Maximising your scores on the new QOF indicators
Dr Simon Clay gives advice on coding and organisation to ensure practices keep up with key changes to the QOF
The current QOF year has seen a large number of changes to the rules, with various indicators being retired, replaced, split up or expanded.
Some entirely new indicators were added while others had their points allocation reduced. Here, I talk through the main areas of change and advise on optimising your claims.
CHD2 – seven points For patients with newly diagnosed angina (after 1 April 2011), the percentage referred for specialist assessment
CHD14 – 10 points The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or angiotensin receptor blocker if intolerant), aspirin or an alternative antiplatelet therapy, ß-blocker and statin
The valid codes to document a new angina referral were changed. All the exercise ECG codes were removed and now the only codes that qualify for CHD2 are as follows:
• 8H44 – cardiology referral
• 8HTJ – referral to rapid-access chest pain clinic
• 8H4R – referral to cardiology special interest GP
• 8HVJ – private referral to cardiologist.
TIP Make sure your new angina patients since
1 April 2011 have one of those codes added if appropriate.
For CHD14, all new MI patients since
1 April need to be offered all of four separate drug families: either aspirin, clopidogrel or an oral anticoagulant;
a ß-blocker; an ACE inhibitor or
ARB; and a statin (irrespective of the cholesterol level).
In addition, an ARB is only valid if there is a valid exception code for ACE inhibitors. The absence of any of these drugs excludes the patient from the indicator, unless there is a valid exception code for each family of drugs they're not on.
TIP Call in those few patients with MIs since April who aren't on all four families and review whether you can start the rest, or add relevant exception codes.
COPD15 – five points The percentage of all patients with COPD diagnosed after 1 April 2011 in whom the diagnosis has been confirmed by post-bronchodilator spirometry
Only two codes are now valid to define completed spirometry – 8HRC or 745D4.
None of the following spirometry codes are now valid:
• 66Ya. – 66Yb..
TIP Check that all new COPD patients diagnosed since 1 April 2011 have had their spirometry coded using 8HRC or 745D4.
DEP5 – eight points In patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity four to 12 weeks after initial recording of severity
Under DEP3, the time window within which to do a second depression severity assessment has been relaxed slightly from five to 12 weeks, to four to 12 weeks.
DEM3 – six points The percentage of patients with a new diagnosis of dementia (from 1 April 2011) with a record of FBC, calcium, glucose, renal, liver and TFTs, serum vitamin B12 and folate levels recorded six months before or after entering onto the register
DEM3 has been added. We now need to do eight separate blood tests on patients newly diagnosed since 1 April: FBC, calcium, glucose, renal and liver function, thyroid function, serum vitamin B12 and folate levels, all of which need to be done within six months either side of the date of diagnosis.
Version 21.0 of the business rules has added several bilirubin Read codes for LFT (44E.. serum bilirubin level, 44E9. plasma total bilirubin level and 44EC. serum total bilirubin level). Also, for the folate requirement a red cell folate code is now valid: (42U4. red blood cell folate).
TIP Go through your new dementia patients since April and ensure they've had all eight tests done. If they miss one, they ‘fail' the whole indicator.
DM29 – four points The percentage of patients with diabetes with a record of a foot examination and risk classification
DM30 – eight points The percentage of patients with diabetes in whom the last blood pressure is 150/90mmHg or less
DM31 – 10 points The percentage of patients with diabetes in whom the last blood pressure is 140/80mmHg or less
DM29 now replaces DM9. We need to check both the foot pulse status (but need no longer record it) and the foot sensation, then code their feet with a ‘foot risk status'.
To code for this indicator, a GP has to know three things:
• the pulse status of the feet
• the neuropathy status (even though that is separately coded in DM10)
• the degree of foot risk present.
But to score DM29, the GP only has to record the foot risk classification (not the pulses and not the neurological examination). Furthermore, to score it, only one foot has to be scored, though there are codes available for each foot (2G5E to 2G5L). Recording amputations is helpful, but only if both feet are amputated.
The four pairs of codes relevant to each foot classification ‘state' are:
• low risk (normal sensation, palpable pulses) – right foot: 2G5E, left foot: 2G5I
• increased risk (neuropathy or absent pulses) – right foot: 2G5F, left foot: 2G5J
• high-risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) – right foot: 2G5G, left foot: 2G5K
• ulcerated foot within the preceding 15 months (irrespective of pulses or neuropathic status) – right foot: 2G5H, left foot: 2G5L.
We found a lot of patients with diabetes where a GP had coded the pulses and the sensation, but had not added a foot risk score – so there were zero points.
TIP Go through your patients with diabetes who are ‘failing' DM29. You may find you can retrospectively add the foot risk codes if the pulses and sensation are recorded.
DM30 and DM31 are two new indicators relating to blood pressure that jointly replace DM12. Now eight points are available for getting 71% of patients with diabetes to a blood pressure of 150/90mmHg and a further 10 points for getting 60% of them to 140/80mmHg.
TIP Call in your patients with diabetes who are not reaching this tougher target now. You've got enough time to add an exception code for blood pressure control, if you feel they're on maximal treatment (8BL0). Alternatively, you could make one more change to their treatment and see them in a month, either to record their new lower blood pressure or to then feel justified in adding that same exception code.
EP9 – three points The percentage of women under 55 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the preceding 15 months
EP9 is a new indicator that requires eligible women under the age of 55 to be documented as having received information relating to epilepsy's effect on the issues of contraception, pre-conception and pregnancy. Three separate Read codes are required, representing these three areas of advice in the last 15 months (three points, threshold 90%).
Hysterectomised or sterilised women are excluded.
Contraception advice should cover areas like best methods for women on various anticonvulsants. Pre-pregnancy advice should cover folic acid and considering the need to change drugs before conception.
Pregnancy advice should cover minimising the risks of epilepsy in pregnancy and scans and tests. This advice must be demonstrably given face to face. Giving additional written advice is not necessary. I've compiled a downloadable leaflet, which can either be used as an aide memoire for the clinician or given to the patient.1
The six valid exception codes (two for each of the three areas to be covered) are:
• 8IAg – contraceptive advice for patients with epilepsy declined
• 8IB2 – contraceptive advice for patients with epilepsy not indicated
• 8IAh – pre-conception advice for patients with epilepsy declined
• 8IB3 – pre-conception advice for patients with epilepsy not indicated
• 8IAi – pregnancy advice for patients with epilepsy declined
• 8IB4 – pregnancy advice for patients with epilepsy not indicated.
In my experience, it's mainly women with learning disabilities or women who say they do not want more, or any, babies for whom these exception codes are most pertinent.
TIP This is a small group of women in most practices, so find them and call them in for a chat.
LD2 – three points The percentage of patients on the learning disability register with Down's syndrome aged 18 years and over who have a record of blood TSH in the preceding 15 months (excluding those on the thyroid disease register)
LD2 is a new indicator that requires all patients with Down's syndrome aged over 18 years on the LD register, who are not on the thyroid register, to have TFTs done in the last 15 months (three points, threshold 70%). Note that your patients with Down's syndrome will not be on the LD register unless they have a valid LD code. Just having a Down's code does not qualify.
TIP Check your patients with Down's syndrome to ensure they have an LD code if appropriate and that they have been offered TFTs since 1 April. If they have not, offer this or use an exception code (9hL.. or 9hL0. or 9hL1.)
MH11 – four points The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months
MH12 – four points The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months
MH13 – four points The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months
MH14 – five points The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:HDL ratio in the preceding 15 months
MH15 – five points The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose in the preceding 15 months
MH16 – five points The percentage of patients (aged 25 to 64 in England and Northern Ireland, 20 to 60 in Scotland and 20 to 64 in Wales) with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding five years
There are six new indicators. MH11-16 replaces MH9, the mental health review, which is now retired. These require individual coding of up to six different parameters. Some 28 points in total are available for these indicators.
• MH11 requires alcohol intake coding annually (four points, threshold 90%).
• MH12 requires an annual BMI coding (four points, threshold 90%).
• MH13 requires a blood pressure check annually (four points, threshold 90%).
• MH14 requires all patients aged 40 or older to have an annual total cholesterol:HDL cholesterol ratio (five points, threshold 80%). There was confusion with this initially as the authors got the codes, ratio and rubric wrong. But now it's been corrected and any TC:HDL code will be valid.
• MH15 requires all patients aged 40 or older to have a blood glucose level recorded (five points, threshold 80%). Patients with diabetes are exempted, but not if diagnosed in the same QOF year.
• MH16 requires eligible women to have had a documented smear test within five years (five points, threshold 80%).
• MH17 replaces MH4. This tightens the time window to have had a creatinine test and TFTs checked to within nine months (rather than 15) before the reference date.
• MH18 replaces MH5. This requires documented lithium levels to be within range within four months of the reference date (rather than six months as in the previous code).
TIP It is worth calling in patients who fail one or more of these indicators. All tests can be done by either healthcare assistants or nurses. Many patients are missing more than one indicator, making it a particularly efficient consultation to weigh, measure and take blood, and ask about alcohol and smoking.
Quality and productivity
QP6 – five points The practice meets internally to review data from the primary care organisation on secondary care outpatient referrals
QP7 – five points The practice participates in an external peer review to compare its secondary care outpatient referral data and proposes areas for commissioning or service design improvements to the PCO
QP8 – 11 points The practice engages with the development of and follows three agreed care pathways for improving the management of patients to prevent inappropriate outpatient referrals and produces a report of the action taken to the PCO no later than 31 March 2012
QP9 – 9 points The practice meets internally to review PCO data on emergency admissions
QP10 – 15 points The practice participates in an external peer review to compare its data on emergency admissions and proposes areas for commissioning or service redesign to the PCO
QP11 – 27.5 points The practice engages with the development of and follows three agreed care pathways in aiming to prevent emergency admissions and produces a report of the action taken to the PCO no later than 31 March 2012
Preparatory work for these complex 11 indicator areas will have largely been completed by now.
• Practices should ensure that they optimise point scores for their chosen three prescribing indicators QP3-5 by reviewing patients where there is still scope to change to the chosen drugs.
• For QP indicators 6-8, ensure that the respective reports to the PCO have been submitted: for QP6 and QP7, detailing the practices' internal and external reflections respectively on secondary care referrals and for QP8, demonstrating what actions they took to improve referrals, what care pathways they followed and what changes in referral patterns have resulted.
• For QP indicators 9 and 10, ensure that the two reports to the PCT respectively detail the practice's internal and external meetings on emergency admissions.
• For QP11, ensure that practices submit a report detailing their engagement with the process of developing and following three new care pathways aiming to reduce emergency admissions.
In addition to the hints above, do think about looking for valid opportunities to exception report patients where this can be justified.
Every valid exception code, both persisting and expiring, is laid out in a two-page spreadsheet available online.2
Dr Simon Clay is a GP and QOF lead in Birmingham