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Last-minute QOF tips: Exception coding, 2012-13

Dr Simon Clay covers exception coding in the QOF business rules 2012-3, to help practices avoid missing out on valuable points

The exception codes are, in my opinion, a helpful way of improving your QOF scores without unnecessarily over-treating patients.

Expiring and persisting codes

Exception codes are divided into two groups: ‘expiring’ ones, which last for 15 months only in most cases, and ‘persisting’ ones, which as the name suggests are added once, and which permanently exempt the patient from the respective indicator. The latter are better to use, if appropriate, for obvious reasons.

There are an ever-increasing list of options for these codes – now numbering 313 in total: 187 expiring and 126 persisting. A summary sheet I produce (see below) collates these all on a double sheet of A4, for easy reference in surgery.

Sometimes you have a choice of codes: a patient complains of vivid dreams and constant fatigue on beta blocker treatment. You could add ‘Adverse reaction to beta blocker’ (U60B7) or ‘Beta blocker not tolerated’ (8I73). Since the first code is a persisting code (and so once added, will permanently exempt the patient from CHD 10 and 14) this is the one to choose if clinically appropriate.

Adding an exception code to a patient’s record removes the patient from one or more denominator groups of QOF indicators, but doesn’t add the patient to the numerator. So an elderly patient, already taking four antihypertensives, for whom you or the patient feel that further medication is not clinically appropriate, can have ‘Patient on maximum tolerated antihypertensive therapy’ (8BL0) added and the patient’s BP reading of 150/91 will cease to count against you.

Exception codes don’t penalise you

Something that many GPs don’t realise is that adding an exception code never penalises a practice. If, say, you see a patient with COPD who is persistently unable to perform spirometry, you add 33720 (‘Unable to perform spirometry’). Later that year their condition improves and a practice nurse manages to get the patient to have the test. The COPD ruleset checks first to see if the spirometry Read code is present. If it is not, then (and only then) does the ruleset look for an exception code to exempt the patient from spirometry. This is the case for every QOF indicator.  So adding a code can only ever help and never hinder. 

There are four handy codes indicating ‘Maximum tolerated treatment’:

  1. 8BL0 ‘Patient on maximum tolerated hypertension treatment’
  2. 8BL1 ‘Patient on maximum tolerated lipid-lowering treatment’
  3. 8BL2 ‘Patient on maximum tolerated therapy for diabetes’
  4. 8BL3 ‘Patient on maximum tolerated epileptic treatment’

Knowledge of these codes’ availability is useful, especially at this time of year when chasing points.

Top tips for exception coding:

  1. Ensure your clinicians understand persisting and expiring codes and consider distributing a summary sheet of them all - one for each person.
  2. Ensure every relevant practice member knows about the way the rulesets analyse the patient record to ensure clinicians are adding exception codes whenever they could reasonably do so.
  3. Highlight the four ‘maximal treatment’ codes to your doctors and ensure everyone is aware of their availability. These codes are very much under-used, in my experience.
  4. Write a report searching for every expiring code and run it annually each spring. You may then be able to ‘batch re-add’ expiring codes next QOF year, if still appropriate and reduce your denominators. We do this annually.

For information on Dr Clay’s QOF resources, go to http://tinyurl.com/dy9cea8

Dr Simon Clay is a GP in Erdington, Birmingham.

Readers' comments (6)

  • It's a good tip but.......

    I have moral problem with this. I care little for non evidenced QoF indicators but sometimes it can help to remind us about the change in recommended treatment. Like a patient who had an MI before the days of QoF and not on ACE, Bblockers or statin. If I permanently excempt the patient, it won't alert me if a newer medicine becomes available (remember the days Bblockers were big no no in CCF?). Or exempting patient after SE on simvastatin 40mg? Not advising alternate statin may not be illegal but I find it clinically and morally wrong.

    Isn't this money making exercise, rather than good quality care? Like the mid staffs.....

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  • Please use these exception codes with great care. Practices have lost QOF points in validation audits -particularly with use of 'patient on maximum tolerated epileptic treatment' .

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  • There is no moral dilemma. At the outset of nGMS - exceptions were intended to be financial exceptions - they have no relevance to clinical care.
    Many PCOs allow - maximum tolerated hypertension treatment - if on at least 3 AHDs, but this doesnt stop further clinical management or referral.

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  • Anon 11 February 2013 9:31pm

    Not sure about you, but I can't remember to check ALL of the best medical management for all the chronic diseases evey time a patient walks through the door. Clinically validated QoF points are useful reminders for this purpose. By permanatly excepting them, you deny the patients the opportunity to maximize their medical management, not just for this year but for the future as well (e.g. change in recommendations or development of newer drugs in the same group as it happened for Bblockers). You are doing this for your financial benefit, not for the patient (if it was latter, you could just put a drug sensitivity alert which will warn you when you come to prescribe the meds).

    I see that as a moral dilema personally......

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  • Reply from author:
    I take all those comments on board & agree entirely with the concerns raised. I always say at my "QOF talks" that I'm not here to defend the QOF rules but merely to explain them so that colleagues know what their options are.
    I agree entirely that there is potential for gaming here, but also believe that many practices are unfairly compromised by ignorance of their options. It's clearly ideal that practices apply the QOF rules in combination with a rigorous professional ethic of what is reasonable for their patients & when adding an exception code I always consider whether I could defend adding it to a visiting PCT team & always put some additional free text, justifying the code's use.

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  • I could never be sure for diabetic patients who are under hospital care and their HBA1C are above 8 or 9 or 10 etc - are we supposed to exempt those patients saying patient under hospital care or just take is on the chin and get penalised !!

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