serology on a single specimen for IgM testing
- Isolation and/or positive PCR of measles virus from a clinical specimen
Measles (rubeola) is a highly contagious febrile rash illness caused by a paramyxovirus transmitted via the respiratory route. The incubation period averages 10-12 days, and 14 days from exposure to rash onset (range 7 -18 days). The prodrome generally lasts 2-4 days and is characterized by fever, increasing in stepwise fashion and often peaking at 103°-105°F. Fever is followed by the onset of cough, coryza, and/or conjunctivitis. Koplik spots are considered to be pathognomonic for measles and appear as punctate blue-white spots on the bright red background of the buccal mucosa, occurring 1-2 days before rash to 1-2 days afterwards. The measles rash is a maculopapular eruption that begins at the hairline and gradually proceeds to face and upper neck and from there downward and outward. The maculopapular lesions are generally discrete but may become confluent. Other symptoms of measles include anorexia, diarrhea (especially in infants), and generalized lymphadenopathy. Complications can include otitis media, pneumonia, encephalitis, seizures and death.
The Centers for Disease Control & Prevention (CDC) recommends that infants aged 6 through 11 months should receive one dose of MMR vaccine before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later.
All healthcare facilities should ensure that they have updated documentation of immunity status for all staff. Documentation of immunity includes birth prior to 1957, written record of receipt of two MMRs, or positive serological titers.
Further information about measles can be found on the CDC’s website at http://www.cdc.gov/measles/index.html.
The attestation process for Medicaid providers in Texas is now available! Providers eligible for enhanced Medicaid payments can attest using the Texas Medicaid Attestation for ACA Primary Care Rate Increases form. The form must be completed by individual providers, signed, and returned by fax to (512) 302-5068, or by mail to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Providers will not immediately see the increased payment on their Remittance and Status (R&S) reports. The increased rates will be applied retroactively. The state is working with the Centers for Medicare & Medicaid Services (CMS) to get federal approval for the state’s plan to increase primary care rates. HHSC will continue to keep providers informed of the process and timeline as information becomes available. Though the deadline for attestation has yet to be established, we recommend that providers complete this process ASAP. If you do not attest before payment increases go into effect, you will not receive retroactive payments.
To qualify for the Affordable Care Act of 2010 (ACA) rate increase for primary care services, a physician must have a specialty designated of general internal medicine, family practice, or pediatrics and must attest to one of the following:
- The provider has a certification recognized by the American Board of Medical Specialties (ABMS), American Board of Physician Specialties (AMPS), or American Osteopathic Association (AOA) and meets the requirements as required by federal and state regulation to receive the increased payment.
- The provider does not have a certification recognized by the ABMS, ABPS, or AOA, but at least 60 percent of the provider’s Medicaid billings for the previous calendar year (or for the previous calendar month if the provider has been enrolled in Medicaid for less than one year) were for the evaluation and management (E/M) and vaccine administration procedure codes as published in the final federal and state regulations and the provider meets the requirement to receive payment.
Note: New providers with no history of Medicaid billings can attest that 60 percent of their Medicaid billing will be for primary care services.
ADDITIONAL INFORMATION
- Group providers may not submit the form using their group Texas Provider Identifier (TPI). Each member of the group must complete the form using their performing provider TPI to attest that they are eligible to receive the increased reimbursement.
- Facility providers may not submit the form using their facility TPI. Eligible providers who are employed by the facility must complete the form using their individual TPI to attest that they are eligible to receive the increased reimbursement.
- Providers that have been issued a TPI with multiple suffixes must submit a separate form for each eligible suffix in order to receive the increased reimbursement for each enrolled practice location, Tax Identification Number, etc.
Important: By signing the form, providers attest that they qualify for the rate increase, and that the increase will be applied to paid claims for primary care services on or after the effective date. Payment of the rate increase may be subject to retrospective review and recoupment if it is determined at a later time that the provider did not qualify for the ACA primary care services rate increase. Federal regulations require states to conduct an annual audit of provider attestations.
NON-PHYSICIAN PRACTITIONERS
Non-physician practitioners who are under the supervision of a provider who has self attested, are not required to submit a separate provider attestation form. Increased payment may be available to the supervising physician when the following conditions are met:
- The non-physician practitioner renders services under the personal supervision of a provider who has self-attested to meeting the requirements.
- Services are billed under the qualifying provider’s provider identification number.
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP/CSHCN Services Program Contact Center at 1-800-568-2413.
Frequently Asked Question on Enhanced Medicaid Rates
HHSC Presentation on Enhanced Payments - TPS ALPS Meeting, April 2013
Flu season is well under way in many parts of Texas. Given this early start, and considering the mild flu season experienced last winter, experts believe we may experience higher influenza activity with a higher number of cases this year. Providers from around the state are seeing cases of laboratory confirmed influenza A and B virus infection – and some children’s hospitals are starting to report hospitalizations and deaths from influenza.
Initial testing of circulating strains by the CDC indicates a good match with the 2012-13 influenza vaccine. Vaccination is the best method of prevention of influenza; however, understanding treatment guidelines is imperative for providing care to patients exhibiting flu-like symptoms.
The AAP recommends treatment with influenza antivirals in all children who are hospitalized, children at risk of complications from the flu, children with complicated or progressive illness, and in anyone who want to shorten their illness. In outpatients without risk factors for complications, antiviral treatment should be considered if treatment can be initiated within 48 hours of symptom onset. The following are some suggestions from the TPS Committee on Infectious Diseases and Immunizations on treating influenza:
Treatment
Antiviral treatment for influenza is most effective if started early, with the greatest benefit seen when providing antiviral medication within the first 2 days of illness. However, there may still be some benefit to treatment when started after 48 hours of onset of symptoms, particularly in more severe cases that result in hospitalization. Antiviral treatment can be started when patients present with flu-like symptoms and flu is suspected. You do not need to wait for laboratory confirmation of influenza to start treatment.
Use of Anti-viral Medications
The neuraminidase inhibitors, Oseltamivir (administered orally) and Zanamavir (administered through inhalation) are at present the preferred antiviral agents to treat influenza. Oral oseltamivir is safe and effective, but it may cause nausea and vomiting in some children. Allergic reactions and other reported side effects are rare. Resistance to oseltamivir is very rare (<2%) and is not associated with the use of the drug. Zanamavir is safe and effective, but requires understanding of the use of the device to administer the dose through oral inhalation. Treatment and prophylactic dosing recommendations for these antivirals in children is described below.
Treatment in Children Under 1 Year of Age
On December 21, 2012, the U.S. Food and Drug Administration expanded the approved use of oseltamivir to treat children as young as 2 weeks old who have shown symptoms of flu for no longer than two days. The AAP, CDC, and other experts recommend treatment for children under one year old, as they have the highest risk of complications. Although there is a fixed dosing regimen for patients 1 year and older according to weight categories, the dosing for children younger than 1 year must be calculated for each patient based on their exact weight. These children should receive 3 milligrams per kilogram twice daily for five days. These smaller doses will require a different dispenser than what is currently co-packaged with Tamiflu. Dosing recommendations are based on clinical and pharmacokinetic studies
Current Dosing for Children
Tamiflu®, or Oseltamivir, is available as:
30, 45, and 75 mg capsules
6 mg/ml and 12 mg/ml suspension
|
Age/Weight |
Treatment x 5 days |
Prophylaxis x 10 days |
|
< 3 months |
3mg/kg/dose bid |
Not recommended |
|
3-11 months |
3mg/kg/dose bid |
3mg/kg/dose qd |
|
1 Year and Older |
||
|
< 15 kg |
30 mg po bid |
30 mg po qd |
|
16 – 23 kg |
45 mg po bid |
45 mg po qd |
|
24 – 40 kg |
60 mg po bid |
60 mg po qd |
|
>40 kg |
75 mg po bid |
75 mg po qd |
Relenza®, or Zanamivir, recommended dosing:
| Approved for children > 7yrs old | 10 mg (2 inhalations) twice daily |
| Approved for children > 5 years old | 10 mg (2 inhalations) once daily |
References
- Centers for Disease Control and Prevention. Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. 1):1-25. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr6001.pdf
-
2011-2012 Influenza Season: Antiviral Medication Recommendations. Clinician Outreach and Communication Activity (COCA) Conference Call; February 28, 2012.
- PowerPoint Presentation at: http://txpeds.org/webfm_send/1811
- Transcript at: http://txpeds.org/webfm_send/1809
- Influenza Antiviral Medications: Summary for Clinicians: http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
- 2012 – 2013 Seasonal Influenza Information: http://www.cdc.gov/flu/weekly/
- Tamiflu In Children Under 1 Year of Age: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm333205.htm
-
Texas DSHS Flu Surveillance: http://www.dshs.state.tx.us/idcu/disease/influenza/surveillance/2013/
Effective November 1st, Pfizer has increased the price of Prevnar-13 from $120.20 to $127.41. The AAP and TPS are working to inform payers of this change, and Pfizer will be allowing providers to purchase Prevnar at the pre-increase price of $120.20 until November 30, 2012.
With RSV season already underway in parts of the state, it is important to be aware of the RSV activity in your area – and use regional epidemiological data to help make decisions on administering prophylaxis. Throughout RSV season, the TPS RSV Taskforce reviews data submitted from around the state to the CDC’s NREVSS, and posts information and guidance at http://txpeds.org/rsv-data.
2012 - 2013 Prophylaxis Guidance
2012 - 2013 Statewide and Regional RSV Data
Average Start and End Date (by Region, 2001-2011)
Map of Texas Regions
Due to an unusually high number of illnesses related to West Nile Virus in north Texas, the Department of State Health Services (DSHS) has begun aerial spraying to control mosquitoes and help prevent the spread of this disease. Aerial spraying will continue through the weekend and may extend into next week .
DSHS has confirmed 552 human cases of West Nile illness in Texas this year, including 21 deaths.This is the highest number of reported cases since West Nile first appeared in the state in 2002. Humans can contract West Nile virus from a mosquito bite, and the virus can cause serious illness or death. “Aerial spraying is a safe and very effective tool, but it doesn’t take the place of the basic precautions," said Dr. David Lakey, DSHS commissioner. “We are urging people to continue using insect repellent every time they go outside.”
DSHS has created an online educational module to help update physicians on the epidemiology, presentation, diagnosis and treatment of West Nile Virus illnesses, which can be found along with several other useful resources at: http://extra.dshs.state.tx.us/grandrounds/default.htm. (Please note: audio for the online webinar begins at about 3 minutes in to the presentation.)
Aerial spraying typically occurs between the hours of 9pm and 3am, though may vary due to weather conditions. For people concerned about exposure during aerial spraying, health officials suggest the following precautions:
- Minimize exposure. Avoid being outside, close windows and consider keeping pets inside while spraying occurs.
- If skin or clothes are exposed, wash them with soap and water.
- Rinse homegrown fruits and vegetables with water as a general precautionary measure.
- Cover small ornamental fish ponds.
- Because the chemical breaks down quickly in sunlight and water, no special precautions are suggested for outdoor swimming areas.
For more information on West Nile Virus and the schedule for aerial spraying, please visit http://www.dallascounty.org/department/public_info/westnile.php. The latest case count on West Nile Virus in Texas can be found at www.dshs.state.tx.us/news/updates.shtm.
In today's 5-4 decision, the Supreme Court has largely upheld the health care reform law. The ruling did restrict one major portion of the law: regulations around the expansion of Medicaid. The majority of the court held that the expansion of Medicaid was constitutional, but states cannot be stripped of all their Medicaid funds if they fail to participate in that expansion - and will only lose new funds if they don't comply with the new requirements, rather than all of their funding.
MORE INFO
American Academy of Pediatrics Commends Supreme Court Decision to Uphold the Affordable Care Act
The Version 5010 Enforcement Discretion Period ends on June 30, 2012. All HIPAA-covered entities were required to upgrade to the new ASC X12 Version 5010 (Version 5010) and NCPDP Versions D.0 and 3.0 by January 1, 2012, however the Centers for Medicare & Medicaid Services' (CMS) initiated an enforcement discretion period to give the industry additional time to upgrade to the new transaction standards.
As of July 1, 2012, all non-compliant entities will be subject to enforcement action under the existing HIPAA transaction and code set enforcement process. Entities still experiencing issues regarding use of the new electronic standards in their transactions should refer to their respective vendor, clearinghouse, payer's website or provider service department for assistance.
At this point, your Version 5010, D.0 or 3.0 implementation should be complete. However, if you have not yet finalized your upgrade, you should consider the following steps:
- Reach out to clearinghouses for assistance and take advantage of any free or low cost software that may be available from payers
- Check with payers now to see what plans they will have in place to handle incoming claims
- Contact financial institutions to establish lines of credit to cover any temporary interruptions in claims reimbursement as a result of not being Version 5010 compliant
For more information regarding the updated standards, please visit:
http://www.cms.gov/Medicare/Coding/ICD10/Version_5010.html
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplif...
http://www.texmed.org/5010/
The Bell County Public Health District, in central Texas, has recently issued a press release citing an increase in pertussis (whooping cough) - with 88 reported cases. McLennan County is also seeing more cases, presumably due to the increase in the neighboring Bell County. Anderson County is investigating increased activity, but a pertussis outbreak has not yet been confirmed there.
With uncommonly high rates of pertussis being reported in these Texas Counties, as well as the significant increase in several other states around the country, it is more important than ever to make sure that patients and close contacts of infants are being vaccinated.
CDC Summary of Pertussis Vaccine Recommendations
TPS has recently put together some videos and information to help physicians communicate with parents about the importance of vaccines. The videos feature Texas families who have lost their children to vaccine preventable diseases, and the Throgmorton's story about their daughter Haleigh underscores how devastating exposure to pertussis can be for a family. For more information, please visit: http://txpeds.org/vaccine-information or go to the Department of State Health Services website, "Protect Babies, Get Vaccinated", which is focused on cocooning efforts to help protect infants.
The Department of State Health Services also wants to remind providers that an NP for PCR testing is the preferred method of testing (not DFA or serology), and if you suspect pertussis, you should report it to the health department at once and not wait for lab results.
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Recent News
The Denton County Health Department has confirmed a second case of measles, with history of exposure to a previous, imported case reported in April 2013. This new case...
On April 7, 2013 a one year old unvaccinated male resident of Harris County with history of recent international travel was diagnosed with measles, confirmed via laboratory...
The attestation process for Medicaid providers in Texas is now available! Providers eligible for enhanced Medicaid payments can attest using the...
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