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Physician Program & Policy UpdateOctober, 1999

MEDICAL POLICIES....................................................................................................................................2

SPECIAL CARE FOR HEARING-IMPAIRED MEMBERS...............................................................................3

CONNECTICUT MENTAL HEALTH PARITY................................................................................................4

OXFORD SELLS DIRECT SCRIPT® TO CAREMARK, INC.............................................................................4

PHARMACY UPDATE....................................................................................................................................5

PRIOR AUTHORIZATION PROGRAMS

QUALITY MANAGEMENT PROGRAM: CONTROLLED DRUG USE EVALUATION (DUE)

RADIOLOGY PRIVILEGING UPDATE..........................................................................................................5

LABORATORY EXCEPTION LIST UPDATE.................................................................................................7

OXFORD Y2K READINESS UPDATE.............................................................................................................8

OXFORD’S EDUCATION & OUTREACH PROGRAM: EXTRA ATTENTION FOR YOUR OXFORDMEDICARE ADVANTAGE PATIENTS........................................................................................................9

EXPIRATION OF NEW JERSEY MEDICAID ASSIGNMENT..........................................................................9

CULTURAL COMPETENCY..........................................................................................................................9

MEMBER RIGHTS AND RESPONSIBILITIES.............................................................................................10

1999 MEMBER SATISFACTION SURVEY RESULTS...................................................................................12

PROMPT PAY PROGRAM IMPLEMENTATION..........................................................................................12

OXFORD’S QUALITY MANAGEMENT PROGRAM.....................................................................................13

ICD-9-CM, CPT AND HCPCS CODES EXPLAINED......................................................................................14

PREVENTIVE TREATMENT FOR RESPIRATORY SYNCYTIAL VIRUS (RSV) IN PREMATURE INFANTS.16

OXFORD’S DIABETES MANAGEMENT PROGRAM....................................................................................17

CLINICAL PRACTICE GUIDELINES..........................................................................................................19

TOBACCO AND SMOKING CESSATION .............................................................................................................19

FOR ADDITIONAL QUESTIONS, PLEASE CALL 800-666-1353

Oxford Health Plans welcomes your assistance in holding down healthcare costs.Please contact us at 800-915-1909 if you are aware of any fraudulent activity.

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MEDICAL POLICIESFor information regarding existing policies, please utilize the following resources:

Issue ExplanationMedical Policy Medical Policies can be requested in writing

and mailed to:Policy Requests and Information

Oxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

M&R and MCAP criteria Please remember that these are proprietaryservices to which Oxford subscribes. Forinformation on specific cases, requests canbe made in writing and mailed to:

Policy Requests and InformationOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

Payment Policies Our payment policies are proprietary andcannot be distributed. For questionsregarding claims payment, please contactour Provider Services Department at 800-666-1353 for clarification. For a summaryof a specific payment policy, please sendwritten requests to:

Policy Requests and InformationOxford Health Plans48 Monroe TurnpikeTrumbull, CT 06611

Requests for Fees To request information regarding fees,please contact our Provider ServicesDepartment at 800-666-1353.

Global Surgery Policy A global surgical package is a system thatassigns a specific number of days to eachsurgical procedure. Follow-up hospital oroffice visits performed within this timeperiod are considered inclusive in thesurgical fee and are not reimbursedseparately.

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SPECIAL CARE FOR HEARING-IMPAIRED MEMBERS

Title III of the Americans with Disabilities Act, 42 U.S.C. Sect. 12182, 12183 (referred to as the“ADA”) states that people with disabilities have the right to equal access to public accommodations.Additionally, the U.S. Department of Justice has added a regulation to Title III of the ADA that requirespublic accommodations, such as healthcare providers and/or services, to supply necessary auxiliary aidsto enable a person with disabilities to benefit from their services. Specifically, this regulation states that“a public accommodation shall furnish appropriate auxiliary aids and services where necessary to ensureeffective communication with individuals with disabilities.” 28 CFR Sect. 36.303(c).

Auxiliary aids and services required by the ADA include “qualified interpreters” (28 CFR 36.303(b)(1))to ensure that effective communication with the hearing-impaired is provided at critical points during theprovision of healthcare services, such as:• When critical medical information is communicated;• When a medical procedure is explained; and• When informed consent is required for treatment.

Please note that refusing to provide care or the assistance of an interpreter while rendering care to aperson with a qualifying disability is a violation of the ADA.

Oxford maintains its policy of fully reimbursing providers for the cost of providing an interpreter to ourMembers with disabilities. Providers must not bill Oxford Members for these services (28CFRSect. 36.301(c)). In order to be reimbursed by Oxford for supplying an interpreter’s service, thefollowing procedure must be followed:

• The interpreter must submit bills for service directly to the provider or facility that requested them.Interpreters should not bill Oxford directly. Any bills received from an interpreter, whethersent directly by the interpreter or submitted by the Member, will be denied.

• The provider/facility must submit a claim to Oxford that clearly indicates CPT code M0001.In addition to using this Oxford-specific code, the interpreter’s original invoice must be attached tothe claim form.

For your easy reference, the following is a list of agencies within the tri-state area that can help connectMembers and providers with qualified interpreters for the hearing-impaired.

NY NY Society for the Deaf 212-777-3900 New York City Metro Registry of Interpreters for the Deaf 212-821-9588 Deaf and Hard-Of-Hearing Interpreting Services, Inc. 718-433-1092

NJ NJ Department of Human ServicesDivision of the Deaf and Hard of Hearing 609-984-7281

CT State of ConnecticutCommission on Deaf and Hard of Hearing 860-566-7414

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CONNECTICUT MENTAL HEALTH PARITY

The state of Connecticut has enacted Mental Health Parity legislation (Managed Care Act – Public ActNo. 99-284) which states that all Connecticut Commercial Group products will be required to providebenefits for the diagnosis and treatment of mental or nervous conditions as part of the base medicalbenefit, effective upon renewal, issuance or amendment January 1, 2000.

For purposes of this legislative requirement, “ ‘mental or nervous conditions’ means mental disorders, asdefined in the most recent edition of the American Psychiatric Association’s Diagnostic and StatisticalManual of Mental Disorders.” The definition does not include mental retardation, learning disorders,motor skills disorder, communication disorders, caffeine-related disorders, relational problems, oradditional conditions that may be a focus of clinical attention, that are not otherwise defined as mentaldisorders in the “Diagnostic and Statistical Manual” referenced above. Note: Parity is also requiredfor disorders related to the complications of alcohol and substance abuse, as defined in themanual.

This law does not affect Medicare or self-funded plans. In addition, the law does not otherwise affectmedical necessity, precertification, or referral requirements.

Oxford recognizes the importance and sensitivity surrounding mental health and substance abusetreatment. We are in the process of taking the steps necessary to achieve compliance with this importantlegislation.

OXFORD SELLS DIRECT SCRIPT® TO CAREMARK, INC.

Recently, Oxford sold its mail-order prescription program, Direct Script , to Caremark, Inc. — a leadingprovider of prescription drug management programs. Effective September 13, 1999, Caremark is nowproviding Oxford Members with the same quality mail-order products they have come to know throughDirect Script . Although we anticipate no interruption in the mailing and/or filling of Memberprescription orders, it is important to note that prescriptions for maintenance medications canno longer be ordered via telephone or fax. Members and physicians should mail all prescriptions formaintenance medications to Caremark with applicable copayments at the following address:

Caremark, Inc.P.O. Box 407010Ft. Lauderdale, FL 33340-9883

Physicians may continue to submit orders for specialty products via fax at 800-266-1644, or viamail at the address above.

Physicians can call Caremark at 800-835-7628 to speak to a customer service representative Mondaythrough Friday from 7:30 AM to 5:30 PM , and Saturday from 8:00 AM to 12:00 PM .

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PHARMACY UPDATE

Oxford’s pharmacy system is a comprehensive package of benefits, formularies, and managementprograms designed to ensure that our Members receive maximum value from their pharmacy benefit. Asnew drugs are approved, new indications for old drugs emerge, and new medical knowledge becomesavailable, these programs are updated.

PRIOR AUTHORIZATION PROGRAMS

Together with Diversified Pharmaceutical Services (DPS), Oxford’s pharmacy benefit manager, we havedeveloped programs to ensure that Oxford Members receive drug therapy that is effective, andeconomical. These programs are largely based on guidelines established by the Food and DrugAdministration (FDA), are approved by our P&T committee, and require prior authorization throughDiversified for coverage of the drugs involved.

To obtain prior authorization, please call the DPS Physician Hotline at 800-417-8164. This line isdedicated exclusively to providers who wish to obtain prior authorization.

A DPS representative will gather the information needed to meet criteria for approval of the drug or sendthe information to an Oxford Health Plans Medical Director for further evaluation. If the MedicalDirector does not approve the request, you will be notified by phone, and you will have an opportunityto provide more information and speak to the Medical Director.

QUALITY M ANAGEMENT PROGRAM: CONTROLLED DRUG USE EVALUATION (DUE)

The objective of DUE is to promote high-quality, cost-effective drug therapy for your Oxford patients.On a quarterly basis, Oxford reviews the medication profiles of patients who receive frequentprescriptions for narcotic analgesics and other controlled drugs at high doses. Patients selected for reviewreceived 12 or more controlled drug prescriptions, at an average daily dose of 10 or more dosage units perday, or received prescriptions from three or more physicians. If any patients for whom you prescribecontrolled drugs meet these criteria, you will be notified by mail. The intention of this letter is to provideinformation and, when indicated, in your opinion, facilitate action toward modifying your patient's druguse behavior. Please review this information carefully if you are contacted.

RADIOLOGY PRIVILEGING UPDATE

In response to your feedback, we have made changes to the privileging list. Please see the complete liston the next page for those procedures that the specified physician can perform in his or her office.• If a procedure is on both the privileging and the precertification lists, you must still precertify it

before you perform the service by calling NYMI at 877-PRE-AUTH (877-773-2884). We havestarred those procedures in the updated list.

• The privileging program applies to all settings, including inpatient.

Precertify CT scans, MRIs/MRAs, PET scans, bone densitometry, and nuclear medicine studies bycalling NYMI at 877-PRE-AUTH (877-773-2884).

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PRIVILEGING BY S PECIALTY—UPDATED LISTING

PHYSICIAN TYPE CPT CODES DESCRIPTION

Primary Care Physicians:Internal Med, Family Prac.

71010-7103076075*, 76076* 1

Chest imagingDEXA studies, bone densitometry

Cardiologists

Cardiologists – Pediatriconly

71010-7103078464*, 78465*, 78469*78472*, 78473*78478 *76825,76826

Chest imagingTomographic SPECT studiesCardiac blood pool imagingWall motion studyEchocardiography, fetal

Chiropractors 72010, 72040, 72069, 72070, 72080, 72100

Spine imaging

Endocrinologists 76075*, 76076* 1

76942DEXA studies, bone densitometryUltrasonic guidance for needle biopsy

Infertility Specialists 7609276805-7685776930, 76945, 76946

Screening mammographiesUltrasounds--pelvisUltrasonic guidance

OB/GYNs 7609276805-7685776930, 76945 , 7694676075*, 76076* 1

Screening mammographiesUltrasounds--pelvisUltrasonic guidanceDEXA studies, bone densitometry

Oral Surgeons 70100, 70110, 70140, 7015070300, 70310, 7032070328, 703307035070355

Mandible and facial bone imagingTeeth imagingTMJ imagingCephalogram, orthodonticOrthopantogram

Orthopedists 71100-7111171120-7113072010-72120,72170, 72190, 72200-7222073000-73140, 73500-7366076000, 760037604076066

Radiologic examination, ribsRadiologic examination, sternumSpine and pelvis imaging

Imaging--upper and lower extremitiesFluoroscopiesBone length studiesJoint survey

Pediatricians 71010-71030 Chest imagingPerinatologists 76092

76805-7685776930, 76945 , 76946

Screening mammographiesUltrasounds--pelvisUltrasonic guidance

Podiatrists 73620, 73630, 73650, 73660 Lower extremity imagingPulmonologists 71010-71030 Chest ImagingRadiation Oncologists 76370 Computerized tomography guidanceRheumatologists 72010-72120,72170, 72190,

72200-7222073000-73140, 73500-7366076000, 76003760407606676075*, 76076* 1

Spine and pelvis imaging

Imaging--upper and lower extremitiesFluoroscopiesBone length studiesJoint surveyDEXA studies, bone densitometry

Urologists 76870, 76872, G005076942

Ultrasounds--echography, genitalia, bladderUltrasonic guidance for needle biopsy

*These procedures require precertification. Please call 1-877-PRE-AUTH.1Effective January 1, 2000, CPT 76076 will no longer be covered and we recommend CPT 76075 for all DEXA studies.

• This is effective May 1, 1999, with the exception of italicized codes which are effective June 15, 1999, and underlined codeswhich are effective August 1, 1999.

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LABORATORY EXCEPTION LIST UPDATE

The following is Oxford’s updated Laboratory Exception List. Please remember that any lab test notincluded on this list will not be reimbursed if performed in your office and should therefore be forwardedto one of Oxford’s network labs. You can send your specimens to any of the participating labs withoutreferral. CPT codes 83014 and 85018 are new additions.

PRIMARY CARE PHYSICIANS AND S PECIALISTS

* 81000 Urinalysis, with microscopy

* 81002 Urinalysis, non-automated, without microscopy

* 81003 Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods

82270 Blood, occult; feces screening, 1-3 simultaneous determinations

82273 Blood, occult; other sources, qualitative

82962 Glucose, blood sugar by glucometer

83014 Helicobacter Pylori, breath test analysis; drug administration and sample collection (Note: Dianon is providing atest kit free of charge – call 800-328-2666)

83026 Hemoglobin; by copper sulfate method, non-automated

85013 Spun microhematocrit

85018 Blood count, hemoglobin

85651 Sedimentation rate, erythrocyte; non-automated

86588 Streptococcus, screen, direct

87208 Smear, direct or concentrated, dry, for ova and parasites

87210 Smear, wet mount with simple stain, for bacteria, fungi, ova, and/or parasites

87211 Smear, wet and dry mount for ova and parasites

87220 Tissue examination for fungi (e.g., KOH slide)

**87060 Culture, throat or nose

**87081 Culture, bacterial, screening only, for single organisms

***85022***85023***85024***85025

Hemogram, automated and manual differential WBC count (CBC)Hemogram & platelet count, automated and manual differential WBC count (CBC)Hemogram & platelet count, automated and partial differential WBC count (CBC)Hemogram & platelet count, automated and automated complete differential WBC count (CBC)

*, **, *** Reimbursement is limited to one procedure (within the related family of codes) per visit.

RHEUMATOLOGISTS ONLY

89060 Crystal identification by light microscopy with or w/o polarizing lens analysis, and body fluid (except urine)

PEDIATRICIANS ONLY

82247 Bilirubin, total

HEMATOLOGISTS AND ONCOLOGISTS ONLY

85097 Smear interpretation only, with or without differential cell count

S PECIMEN HANDLING AND VENIPUNCTURE• If specimen handling and venipuncture codes are billed in conjunction with a lab code, only the lab and venipuncture

codes will be reimbursed (and only if that lab code is on the above Lab Exception List).• If specimen handling and venipuncture codes are billed without a lab code, the specimen handling and venipuncture

codes will be paid per the Oxford fee schedule.

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OXFORD Y2K READINESS UPDATE

The statements made herein are Year 2000 Readiness Disclosures and Year 2000 Statements, as thoseterms are defined in the Year 2000 Information and Readiness Disclosure Act (the "Act"), and byidentifying these statements as such, the Company intends to take full advantage of the protections affordedby the Act.

Oxford has completed its Year 2000 readiness project for its internal systems. This encompasses theremediation and testing of over 6,000 applications, including those applications that support enrollment,eligibility, medical management, claims processing, and billing. Oxford tested these applications across 12future dates, which ranged from September 9, 1999, through February 29, 2004. In addition, we havecompleted detailed contingency plans for all business functions and departments.

Our focus for the remainder of 1999 will be on the following:• Continuing to monitor any compliance updates from our desktop software vendors.• Maintaining the compliance of our mission-critical systems and re-testing for January 1st, 2000.• Continuing to communicate with external vendors regarding their compliance efforts.• Testing the procedures for the weekend of January 1, 2000.

To protect the interest of our Members, we expect all Oxford providers to continue to provide the samelevel of service outlined in our provider contracts, both before and after the millennium date change.HCFA expects Oxford and its providers to engage in risk mitigation to facilitate Medicare beneficiaryrequests for immediate Peer Review Organization (PRO) review of Notices of Discharge and MedicareAppeals Rights for non-coverage of inpatient hospital stays. The PRO review process assistanceincludes, but it is not limited to: 1) obtaining and distributing the appropriate notice of dischargedocumentation, 2) facilitating the delivery of appeal notification to the PRO at the member’s request,and 3) providing the PRO with timely medical records.

As a health care provider servicing government program beneficiaries, your office(s) is required to havetaken all appropriate steps to comply with necessary Year 2000 upgrades. Should that not be the case,please either contact your Oxford provider representative or call Oxford's provider service number at 1-800-666-1353. If you do not intend to be Year 2000 compliant by the end of 1999, please notify ourYear 2000 Program Office as soon as possible, and forward documentation that outlines the reasons whyyou will not be compliant by that date. We thank you for your cooperation. All documentation shouldbe forwarded to:

Year 2000 Project Office

Oxford Health Plans800 Connecticut AvenueNorwalk, CT 06854

Please note that during the Day One Period (12/28/99-1/4/00) Oxford’s schedule for claims receipt,provider inquiry, referrals, authorizations, appeals, and payment will remain as usual. Oxford will beopen for the routine business on January 4, 2000.

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OXFORD’S EDUCATION & OUTREACH PROGRAM: EXTRA ATTENTION FOR

YOUR OXFORD MEDICARE ADVANTAGE PATIENTS

Oxford’s Education & Outreach (E&O) team is dedicated to helping your Oxford Medicare Advantage

patients who may be confused by the protocols of managed care or appear to be having trouble accessingcommunity resources. By calling Oxford at 800-666-1353 and asking for a referral to our Medicare E&Oteam, you can give us the information necessary to contact your patient so we may provide theappropriate assistance.

Oxford’s E&O team can assist with the following Oxford Medicare Advantage Member issues:

• Plan education and protocols – E&O can assist Members who are having difficulty using theirbenefits appropriately or following managed care protocols. The team provides intensive planeducation and can help solve complex issues that arise due to inappropriate plan utilization.

• Community resources – The E&O team coordinates the use of community resources and socialservices for Members whose needs are beyond those that are covered under Oxford’s benefits.Examples of service types include transportation, custodial home care services, state and governmentbenefits, pharmaceutical assistance plans, disease specific support groups, and bereavement supportgroups.

• Translators and Interpreters⇒ Resources for deaf and hearing-impaired Members - E&O can help connect Members and

providers with qualified interpreters. (Please refer to the article on page three titled Special Carefor Hearing-Impaired Members for more information.)

⇒ Resources for Members with limited English proficiency –E&O will assist Members in locatingproviders who are most appropriate for their language needs.

EXPIRATION OF NEW JERSEY MEDICAID ASSIGNMENT

On July 1, 1998, in accordance with the transition of our Medicaid program in New Jersey, OxfordHealth Plans (NJ), Inc., assigned the Medicaid product portion of participating providers’ agreements toAmericaid Community Care, Inc. The effective period for this agreement was one year; as of July 1,1999, participating providers in New Jersey are no longer bound by the terms of the Medicaid productportion of their Oxford contract. Americaid has been establishing direct contracts with New Jerseyproviders since this assignment expired. If you have not established a contract but wish to do so, pleasecontact Americaid at 800-454-3730.

CULTURAL COMPETENCY

According to HCFA guidelines, Oxford is required to ensure that services are provided in a culturallycompetent manner to all plan enrollees, including those with limited English proficiency or reading skills,

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those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical andmental disabilities. Oxford providers can play a key role in fulfilling this requirement by:• Being responsive to the needs of and effectively addressing a diverse patient population;• Demonstrating knowledge of, and sensitivity to, the unique, culturally-based healthcare beliefs of

patients;• Incorporating educational programs for office staff to increase and improve their knowledge,

attitudes, and skills to be culturally appropriate and more clinically competent.

Oxford anticipates that more emphasis will be placed on cultural competency in healthcare delivery inthe future. We will share new strategies for increasing cultural competency as they are developed.

MEMBER RIGHTS AND RESPONSIBILITIES

Oxford is committed to treating Members in a manner that respects their rights. This is reflected in theestablishment of policies addressing Member rights, which are listed below (as they appear in Oxford’sProvider Reference Manual) and included in the Member literature. Oxford Members have the right to:

• Choose a qualified contracting primary care physician and contracting hospital. (Note: Selectionchoice may be limited by the provider’s patient caseload.)

• A candid discussion of appropriate or medically necessary treatment options for their condition,regardless of cost or benefit coverage.

• Timely access to their primary care physician and referrals to specialists when medically necessary.• Coverage for emergency services when they, as prudent laypersons acting reasonably, believe that a

medical emergency condition exists. Payment will not be withheld in cases where Members seekemergency services.

• Actively participate in decisions regarding their own health and treatment options.• Receive urgently needed services when they travel outside the plan’s service area or in the plan’s

service area when unusual or extenuating circumstances prevent them from obtaining care from theirprimary care physician.

• Be treated with dignity and respect and have the right to privacy recognized.• Exercise these rights, regardless of race, physical or mental disability, ethnicity, gender, sexual

orientation, creed, age, religion, national origin, cultural or educational background, economic or healthstatus, English proficiency, reading skills, mental abilities, source of payment for care, cost or benefitcoverage. Members have the right to expect that these rights will be upheld by both the plan and thecontracted providers.

• Confidential treatment of all communications and records pertaining to their care. Members have the rightto access their medical records. The plan must provide timely access to a Member’s records and anyinformation that pertains to them. Written permission from them or their authorized representative shallbe obtained before medical records can be made available to any person not directly concerned with theircare or responsible for making payments for the cost of such care.

• Extend their rights to any person who may have legal responsibility to make decisions on their behalfregarding the Member’s medical care.

• Refuse treatment or leave a medical facility, even against the advice of physicians (provided that theMember accepts the responsibility and consequences of the decision).

• Complete an advance directive, living will, or other directive to the Member’s contracting medicalproviders.

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• Receive information about Oxford, the health plan, and covered services.• Know the names and qualifications of physicians and healthcare professionals involved in their

medical treatment.• Receive information about an illness, the course of treatment, and prospects for recovery in terms

that the Member can understand.• Receive information regarding how medical treatment decisions are made by the contracting medical

group or Oxford, including payment structure.• Receive information about medications: what they are, how to take them, and possible side effects.• Receive as much information about any proposed treatment or procedure as the Member may need

in order to give an informed consent or to refuse a course of treatment. Except in cases of emergencyservices, this information shall include a description of the procedure or treatment, the medicallysignificant risks involved, any alternative course of treatment or non-treatment and the risks involvedin each, and the name of the person who will carry out the procedure or treatment.

• Be provided with reasonable continuity of care and to know in advance the time and location of anappointment, as well as the name and qualifications of the physician providing care.

• Be advised if a physician proposes to engage in experimentation affecting their care or treatment. TheMember has the right to refuse to participate in such research projects.

• Be informed of continuing healthcare requirements following discharge from inpatient or outpatientfacilities.

• Examine and receive an explanation of any bills for non-covered services, regardless of paymentsource.

• Information regarding all formal actions, reviews, or findings by regulatory agencies or any othercertifying accreditation organizations.

• Make complaints and appeals without discrimination and expect problems to be fairly examined andappropriately addressed.

• Responsiveness to reasonable requests made for services.• Initiate disenrollment from the plan.• Sign-language interpreter services in accordance with applicable laws and regulations, when such

services are necessary to enable the Member to effectively communicate with the provider.

Oxford has also developed policies that address the Member’s responsibility for cooperating with thoseproviding healthcare services. Members are responsible for:• Providing physicians or other care providers and Oxford the information needed in order to care for them.• Doing their part to improve their own health condition by following treatment plans, instructions,

and care that they have agreed to with their physician(s).• Behaving in a manner that supports the care provided to other patients and the general functioning of

the facility.• Accepting the financial responsibility associated with services received while under the care of a

physician or while a patient at a facility.• Reviewing information regarding covered services, policies, and procedures as stated in the Member

Handbook or Evidence of Coverage information.• Asking questions of the primary care physician or Oxford. If Members have suggestions, concern, or

payment issues, we recommend that they call the Oxford Customer Service Department at 800-444-6222.

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1999 MEMBER SATISFACTION SURVEY RESULTS

Recently, the results of the 1999 National Committee for Quality Assurance (NCQA) MemberSatisfaction survey were reported. Oxford scored among the top 25% of health plans nationally in theareas of Rating of Personal Doctor, Rating of Specialists, Rating of Overall Healthcare, and PhysicianCommunication§, while customer service and claims processing were areas identified in need of qualityimprovement. Oxford has been actively pursuing improvement in both areas: During 1998, resourceswere dedicated to ensuring system stability in order to effect steady improvements in customer serviceand claims processing. Oxford’s average speed to answer (the time it takes for Members and providersto reach an associate on our Customer Service line) has improved from 101 seconds in 1998 to 8 secondsin July 1999. The task force assigned to troubleshoot both short- and long-term claims issuessuccessfully stabilized claims payment and made significant improvements in the average time it takesOxford to process claims, including a reduction in turnaround time from 25 days in 1998 to 14 days inJuly 1999. Oxford hopes that continued improvements in these areas will lead to even higher overallratings in the NCQA’s next Member Satisfaction survey.

§ Source: 1999 CAHPs 2.0 survey results for Oxford Members in New York, New Jersey, and Connecticut.

PROMPT PAY PROGRAM IMPLEMENTATION

Effective October 11, 1999, Oxford will be implementing the Prompt Pay program. Connecticut, NewJersey, and New York state regulations require HMOs to notify providers within a certain amount oftime when a claim is contested. A contested claim is a claim with missing pieces of vital information,which are required for accurate and timely processing. Vital pieces of information include:

• Member information (name, address, Social Security number, and Oxford ID number)• Provider information (name, address, FTIN, Oxford ID number)• CPT code(s)• ICD-9 codes(s)• Date(s) of Service• Billed amounts• Place of service• Provider signature

When a claim arrives at Oxford, the claim will pass through a set of validation rules. The validation ruleswill determine whether the claim contains the specific criteria needed to accurately process the claim. Ifthe claim is not complete, the claim will be deemed contested.

Once a claim is classified as contested, Oxford will notify the Member/provider by letter, detailing theadditional information needed to accurately process the claim. The requested information may come back toOxford via phone, fax, or return mail. If the additional information is received within 30 days, the claimswill be forwarded appropriately for processing. If the information requested is not received after 30 days, theclaim will be processed based on the original information received and may be denied.

The Prompt Pay program will be implemented for all lines of business, regardless of dates of service. Ifyou receive a letter notifying you that additional information is necessary to properly process a claim,

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please do not submit the original claim. Rather, supply Oxford with the missing information via phone,fax, or return mail. If you have further questions, please contact Provider Services or your providerrepresentative.

OXFORD’S QUALITY MANAGEMENT PROGRAM

Oxford’s Quality Management program (QM) ensures the provision of high-quality healthcare andservices for all Oxford Members through the implementation of a comprehensive, integrated, systematicprocess that is based on quality improvement principles. QM program activities include:• identification of the scope of care and service provided by the plan;• development of healthcare treatment guidelines and service standards to improve the care given to

Members;• objective and systematic monitoring and evaluating of the quality and appropriateness of Oxford’s

services and medical care;• ensuring the medical qualifications of participating providers of care;• pursuit of opportunities to improve healthcare and Member service; and• resolution of identified quality issues.

To execute the above strategies and to address important aspects of care and service, Oxford’s QM programperforms the following monitoring and assessment activities:• requires that participating doctors make appointments in a timely fashion;• makes certain that providers maintain accurate medical record-keeping;• ensures that providers’ offices are close by and easily accessible to Members;• makes certain that Members get answers promptly from Member Services;• ensures that Oxford accommodates all Members, regardless of their cultural background and language;• analyzes Member and provider satisfaction surveys;• analyzes the amount and types of complaints, appeals, and grievances about providers and/or health

plan; and• reports important and required data to state, and federal agencies, and accrediting organizations.

The ultimate authority and oversight responsibility for Oxford’s Quality Management program lies withthe Board of Directors. The Board of Directors has delegated the responsibility of day-to-day QMprogram operations to Oxford’s Senior Medical Director of Quality Management. Regional QMcommittees, which include network practitioners, oversee the QM activities in their respective regions.For more information about Oxford’s Quality Management program, please write to us at:

Oxford Health PlansAttn: Accreditation44 South BroadwayWhite Plains, NY 10601

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ICD-9-CM, CPT AND HCPCS CODES EXPLAINED

Many third-party payers, including Medicare, use the International Classification of Diseases, 9th

Revision, Clinical Modification (ICD-9-CM), Current Procedural Terminology (CPT), and the HealthCare Financing Administration’s Common Procedure Coding System (HCPCS) to forecast and evaluatehealthcare service utilization and determine provider reimbursement. ICD-9-CM codes describe thecondition or reason for a patient’s encounter. These codes also serve to supply information regardingsurgical, therapeutic, and investigative procedures — they are used primarily by hospitals whileproviding inpatient care. The CPT/HCPCS codes describe the professional component of care andindicate which services or supplies were rendered, as well as which procedures were performed duringthe patient’s visit or surgical session. In order for a provider to receive appropriate reimbursement, allclaims must be submitted with proper coding to link the ICD-9-CM diagnostic code with theCPT/HCPCS procedure code.

THE BASICS FOR USING ICD-9-CM CODING

The ICD-9-CM coding system is a method of translating medical terminology into codes. Codes withinthe system are made up of three, four, or five characters. All characters are either numeric oralphanumeric. A decimal point follows all three-character codes when a fourth and fifth character isneeded in a diagnostic statement. In a procedure statement, a decimal point follows all two-charactercodes when a third and fourth character are required.

I. First, list ICD-9-CM code for the diagnosis, condition, problem, or other reason for the patient’sencounter/visit shown in the medical record. List additional codes (secondary diagnosis) thatdescribe any coexisting conditions (only if they affect patient care, treatment, or management).

II. It is necessary to use both the ICD-9-CM Alphabetic Index and the Tabular List when locating andassigning a code. Reliance on only the Alphabetic Index leads to errors in code assignments. Begin bylocating each term in the Alphabetic Index and verifying the code selected in the Tabular List.

III. Code the outpatient condition to the highest degree of certainty for that encounter/visit. If thediagnosis documented is “probable,” “questionable,” “suspected,” “rule out,” or “workingdiagnosis,” then code symptoms, signs and ill-defined condition. Example: Do not code “rule out”breast CA as 174.x ; instead, code 611.72 (lump or mass in breast).

II. Codes that have fourth or fifth digit sub-classification are considered invalid unless they are codedcompletely (including all necessary digits). Example: Diabetes Mellitus coded as 250- is an invalidcode. Complete code needs five digits to fully describe the condition: 250.01- Diabetes Mellitusw/out complication, Type I, not stated as uncontrolled.

THE PHYSICIANS’ CPT FOURTH EDITION

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The Physicians’ CPT Fourth Edition, developed by the American Medical Association (AMA) andHCPCS and created by the Health Care Financing Administration (HCFA), is a three-level codingsystem.

Level I - CPT is a five-digit numeric code that describes the procedures and services physicians providepatients. These codes are grouped by body system, site, and/or type of procedure or service.

Level II - These codes are commonly referred to as national codes or by the acronym HCPCS. They areassigned for non-physician procedures, durable medical equipment, or specific supplies. Example:ambulance services, wheelchairs, and drugs. National codes consist of one alphanumeric (A through V,except S) followed by four digits. Example: A4462 – abdominal dressing holder/binder.

Level III - These codes represent local codes. Medicare carriers are responsible for providing local codes.They are five-digit alphanumeric codes using the letters W through Z and S. Example: X1094 triggerpoint injection.

CPT CODE ORGANIZATION

The layout and design of the CPT lends itself to quick and easy location of codes. All codes begin withthe numbers 0-9 and are assigned to specific anatomic sites (example: all radiology codes begin with thenumber 7). The 99 codes are listed first because the majority of specialties use them most frequently.The numbers listed at the top of each page provide an easy reference and give the range of codes locatedon that particular page.

There are two ways to locate a procedure: anatomically and via indexing. The index is organized by mainterms and is shown in bold typeface. Each main term can stand alone or be followed by up to threemodifying terms. There are four primary classes of main entries:

• Procedure or service: endoscopy, anastomosis, splint• Organ or other anatomic site: tibia, colon, salivary gland• Condition: abscess, entropion, tetralogy of Fallot• Synonyms, eponyms, and abbreviations: EEG, Bricker operation, Clagett procedure

EVALUATION AND M ANAGEMENT

The first section of the CPT manual covers evaluation and management. Evaluation and managementservices are based on the intensity or complexity of the service provided to the patient during anencounter. The CPT manual includes the average time for some of the levels of service code descriptors.The indication of time should be used to assist physicians and their staff in assigning the appropriatelevel of service. It is important to remember that time is not a key factor in determining the codeassignment unless counseling or coordination of care accounts for over 50 percent of the time spent withthe patient and/or family.

There are three key components, each involving several elements, that must be met or exceeded whendetermining the appropriate level of service. They are as follows:

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• History - chief complaint (CC); history of present illness (HPI); review of systems (ROI); past,family, and/or social history.

• Examination - body site or organ system.

• Medical Decision Making - number of diagnoses or management options; amount or complexity ofmedical data to review; and risk of complication, morbidity, or mortality. In addition to these threecomponents, there are four factors that will contribute to the determination of the appropriate levelof service. They are as follows: counseling; coordination of care; nature of the presenting problem;and time. For a more detailed explanation, refer to CPT manual pages 1-8.1

PREVENTIVE TREATMENT FOR RESPIRATORY SYNCYTIAL VIRUS (RSV) INPREMATURE INFANTS

Infection with Respiratory Syncytial Virus (RSV) is the most frequent cause of bronchiolitis andpneumonia in children under the age of 24 months. Oxford Health Plans has recognized the need for thepreventive treatment of RSV since the advent of Respigam (Respiratory Syncytial Virus ImmuneGlobulin, Human) in 1996 and Synagis (Palivizumab, genetically engineered antibody) in 1998. Respigamis an IV infusion, whereas Synagis is an intramuscular injection that can be given in the physician’soffice. Both are administered once a month for five to seven months during the RSV season (betweenOctober and April). The Disease Management Neonatal Critical Care team at Oxford Health Plansreviews all requests for these treatments in children less than one year of age. Based on guidelinespublished by the American Academy of Pediatrics (see reference), as well as extensive consultation witha panel of Oxford Neonatologists, Oxford medical policy was established for the preventative treatmentof RSV, which is primarily aimed at infants at high risk for adverse outcome from respiratory infection.

Indications:Any child less than two years of age with chronic lung disease (CLD), formerly referred to asBronchopulmonary dysplasia, who have required medical therapy (e.g., oxygen therapy, chronicnebulizers, or hospitalizations for respiratory illness) for their CLD within six months prior to the RSVseason. Uncomplicated reactive airway disease (RAD) in the full-term infant is not included in thisindication.

Infants born at a gestational age of 32 weeks or less without CLD who do not meet criteria above.Infants born at a gestational age of 28 weeks or less may benefit from prophylaxis up to 12 months ofage. Infants born at a gestational age of 29 to 32 weeks may benefit most from prophylaxis up to sixmonths of age. When these infants are being discharged from the hospital during RSV, it is expected thatthe first dose of Synagis or Respigam will be administered by the hospital as part of the daily NICUcare. Due to the increased risks caused by a delay in administration of prophylaxis to these infants, earlyadministration is critical.

Due to lack of adequate cost-benefit analysis as reviewed by the AAP statement, the use of Synagis inthe large number of infants born between 32-35 weeks gestation should be reserved for those infants

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with additional medical risk factors present, including severe initial respiratory course, continuedrespiratory needs, ongoing apnea and bradycardia requiring home medication and/or monitoring, andcompromising neurologic disease. Factors such as documented increased exposure via daycare or homesetting, smokers in the home, and multiple births do not, in and of themselves, constitute major riskfactors but should be considered in conjunction with the entire clinical picture.

Contraindications to the drug (e.g., cyanotic congenital heart disease) or off-label uses (congenital heartdisease, immunocompromised patients) follow the AAP guidelines found in the reference material.

We encourage physicians and healthcare providers to reinforce the most critical aspect of RSVprevention in all infants that lies within the purview of the caregivers: to reduce transmission andexposure to the virus via handwashing and avoidance of contagious settings and cigarette smoke.

Please note: If precertification is given for a request for Synagis based on the aforementioned medicalpolicy, Oxford can arrange for our Caremark pharmacy to deliver medication to the physician’s office foradministration. Any infant who is deemed homebound due to the inability to get to the physician’soffice based on the medical condition (e.g., ventilator dependency) can be evaluated by our case managersfor administration of the drug in the home setting by an Oxford-contracted home care agency.

Reference: American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Fetus and Newborn.Prevention of Respiratory Syncytial Virus Infections: Indications for the Use of Palivizumab and Update on the Use ofRSV-IGIV. Pediatrics. Vol. 102 No. 5 Nov 1998; 1211-1216.

OXFORD’S DIABETES MANAGEMENT PROGRAM

Diabetes mellitus affects 5.9% of the population and is the most common cause of adult blindness, non-traumatic lower extremity amputations, and kidney disease requiring dialysis. Oxford remains committedto improving and maintaining the highest quality of life for our diabetic Members. We empower themwith the tools necessary for self-management and encourage them to actively participate in their care.

In 1998, Oxford initiated a comprehensive telephonic diabetes case management program. Additionally,we piloted two programs comparing on-site group education to individual one-on-one home education.All three programs demonstrated a decrease in length of stay (LOS) and admissions. The most significantfinding, however, was an improvement in the Hemoglobin A1c level. Some of the best results wereobtained in the home education program (which was conducted by Visiting Nurse Services), where 29patients demonstrated a decrease of the Hemoglobin A1c value from 9.9 to 7.9 (20%) over a six-monthperiod.

After carefully reviewing the pilot programs, Oxford developed an intensive telephonic educational casemanagement program staffed by a team of skilled, nurse-certified diabetes educators. In this program,Members at high risk for developing complications from poor glucose control are identified and enrolledon a voluntary basis. Case managers proactively assess the knowledge base of each Member, payingspecial attention to the disease process, adherence to medication, home blood glucose monitoring, andnutrition. All appropriate Oxford resources for education and supplies are identified, and Members areeducated regarding the American Diabetes Association guidelines of quarterly Hemoglobin A1c testing

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and annual diabetic retinal exams, foot exams, and micro-albumen urine testing. Initial results for enrolledMembers have been very promising, with an average decrease of Hemoglobin A1c values from 13.4 to10.9 (18%).

If you have any questions regarding the Diabetes Case Management program, please call Oxford’sDiabetes Hotline at 888-585-0631.

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CLINICAL PRACTICE GUIDELINESWe value your input on our guidelines, so if you have any questions or comments, please e-mailvsulliva@oxhp.com, or write to:

Quality Management Attn: Vicky SullivanOxford Health Plans44 South BroadwayWhite Plains, NY 10601

TOBACCO AND S MOKING CESSATION

P U R P O S E O F T H E G U I D E L I N E

Tobacco use has been cited as the chief avoidable cause of illness and death in our society.Recent estimates are that 25% of Americans smoke and that smoking prevalence among adolescents isrising. These guidelines are based on recommendations of The Agency for Health Care Policy andResearch (AHCPR). The AHCPR encourages implementation of measures into regular physician officepractice that consistently identify tobacco usage and employ focused interventions designed to motivateand assist smokers to quit. To this end, Oxford Health Plans has introduced a policy to reimbursephysicians for counseling their patients about tobacco and smoking cessation.1. Every patient who smokes should be identified and offered effective cessation interventions at each

clinical visit with a healthcare practitioner.2. Clinicians should incorporate brief but effective cessation interventions into physician practice.3. Cessation interventions should include:

motivation —— evaluation —— support —— instruction —— distribution of relevant materials andquitting aids (e.g., self-help guide, instructional manual, adjunctive nicotine replacement).

I N I T I A L C O U N S E L I N G S E S S I O N

1. Ask all patients if they use tobacco. (Expand the vital signs record to include documentation ofsmoking status.) Inquire what age first smoked, pack years (# of packs per day x # years smoked),and number of previous quit attempts.

2. Strongly advise every patient who smokes to quit. Advice should be: • Clear…… “I think it is important for you to quit smoking now, and I will help you.”• Strong….“As your physician, I know that quitting smoking is the most important thing you can

do to protect your health now and in the future.”• Personal… “You’ve already had one heart attack,” or “You know your children need you.”

3. Agree on a quit date, ideally within two weeks.4. Counsel total cessation — tapering is not effective.5. Assess need for nicotine replacement therapy (see guide below).6. Assist patient in planning for quit date:

• Encourage smoker to inform friends, family, and co-workers of plans to quit, and ask for theirsupport.

• Instruct to remove cigarettes from home, car, and workplace, and avoid smoking in theseplaces.

• Review previous quit attempts — what helped, what led to relapse.• Anticipate challenges, particularly in the critical first few weeks, and discuss coping strategies• Alcohol use is strongly associated with relapse — counsel abstinence while quitting.• Distribute appropriate materials on smoking cessation techniques with counseling.• Provide contacts with recognized supportive resources (see below).

7. Arrange follow-up counseling at initial counseling session (within 1-3 weeks of the quit date).

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N I C O T I N E R E P L A C E M E N T T H E R A P Y ( N R T )

• Nicotine withdrawal typically begins six to twelve hours after quitting, with a peak reported at oneto three days. In 60% of smokers, the symptoms last three to four weeks.

• Many successful quitters do not require NRT.• Nicotine replacement alone, without support counseling, is no better than a placebo and

is not recommended.• NRT, if indicated, should not exceed eight weeks.• Nicotine replacement is available in three forms (see chart below).• Emphasize no smoking while on nicotine replacement therapy.• Therapy for four to eight weeks.

P R O D U C T G U M P A T C H N A S A L S P R A Y / I N H A L E R

availability prescription and over the

counter

prescription and over the

counter

prescription only

use/efficacy requires specialinstructions; frequently

misused

ease of use;predictable levels of nicotine

most effective inheavily nicotine-addicted smokers

dosing 2mg & 4mg9 to 12/day

15-22mg/24 hrs for 4-6 weeks;5-14mg/24 hrs if required

additional weeks

Depends on product;not to exceed 5

doses/dayOxford’s medical policy states that nicotine cessation aids are not covered. However, some Oxfordpharmacy plans do cover these products. Please verify with each Member their individual prescriptionplan coverage.

F O L L O W - U P C O U N S E L I N G S E S S I O N

1. For Successfully Abstinent Patients — Deliver Relapse Prevention• Congratulate their success at remaining abstinent.• Reinforce their decision to quit; encourage them to remain abstinent.• Review and reinforce physical, social, and emotional benefits of remaining abstinent.• Inquire about current and future threats to abstinence.

2. For Patients Who Have Relapsed — Reassess Willingness to Quit• Provide or arrange an additional intervention.• Evaluate for more intensive psychosocial treatment.• Review for appropriate use of nicotine replacement therapy; consider revising therapy or

dose.• Counsel that most smokers quit successfully only after multiple attempts.• Relapsed patients unwilling to quit currently should receive a brief intervention to promote

motivation.

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I M P O R T A N T T O P I C S f o r A L L C O U N S E L I N G S E S S I O N S :

The counselor should provide the patient:1. Supportive communication (talking points):

• Reinforce the effectiveness of available cessation treatment.• Half of all who have ever smoked have successfully quit.• Most who succeed at quitting do so only after several quit attempts.• Review patient’s strengths and life achievements.

2. Basic information:• The addictive nature of smoking and time course of withdrawal.• Specific immediate and long-term health risks of continued smoking (shortness of breath,

asthma, fetal risk, infertility, impotence, heart disease, stroke, cancer).• Risks of second-hand smoke to children, pregnant mothers, the elderly, and the infirm.

3. Recognition of danger situations:• Being around other smokers.• Time pressure.• Arguing.• Negative moods.• Drinking.

4. Dosing instructions:• Appropriate use of nicotine replacement, if applicable.

The counselor should explore with the patient:1. Developing coping skills:

• Anticipation and avoidance of danger situations.• Lifestyle changes to reduce stress and produce pleasure (exercise/sports; hobbies/handiwork;

deep breathing).• Positive activities that distract attention from smoking urges.

2. Positive incentives to quit:• Improved health.• Improved sense of well-being.• Freedom from addiction and social stigma.• Financial savings.• Improved sense of smell and taste.• Providing a good example for family and children.

3. Patient’s fears:• Weight gain.• Negative mood or depression.• Lack of support from family and friends.

4. Availability of help:• How to reach clinician.• Efficacy of alternative treatments (hypnosis, acupuncture; see below).• Resources for further information and follow-up: how to find out about more intensive

programs, if desired.

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O T H E R T H E R A P E U T I C O P T I O N S

• Hypnosis, relaxation and/or acupuncture have been incorporated in some successful smokingcessation treatments. However, evidence is insufficient to assess their effectiveness in isolation fromother interventions.

• Behavioral modification therapy has proven quite successful, particularly when combined withnicotine replacement for those with high-nicotine dependence.

• Aversion therapy is not recommended, even as part of a comprehensive cessation program.• Non-aversive techniques, both cognitive and behavioral, are frequently used in combination as part

of comprehensive treatment program.• The efficacy of Clonidine, antidepressants, Anxiolytics, Benzodiazepines, or Silver Acetate in

smoking cessation are inconclusive because of a lack of data.• Routine Screening CXR or Sputum Cytology are NOT recommended as screening for smoking

cessation. These tests are expensive and have not increased life expectancy or quality of life, evenfor smokers.

R E S O U R C E S F O R P A T I E N T M A T E R I A L S A N D P R O G R A M S

American Cancer Society800-ACS-2345 (800-227-2345)

Agency for Health Care Policy and Research800-358-9295www.ahcpr.gov

American Lung Association800-586-4872www.lungusa.org

American Heart Association800-242-8721

National Cancer Institute800-4-CANCER

Office on Smoking and HealthCenters for Disease Control & Prevention800-CDC-1311 (800-232-1311)www.cdc.gov/tobacco

B I L L I N G F O R S M O K I N G C E S S A T I O N C O U N S E L I N G

• The code SMOK 1 in addition to Regular Office Visit Code will cover one initial counselingsession over and above the reimbursement for a yearly physical examination or a separate officevisit ($30).

• The code SMOK 2 in addition to Level 1 or 2 Office Visit Code will cover one follow-upcounseling session in the context of an office visit ($25).

• Oxford will allow two counseling sessions each calendar year per patient.• This may be billed by a primary care provider, cardiologist, or pulmonologist.• This benefit does not require precertification.• This benefit does not require any additional supporting documentation.

The following screening and chart documentation tools are designed to assist the clinician in screening fortobacco use and in documenting counseling sessions. Please feel free to reproduce these pages and incorporatethem into your medical practice and record keeping.

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SMOKING CESSATION FLOW CHART

Patient Name_______________________________ ID Number______________ Sex_____

Birth Date_____________ Age 1st smkd._____ Pack/yrs.______ # of Quit Attempts_____

AHCPR Recommendation Initial Visit Follow-up Visit Follow-up Visit

Date:Tobacco History:Advise to Quit:Risks to Health—Review:Asthma—Stroke—Cancer—FetalRisk—Heart Disease—LungDisease—Impotence—InfertilityImpact on Spouse, ChildrenRewards of Quitting:Improved Health—MoneySavings—Improved Sense ofSmell and Taste—Freedom fromAddiction and Social StigmaSet a Quit Date:Assist with a Quit PlanPlan support network. Removal ofall cigarettes & ashtrays.Review previous quit attempts:What helped?What led to relapse?Identify triggers to smoking.Coping with Craving:Exercise, Handiwork, DeepBreathing, Plan Activities, DrinkLiquids, Adopt HobbiesThings to Avoid:Alcohol, Company of Smokers,StressPharmacology:Nicotine Replacement Therapy(NRT):Other:Arrange Follow-up Visit:(Ideally within 2 wks. of QuitDate) Follow-up Date:Provide educationalmaterials: Self-help booklets,etc.

Referral to Recognized Resources:American Cancer Society800-227-2345

American Heart Assoc.800-242-8721

National Cancer Institute800-4-CANCER

American Lung Assoc.800-586-4872

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PATIENT NICOTINE DEPENDENCE EVALUATIONThis questionnaire is the standard analysis for estimating a smoker’s physical dependence (or addiction) tonicotine, the drug in tobacco. While not always accurate or reliable, the test can often give an understandingof the degree of nicotine addiction and can help guide your physician in determining whether you wouldbenefit from nicotine replacement therapy and what would be an appropriate dosage.1

Instructions: Circle the number in the “Points” column that corresponds toyour answer to each question.

Questions Answers Points

1. How soon after you wake up do you smoke your first cigarette? Within 5 minutes……….

6–30 minutes…………..

31–60 minutes…………

After 60 minutes………..

3

3

1

0

2. Do you find it difficult to refrain from smoking in places whereit is forbidden, e.g., church, library, movies, airplanes, etc.?

Yes…………………..…..

No……………………….

1

0

3. Which cigarette would you hate most to give up? The first one in themorning…………………

All others……………….1

0

4. How many cigarettes per day do you smoke? 10 or less………………..

11–20……………………

21–30……………………

31 or more……..…………

0

1

2

3

5. Do you smoke more frequently during the first hours afterwaking than during the rest of the day?

Yes………………………

No……………………….

1

0

6. Do you still smoke if you are so ill that you are in bed most ofthe day?

Yes………………………

No…………………….….

1

0

TOTAL SCORE:

Scoring Level of Addiction:

0-2 3-4 5 6-7 8-10Very Low Low Medium High (Heavy) Very High

1Orleans CT, Glynn TJ, et al: Minimal -Contact Quit Smoking Strategies for Medical Settings in Nicotine Addiction . CT,Orleans and J Slade (eds); New York, Oxford University Press. 1993