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QOF coding tips: cancer patients

Dr Simon Clay looks at the rules for read codes for cancer reviews and what to do if your practice inherits a patient with a pre-existing diagnosis.

Dr Simon Clay looks at the rules for read codes for cancer reviews and what to do if your practice inherits a patient with a pre-existing diagnosis.

This article will look at the rules underpinning cancer Read codes and the review that is required. It will also discuss options when you ‘inherit' one or more patients with a pre-existing diagnosis of cancer that qualifies under QOF.

Patients with cancer

Under version 10.0 of the QOF onwards, the following rules apply to the analysis of patients with cancer and deciding whether or not their cancer review, or lack of it, counts either for the practice, or against it.

These rules have not changed since, and version 16.0 of the rules (QOF 2009-10, Dec 09) continues same rules as before.

For the purposes of these definitions, let's take a hypothetical 18 month period from 1 October 2009, to 1 April 2011 (the ‘reference' date).

1. In the ruleset analysis for the indicator Cancer 3 (whether a cancer review was done), all cancers diagnosed in the 18 months before the reference date are looked at, but only those cancers added in those 18 months, whose cancer reviews were done in the twelve months before the reference date count for the practice.

2. If a cancer was diagnosed from 2 October 2009 onwards and the review was not done by the end of that QOF year – i.e. by 31 March 2010 – the patient is exempted from the Ca3 indicator for 2009/10, because there was not a complete six month period available for the practice to get the review done, before the next reference date on 1 April 2010 .

3. If a cancer is diagnosed after 1 October 2009 and the review is never done at all, the patient is removed from the catchment denominator for Ca3 for that year 2009/10, (see 2. above), but will remain in the denominator group for Ca3 the following year 2010/11, when he/she will count against the practice, (being in the 18/12 window for the QOF year ending on the 1 April 2011)

4. If a patient diagnosed after 1 October 2009 does have a Ca review done in the following six months, and before the following April 2010, the practice will score on the Ca3 indicator in that year (2009/10), but not the following QOF year, so this patient's cancer review will neither count for the practice nor against the practice in the QOF year 2010 /11.

5. If a patient diagnosed after 1 October 2009 does not have a Ca review done before the following reference date on 1 April 2010, but does have one done within six months of the diagnosis being added, he will count in the following QOF year 2010/11.

So although it might be tempting to relax about patients whose cancers are diagnosed in the second half of the year, because they won't penalise the practice in that year, you should be aware that they can count for the practice if the review is done that year, even though they do not count against the practice that year, if the review is not done. They will however count against the practice the following year, if not done.

Thus any points potentially lost through cancer diagnoses in the first half of the year where the review is missed for some reason, may be mitigated by getting enough reviews done in patients whose cancers are added to the system after 1st October, provided that they are added before the following April.

A simple way of summarising this ridiculously complicated piece of logic, is to say that if every patient with a cancer has a cancer review added within 6 months of the diagnosis being added, the practice must score full points for Ca3!

Patients with a pre-existing diagnosis of cancer

There are a number of things to ensure when a patient with a qualifying cancer joins a new practice's list.

The first thing is to point out that non-melanoma skin cancers don't count, so SCC and BCC are irrelevant here.

The second thing to point out is that each reference date (1 April each year), the software only looks back at cancers diagnosed in the previous 18 months.

For example, a patient joins your list in May 2010. A breast cancer was added to the patient's record on September 4 2009 and no cancer review was done. Although you've missed the six month window of opportunity, by the next Reference date (1 April 2011) this cancer will be more than 18 months old and so this patient will not be in your denominator group.

You can ignore the Cancer R/V, for QOF purposes.

The third thing to point out is that the key date is the date the cancer was added to the patient's clinical record.

It may seem unfair, but the fact that they may have changed GP's in the interim since the cancer was diagnosed and added is entirely irrelevant and you do not get six months from the registration date with your practice.

The cancer review needs to be done within six months of the diagnosis date. Full stop.

If a patient joins your list with a cancer diagnosed less than six months previously, then clearly, the important thing is to notice that and get the cancer review (Ca R/V) done.

Realistically, the only way of optimising your chance of doing this is to prime all your clinicians, healthcare assistants and summarising staff as to the importance of spotting such patients at new patient checks or when being summarised, or consulted, and then alerting a GP if the window of opportunity is still there.

If the six month window has already passed then your options are as follows:

a) Review the written and computer notes from the last practice to see if there is any evidence that a Ca R/V WAS done but was not coded

b) Phone the previous practice, speak to the relevant previous GP and check verbally that a Ca R/V was not done

c) If neither of these options is possible, and you end up with at least 90% of your denominator group for Ca3 scoring cancer reviews by next March 31, then this one patient won't pull your points down at all, as the threshold for maximum points is 90%, so one out of every nine cancer patients ‘failing' will be enough to score full points.

d) In the last resort, ask the PCT if they would be prepared to manually alter the QMAS submission, on the basis that you had no power to get this patient's cancer review done in time. The PCT will take a view on this, but are under no obligation to comply, as they might argue that that's why the target is 90% of patients, not 100%.

There is no valid exception code that is permissible to remove such a patient from the denominator for Ca3, even though it seems unfair that a new practice – particularly small practices with only a few cancer patients - may be unfairly penalised by another practice's sloppy QOF coding, through no fault of the new practice.

The only exception codes relevant for cancer patients are 9h8 (cancer: exception reporting: cancer quality indicators); 9h81 (cancer: patient unsuitable) and 9h82 (cancer: informed dissent). But I think a PCT would take a dim view of a new practice using one of these codes to remove the patient from the denominator group in this situation & might regard it as fraudulent.

Dr Simon Clay is a GP in Erdington, Birmingham

Dr Simon Clay More on QOF coding

Click here for Dr Simon Clay's tips on ten common QOF coding errors that could be costing you cash.

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