Technical tips on
Optimising your QOF scores
With the end of the 2006/7 QOF year upon us, Dr Simon Clay suggests some last-minute ways to maximise your earnings
In April 2006, the Department of Health gave us nine new QOF clinical areas to work on. The rules underpinning some of the diseases and the release of 21 new rule sets in December 2006 make it difficult for GPs and practice managers to get to grips with the changes, particularly since the first sets of rules were only released in July 2006.
Below I cover some of the areas where extra knowledge may allow you to increase your QOF point scores.
Because of complexities in the QOF rules, not all depression codes added this year will count. Also, there is a risk that some depression severity questionnaires such as PHQ-9 will be missed by the software.
Any depression code added after
1 April 2006, followed by a PHQ-9 within a month, may not count if the patient has had a previous depression code. This is because the QOF rules only look at the first diagnosis of depression and ignore subsequent depression codes, unless the new depression code has an episode code of 'first' or 'new'.
The solution is to retrospectively add an episode code of 'new' for all new depression diagnoses since April 2006.
Look for any entries of E204 'neurotic (reactive) depression'. This is not a valid depression code for QOF, so won't count. Add another valid code like E2B 'Depressive disorder' to include the patient. Make the date the same as the E204 code.
The date the PHQ-9 was added must be the same day or within a month after the diagnosis was added, not before. Practices may want to review the dates of the depression codes and their respective PHQ-9s to ensure their dates fulfil this requirement.
One option is to avoid coding the patient as depressed at all until the PHQ-9 is returned. Use a non-triggering Read code like 1BT 'low mood'. Then add a proper depression code and PHQ-9 code once the questionnaire is handed back.
However, if this method is adopted, ensure that all patients with a PHQ-9 score
consistent with depression have had a depression code added. It is all too easy to leave the Citalopram linked to 'low mood'. The PHQ-9 then counts for nothing.
All practices will have diagnosed patients as depressed in the early months of this QOF year, before they realised the severity questionnaires were required. This leaves some patients diagnosed and treated but without evidence of a PHQ-9 result.
Patients whose depression has resolved and are apparently well, for example no longer taking medication for depression, may be eligible to have the Read code 212S added – 'depression resolved'. These patients are then removed from the depression register, whether or not they completed a PHQ-9 questionnaire at the time. Coverage for DEP2 may increase.
A useful task is to design a report, looking for all patients with PHQ-9 codes added since 1 April 2006, and then compare this list with the smaller list of patients you know are 'counting' for you under DEP2.
In the remaining list of patients, some will be those whom it was decided had no significant depression, but there will almost certainly be patients who should count for the practice but are not doing so.
MH7 is another area where proactive practices can gain points.
A patient who does not attend a scheduled mental health review must be followed up. Previously, to score the points for the indicator, a review had to be actually done. This is no longer so. All that is required is to note they did not attend and follow it up, in a way not clearly specified in the guidance.
So those practices not scoring MH7 at present should mailshot some patients still needing a review and then watch weekly to see if any do not attend. If they do, contact them by phone or visit them – thus following them up, and add the two relevant codes 9N4t and 8HB8. A single patient with these two codes will score the practice 3 points, and, done now, will count next year too.
COPD points may be increased. There is no specific code to exempt patients from the annual FEV1 test. Yet many of these patients are too frail or demented to do the test.
Towards the end of the year, your only
option therefore may be to exception report them using the global exception code 9h51 'COPD – patient unsuitable' and add some explanatory free text for the PCT.
If you are using this code, ensure its date is changed to before 1 January or it will exempt the patient from a flu vaccine next year, which may disadvantage the patient. Also remember there is a specific exception code for spirometry – 8I6L – so use this where appropriate.
The permitted diabetes codes were slashed in the new QOF rules in the summer. C10E or C10F chapters are the only two permitted to trigger inclusion in the diabetes register.
Some practices may have diabetes patients coded with other codes. The QOF software will not pick these up – reducing the practice's prevalence figures and possibly disenfranchising the patient from interventions based on reports run to pick up diabetes patients.
Run reports looking for any C10 code added since 1 April 2006, but excluding those two chapters. These will be wrongly coded diabetes patients.
The AF rules also allow easy points loss. If you are missing points for AF2 – ECG on all new diagnoses of AF, check if an ECG was done but wasn't coded correctly. Only 3272 is a valid ECG code.
If the patient was diagnosed in hospital, an ECG must have been done. That counts towards points.
For asthma, don't forget that 3395 'peak flow' is no longer a valid code, but 339A 'PEF before bronchodilation' is.
Only the first ever cancer per patient counts for QOF, unless the latest cancer code has an episode code of 'new' added. So cancer reviews done on such patients may not be credited. Add a 'new' episode code to all cancers diagnosed this year to ensure they all count.
These suggestions may not get you to 1,000 points, but with luck will move you a little nearer to those happy heights.
Dr Simon Clay is a GP in Birmingham