Clinical Infrastructure

Background

To implement HCV screening, evaluation, and management, our STOP HCC-HCV program offers practical tools and strategies to achieve high rates of baby boomer HCV screening and evaluation and treatment chronic HCV. For practices serving low-income, un/underinsured patients, special tools and information can promote primary care-based management from diagnosis to cure with specialist consultation.

Electronic Medical Record (EMR) Screening Protocol

Where possible, the EMR offers an essential component of successful HCV screening through a best practice alert (BPA) that notifies clinicians and staff when a patient is eligible for screening (e.g. born 1945-1965). Ideally this alert links to a one-time HCV screening test for eligible patients with the appropriate diagnosis code (Z11.59). After the test is completed, the BPA should turn off but highlight a positive result. The most efficient test to order is an anti-HCV antibody that reflexes to a quantitative HCV RNA on the same blood sample to confirm chronic HCV. This is essential as 15-35% of anti-HCV antibody positive patients have cleared the infection. In summary:
Eligible patients for HCV screening:

  • Birth year 1945-1965

Exclusion from eligibility:

  • Prior record of HCV diagnosis based on ICD-9-CM or ICD-10 codes (see below)
  • Prior record of any HCV test based on an array of Current Procedural Terminology (CPT) codes (see below).

 

ICD-10 codes:

  • Z11.59 Encounter for screening for other viral diseases (used for screening)
  • B17.11 Acute hepatitis C with hepatic coma
  • B18.2 Chronic viral hepatitis C
  • B17.10 Acute hepatitis C without hepatic coma
  • B19.20 Unspecified viral hepatitis C without hepatic coma
  • B19.21 Unspecified viral hepatitis C with hepatic coma
  • Z22.52 Carrier of Hepatitis C

ICD-9 codes:

  • 89 Encounter for screening for other viral diseases
  • 62 Hepatitis C Carrier
  • 41 Acute hepatitis C with hepatic coma
  • 44 Chronic hepatitis C with hepatic coma
  • 51 Acute hepatitis C without mention of hepatic coma
  • 54 Chronic hepatitis C without mention of hepatic coma
  • 7 Unspecified viral hepatitis C
  • 70 Unspecified viral hepatitis C without hepatic coma
  • 71 Unspecified viral hepatitis C with hepatic coma
  • 09 Hepatitis C, history of

CPT codes:

  • 86803: Hepatitis C antibody
  • 86804: Hepatitis C antibody, confirmatory test (reflex)
  • 87520: Hepatitis C, direct probe technique
  • 87521: Hepatitis C, amplified probe technique
  • 87522: Hepatitis C, quantification

For a more complete list, visit Support Path

Data Infrastructure

To monitor screening performance and support follow-up care for patients, we recommend developing a report (or several) that accomplish the following:

  • Identify patients within the target population (e.g. baby boomers) that are seen within the clinic on a weekly or monthly basis. This report should capture demographics and HCV testing history to identify the pool of patients who are eligible for screening.
  • Identify incoming patients who have been tested along with their lab results for HCV Antibody testing and HCV RNA testing (if applicable). This data may be compared with the eligibility report to assess the effectiveness of screening protocols.
  • Identify chronically infected patients (i.e. HCV RNA positive), along with the test results to stage the disease (described within the clinical protocols). This data may be used to track and support patients through the care continuum (from diagnosis to staging, treatment, and cure).

Depending on the functionality of the EMR, these types of reports may not be feasible, or may require some creative adjustments. For example, in one clinical site, laboratory data could not be pulled directly from the EMR. In this instance, we developed an account with the laboratory vendor to extract reports on specific test names at the site, and collapsed this data with visit history to provide the clinic with monthly screening reports.

Clinical protocols

A basic workflow for HCV screening within primary care is provided below. See patient education for samples of  posters that support opt-out screening. For an explanation of the teleconsultation office hour treatment modality, see below.

HCV care continuum workflow

 The patient navigator – a key role:

A patient navigator serves a critical role throughout this continuum by providing education about the disease, strategies for overcoming barriers like stigma or financial strain, counseling, and navigation through follow-up testing and treatment.

Treatment modalities

The number of patients with chronic HCV far outstrips the capacity of specialists to address this national epidemic and calls for affordable solutions that allow patients to stay within their medical home. STOP HCC-HCV has developed a process of specialist teleconsultation hours, with the following key components:

  • Prescribing providers (PCPs, NPs, PAs) receive a 1-hour training by webinar about HCV evaluation in addition to HCV treatment
  • A specialist sets aside one hour per week
  • Onsite provider and care navigator sign up to present a case through a structured presentation form
  • The specialist and provider discuss the case for 10-15 minutes
  • The plan is operationalized by care management team
  • The patient receives navigation support through the process of applying to a pharmaceutical assistance program (PAP), receiving treatment, and returning for testing to determine virologic cure.

Note that, through this model, patients that have complications such as decompensated cirrhosis or HCC require more intensive monitoring. For these cases, the STOP HCC-HCV program connects patients to specialists.