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Five steps to maximise income through accurate coding

Dr Gavin Jamie advises on how to protect your practice income from confusion over Read coding – including a list of the new codes it’s vital you should know

A little over a decade ago, in my first year as a partner in general practice, we received various requests for information and audits from the PCG. As I had sold myself at interview as being ‘good with computers’, they were passed on to me to search for the data. Most of these were described as annual collections and so I spent a bit of time setting up systems to enable me to answer the request with very little effort the following year. Needless to say, when next year came, the requests were for completely different data.I stopped setting up reusable searches, moving to quick fixes every year.

With the advent of the QOF, things have become a little more stable but the technology has still lagged behind the contract changes. Generally the collection of data has become more automated, with QOF data being extracted to QMAS or its equivalents in Northern Ireland and Wales. There has been a lag each year, as QMAS data has not been available until the start of autumn. Things should be a bit quicker this year, with the replacement of QMAS by the new Care Quality Reporting Service (CQRS).  

But as we know, clinical practice tends to lag a little further behind the reminders on the computer screen. It takes a while for the new requirements to get fixed in the brains of most clinicians and become part of the normal pattern of consultations.

This article describes five steps to help your practice maximise its performance on the QOF, and old and new DESs, in cases where the codes are new, amended or have not yet been released.

1. Ignore reminders for ‘dead’ or out-of-date QOF indicators

QOF thresholds have been raised this year for many indicators and the time to achieve them has been reduced so there is little leeway in hitting the targets. This means there is not a moment to lose when getting the right codes into the computer.

Practice computer systems have become quick at delivering reminders of what is needed to fulfil the requirements of the QOF indicators. However, at the start of the year these can be out of date – either because the reminder relates to an old indicator or because it is still based on the old timescale for an ongoing indicator. GPs’ brains will also still be attuned to the previous year’s requirements. It can be difficult to know what you should be doing.

The good news is that as some of the indicators have been withdrawn, there are a few of those reminders that can now safely be ignored. Top of that list is the unpopular two-question depression screening that used to be required of any patient with either coronary heart disease or diabetes. That was about one patient in every 14 on a practice list, and an even greater proportion of those who regularly visit their GP.

You can also partly ignore the reminder to measure the BMI in patients with diabetes. In this case, it is still worth doing if the BMI is likely to be over 30 as the patient will then appear on the obesity register and push up prevalence there. The obesity register will count patients with a high BMI whether they have diabetes or not. Only measurements within the QOF year will put patients on this register.

2. Add new QOF codes to existing templates

Reminding yourself of the newer indicators is likely to be more difficult. There is only one new disease area, rheumatoid arthritis, so most patients will be coming in for review anyway. Adding the new codes to existing templates should act as a reminder, especially if backed up by some staff training to explain why these codes have appeared. Once on the template, codes can be entered along with the existing review. Making sure that patients with rheumatoid arthritis are correctly coded is worth doing early in the year as it will ensure that the correct reminders are triggered from the computer.

The codes for QOF are listed in the business rules (the instructions for extracting data from practices systems, which also list all of the codes and how they should be applied). These are written in technical language and allow no ambiguity. But although they are not deliberately obscure, neither are they an easy read.

One of their more user-friendly elements is the list of codes that are valid for each of the indicators. This appears in the first part of each document. These are simply lists of codes without the text which carries their meaning. There are no ‘tricks’ in these codes but there are sometimes areas where the codes are less obvious. Codes similar to the official ones may not count for technical reasons, so it is good to check the rules. For instance ‘depression’ is listed as a diagnosis and will put a patient on the depression register, whilst ‘depressed’ is counted as a symptom and so will not.

Below I’ve listed 23 new codes every practice should know for QOF and DES achievement this year.

Key codes from the rules

Erectile dysfunction (ED)

  • 1ABJ No ED problems
  • 1D1B Patient complains of ED
  • 66Av Patient should go on to have an assessment of his ED

Diabetes

  • 66At Dietary review in adults
  • 8Hj0 New diabetes diagnosis referral (generic)
  • 8Hj3 New diabetes diagnosis referral (DAFNE)
  • 8Hj4 New diabetes diagnosis referral (DESMOND)
  • 8Hj5 New diabetes diagnosis referral (XPERT)
  • 9OLM Patient declined any of these courses 

Depression

  • 38G5 Biopsychosocial assessment  on the day of diagnosis
  • 9H91 Diagnosis review 10-35 days later

Physical activity

  • 138a ‘Moderately active’ according to GPPAQ results
  • 138b ‘Active’ according to GPPAQ results
  • 138X ‘Inactive’ according to GPPAQ results
  • 138Y ‘Moderately inactive’ according to GPPAQ results
  • 9Oq3 If less than active and need a brief physical activity intervention 

COPD

  • 44yA0 Oxygen saturation measurement (other codes don’t count)

Dementia

  • Asking about memory problems – no code yet
  • 38C10 GPCOG
  • 918y Carer
  • 69DC Carer annual review (if patient declines 8IEP)

Rheumatoid arthritis

  • 38DB FRAX
  • 38GR QFracture 
  • 38DP QRisk2

In some cases there are a large number of possible codes and practices will need to pick one or two that they consider to be most suitable. Life is much simpler if only a relatively small formulary of codes is used in the practice.

3. Prepare for a new quarterly payment schedule

The business rules are updated a couple of times a year. The change in April contains the new indicators for the year and there is an update in the autumn which includes any new codes and sometimes fixes problems that have arisen. Codes are occasionally removed mid-year, although this tends to be more common in April. Autumn is largely about adding newly released Read codes.

In previous years, only the QOF data was automatically extracted from practices. This year, in England at least, some of the Directed Enhanced Services will also have their data automatically extracted from practice systems. Whilst this will mean less work for practices compiling and submitting their figures, it will become vital that the correct official codes are used. This is even more urgent than for QOF indicators as these services are to be paid quarterly, beginning with the July to October quarter.

4. Ensure your practice is well prepared to use the CQRS to report on DES achievement

There are currently no published business rules for DESs. Instead the Read codes are listed in the specifications. These are more helpfully presented than the QOF rules as they include the descriptive text alongside the code itself. These are currently less likely to be included in automatic reminders, although the structure of the DESs is similar to the structure of the QOF. In most instances, there is a denominator population who should receive a service and a numerator of patients who have actually received it. One of the crucial differences from the QOF is that there is no lower threshold: practices get paid from the first patient they treat under the DES.

Initially, for the first quarter ending in June, data will have to be manually entered by practices in the CQRS for some of the DESs. For the second quarter, this data will be automatically extracted by the General Practice Extraction Services (GPES) and sent on to the CQRS.

It is not only the new 2013 DESs that are affected by the new systems for processing patient data. Pre-existing DESs covering screening for alcohol problems in newly-registered patients and for delivering annual reviews to patients with learning disabilities will also be paid through the CQRS; the latter will now be paid quarterly. It is well worth checking that you are using recognised codes to record these. Both of the new vaccination DESs - rotavirus in children and shingles in over-70s - will also use the service as will the new dementia screening DES.

The DES for improving online access will also be paid through the CQRS system but there are no Read codes associated with this. The mechanisms for monitoring are not as explicitly stated and the data seems likely to be obtained directly from GP system suppliers.

The importance of the new CQRS means it will be vital to identify which staff in your practice need to become familiar with the system and to ensure you know how to access online training for them.

5. Develop a contingency plan for missing codes

It is one thing to learn new codes to enter - but some of the vital codes (for example in the dementia DES) do not even exist yet. Read codes are updated twice a year, in the spring and the autumn. After their release, they will be loaded onto practice systems by suppliers. As the DES specifications only appeared in April this year, it was too late to incorporate any new concepts into the spring release of new Read code and so the appropriate codes have not yet been specified and will not be available for use until at least October.

But the requirements of the DES will still apply from April so what should you do in the meantime?

Practices should not put off working towards the specifications. Waiting until the codes are released will reduce your achievement and payment. Practices are also being encouraged to prepare for the care.data extraction by the Information Centre later in the year, although some of the codes for patients to opt out are not currently available.

There are several ways to deal with this although none is particularly elegant. The simplest is to set up a local code on your practice computer with the same meaning as the official code. When the recognised code becomes available, you can change them over en masse. Unfortunately the use of local codes has been deprecated for the past few years and newer GP systems do not allow their creation because they make the electronic transfer of records between practices less reliable.

In a similar way to using local codes, computer system suppliers may provide codes of their own which are not part of the formal Read code set. This has the advantage of promoting greater consistency between practices.

Another option is to use another Read code that already exists. Ideally this would have a roughly equivalent meaning, although if such a code existed it would likely already be available in the specification. One option would be to use a less specific term with clarification in free text although switching automatically to the official code will only be possible if that ‘vague’ code is not used for anything else.

Alternatively it is possible, although not recommended, to use a code with an entirely different meaning that is unlikely to be used. Pulse and other places periodically publish lists of bizarre Read codes that would be ideal for this purpose (e.g. U1304, ‘Drowning and submersion while in bath tub - occurring on street or highway’). The real meaning should be recorded in the attached free text.

The problem of records being transferred out of the practice is worse here than for local codes. This is a potentially misleading clinical record and for this reason is generally considered poor informatics practice. It is unfortunate that the withdrawal of local codes makes this necessary. These codes must be stripped out before the record of that patient transfers to a different practice; otherwise there is a risk your practice will become known for accidents involving road-going sanitaryware.

If you decide none of the above techniques is appropriate, some other distinctive marker is needed. Simply making a list of patients, either on paper or a computer file, is entirely feasible for a small number of patients. All that need be recorded is a list of dates and computer numbers. Codes can be manually entered when they become available. More complex systems are simply not needed where there are fewer than 30 or so patients.

In all of these cases do not forget to put in the proper codes later. This must be done by the end of March for QOF payments and by the end of the quarter for the DESs.

Dr Gavin Jamie is a GP in Swindon who runs the QOF Database website.

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