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Making sense of the 2009 QOF rule changes

Dr Simon Clay takes you through the changes to QOF rules for 2009, points out the potential catches and shows how GPs can maximise their points scoring by sorting out their coding.

Dr Simon Clay takes you through the changes to QOF rules for 2009, points out the potential catches and shows how GPs can maximise their points scoring by sorting out their coding.

Version 13 of the QOF business rules released in December made a large number of changes, many of which will be backdated to April 2008 and some to January 2008, about eight months before any GPs were aware of the changes made.

The disease areas where changes have been made are:

1. Chronic Kidney Disease
2. Atrial fibrillation
4. Palliative care
5. Stroke and TIA
6. Smoking management
7. Records 23 (smoking)

CKD changes

There are two changes, one to the sub-divisions of severity and the other to the new importance of proteinuria.

Severity divisions

It has been recommended that CKD 3 is divided into two parts – CKD3a & CKD3b

CKD3a is defined as eGFR of 45-59ml/min & CKD3b as eGFR of 30-44 ml/min.

Although new codes have been added to allow for this coding, there is no obligation to use them in this version of the QOF rules and no points are lost if the new subdivisions are ignored.


The presence or absence of proteinuria becomes of significance for the first time. The obligation to start patients with CKD & hypertension on an ACE/ARB will now only arise if that patient also has documented proteinuria.

The official guidance notes suggest that:

- Non-diabetics with stages 3 to 5 CKD should have an annual urine dip for proteinuria unless they have a previous diagnosis of proteinuria

- Patients testing positive to this (one "+" of protein or more) should then have either:
a) a repeat early morning dipstick to confirm proteinuria, or
b) a quantitative urine albumin creatinine ratio test (ACR) or equivalent protein creatinine ratio test (PCR) within three months.

This should be repeated annually, except where proteinuria has previously been diagnosed. The present rulesets do not check for this however.

What constitutes a "positive" test for proteinuria? Well, according to the guidance, a second positive on repeat morning dipstick testing of one "+" or more is positive. However, rather disappointingly, no figure is given for what value of PCR or ACR should constitute a "positive" finding.

Recommendations from leading authorities vary widely. The UK Consensus Conference on Early Chronic Kidney Disease group recommend a value of PCR >100mg/mMol. However, NICE draft guidance defines proteinuria as either a PCR ? 45mg/mmol or ACR ? 30 mg/mmol.

My practice is going to use the NICE definition which is gaining increasing acceptance.

Coding the Proteinuria, if positive.

There are only 8 permissible codes to code the patient as having proteinuria under the new QOF rules.

4674 : Urine protein test = +
4675 : Urine protein test = ++
4676 : Urine protein test = +++
4677 : Urine protein test = ++++
R110 : [D]Proteinuria
R1100 : [D]Albuminuria
R1103 : [D]Microalbuminuria
R110z : [D]Proteinuria NOS

Another important practical point is there is no time window on when these codes must have been added. So, for example, if a woman had a UTI 15 years ago and a nurse dipped her urine and recorded 4674 One + protein, then this lady is permanently proteinuric under the new QOF rules.

Testing for proteinuria only affects CKD5 (the requirement to start ACEs). If a patient's urine is never checked for protein, that patient is not even entered into denominator for CKD5. This is good news financially but not good clinically as any software a practice is using to help remind them to consider ACEs will not give such a prompt in hypertensive CKD patients unless they have also been coded as proteinuric.

The issue of episode codes is also important. Each CKD code should be episode coded, but many practices don't bother. For example, if a patient is coded as CKD2 (1Z11) but the patient later deteriorates to CKD3 and the code for this is added (1Z12), the latter code will be ignored by the software unless this code is episode-coded as "first" or "new". In the absence of such a code, the first ever CKD code will be the "active one.

Atrial fibrillation

AF2 is changed to AF4.

The permitted time window for recording an ECG on a new case is reduced from 15 months (3/12 before to 12/12 after), to six months (3/12 before to 3/12 after.)

In addition, only patients diagnosed from 1st April 2008 are subject to the new indicator. This means that all your "old" AF patients don't count "for" you any more for AF4. Hence, so missing even one patient's ECG may cause a practice to fall below the percentage threshold required to score full points. For example, we had thirty four patients in AF2 but only three in AF4 and 90% coverage is required.


COPD9 ("New COPD patients need spirometry") is withdrawn & replaced with COPD12:

There are three changes to the rules:

1. The "look back" date is moved to 1/4/08. This means the number of relevant patients will be very small for each practice. Hence, failing on even one may be enough to slip below the maximal coverage threshold (90%) We had 108 patients, we now have 3 in the catchment group.

2. The permitted time window for getting spirometry is tightened from "any time from three months before the diagnosis" to "from three months before to twelve months after the diagnosis".

3. The permitted codes to record spirometry have been drastically reduced. None of the following codes are now valid:

33G..% "Spirometry reversibility"
33K..% "Steroid reversibility"
5882. "Spirometry"
663J – 663K "Airway obstruction reversible or irreversible"
663k. "Reversibility trial of steroids"
68M.. "Spirometry screening"

Only the following codes are permitted for new patients diagnosed from April 2008 :

33H..% "Salbutamol reversibility"
33I..% "Ipratropium reversibility"
33J..% "Reversibility to "Combivent", equivalent
66Ya & 66Yb. "Reversibility trials by bronchodil' or anticholinergic" respectively
8HRC "Refer for spirometry"

Many practices are likely to be caught out by this last change as they will have been using 5882 spirometry or 33G..% spirometry reversibility. Only patients diagnosed since 1/4/08 will need their spirometry coding changed to one of the new codes however.

Palliative care

The only change is that patient under 18 years are now included.


Stroke 11 ("Only stroke patients need a scan") becomes stroke 13: ("Both stroke and TIA patients need a scan").

There are three significant changes.

1. The "look back" window is changes to 1/4/08. This means that only strokes and TIAs diagnosed from this date are considered. Again this means that small patient numbers make every patient crucial.

2. The window for the scan being done or referral for investigations being made, is reduced from "three months before to twelve months after diagnosis" to "three months before to one month after".

3. The window to document an exception code to scanning (scan declined) is also tightened from "up to twelve months after the stroke" to "up to one month after the stroke".


Smok1 has been changed to Smok3:

This brings to 8 the number of diseases where smoking status must be documented annually: CHD, DM, BP, stroke, asthma, COPD and now also CKD and MH.

There are two exceptions to this annual obligation.

1. "Never smokers" where the "Never smoked" code is added after their 26th birthday and on or after the date of the first qualifying diagnosis code. Such patients never need smoking status adding again.

2. For "Ex-smokers" one of two criteria must be fulfilled:
Either a.) Last smoking status is "Ex-Smoker" and was added in last 15 months before the Reference date (next April 1st.)
b.) Last smoking code is "Ex-smoker". ("Ex-smok")
AND a further "Ex-smoker" code was recorded ("Ex-Smok1") between 2 yrs before and 1 yr & a day before date of "Ex-Smok"
AND a further "Ex-Smoker" code ("Ex-Smok2") was recorded between 3 yrs before and 2 yrs & a day before "Ex-Smok".

This ridiculous complexity is the ruleset authors' response to the criticism that we had to continue to record smoking status in demented patients of 93 who had ever smoked but is so convoluted, it makes you wonder whether the previous rules weren't better!

Finally, smok2 is changed to smok4 and the obligation to document smoking cessation advice to these patients annually, now extends to CKD and MH patients too.


Records 22 ("Record smoking status of all patients aged over 15 every 27 months") becomes records 23. There are 3 changes: Two are tightenings of the rules and one is a weak relaxation!

New Records 23 "hurdles"

"Never smokers" continue their exemption from further recording provided that the last smoking status is "never smoked" and patient was over 25 when recorded as a "never smoker".

Patients aged 15 to 25 who are "never smokers" need to have that status re-confirmed and recorded every 15 months, (not even every 27 months) in order to "score" records 23.

With such a young, fit cohort of patients, this is clearly very difficult.

The weak relaxation:

Patients aged over 15, whose last recorded smoking status at any age is "ex-smoker", are exempted further documentation, provided that the last smoking code is "ex-smoker" ("ex-smok")
AND a further "ex-smoker" code recorded ("ex-smok1") between 2 yrs before & 1 yr and a day before date of "ex-smok"
AND a further "ex-smoker" code ("ex-smok2") was recorded between 3 years before and 2 years and a day before "ex-smok".

So, to summarise Records 23:

• You don't have to collect Smoking status of anyone <15 yrs next April 1st
• If the patient is a current smoker, you only need to record that within 27 months of next April
• If the patient is 26+ and you have recorded "never smoker" after they reached 25, then you just need it recorded once
• If the patient is aged 15-25, and a "never smoker" then you need to record smoking status (assuming that status continues) every 15 months
• If the patient is an ex-smoker then you need to
(a) have the ex-smoking status recorded within the last 15 months
(b) have a record of ex-smoker status in THREE consecutive years in their history.

The overall consequence of changes to Records 23 is pretty worrying:

Looking at my practice's data; in Aug 2008, we had 85% coverage of eligible patients' smoking status and needed only 380 more patients to score the full eleven points for records 22. Under records 23, looking at the same data, our coverage dropped to only 65% and we needed 2,115 more patients' smoking data – a virtually insurmountable task and losing the practice £900 at that date.

For a complete guide on how to improve your smoking scores before April, see the linked article "Making the new QOF smoking rules work for you".

Dr Simon Clay is a GP in Birmingham. You can email him at

Making sense of the QOF rule changes for 2009

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