Coding different types of stroke
It’s important to ensure your coders are coding stroke correctly. There are three types of stroke you can add:
– Bleeds (G61 Read code chapter)
– Ischaemic /Infarctions (G64 Read code chapter)
– ‘Unspecified’ (G66 Read code chapter)
Accurate choice of code is important because (with a couple of exceptions) only the second group (Cerebral Infarction) get assessed as to whether they’re on an anticoagulant or antiplatelet agent.
If a patient’s stroke is coded as ‘unspecified’ and you put them on aspirin because the CT showed an infarct, you’re not getting the QOF benefit of adding aspirin to their treatment.
Also, by coding as ‘Unspecified’ you may disenfranchise them from useful blood thinning interventions.
New patients joining your list
Try to ensure, by talking to staff who code patients, that patients moving to your practice list with a pre-existing stroke since 1 April 2008, in addition to having their stroke type coded correctly also have their CT findings added.
Sometimes such patients will have had imaging but not had it added to their records at your practice, so you would lose points as there is no code to score STROKE13 (‘Further Ix done’).
The best time to find and add this is when the record’s being summarised onto your system, at least until GP2GP is really working well across all systems.
‘Blood thinner’ coding for STROKE12
Non-haemorrhagic strokes and TIAs (but not Amaurosis Fugax patients) need to be demonstrably on a blood thinner. Four options are available:
– or any oral anticoagulant, including the three new ones like Rivaroxaban.
If the patient’s in the ‘catchment’ denominator group for a blood thinner, but they’re not on one, they don’t get removed from that denominator until you’ve exception coded them to all four of the drug family options – just adding ‘Aspirin not tolerated (8I70)’ won’t do it. You need four separate exception codes adding before it removes them.
Patients who are not referred for a CT scan
Sometimes we all have a patient at the end of life, often in a residential or nursing home, who develops signs consistent with a stroke. If you decide that clinically, it’s not viable or appropriate to scan them, for instance if they have severe dementia, seem too agitated to stay still, or they’re too ill, then don’t forget that there are exception codes that would exempt the patient from having a CT scan, such as 56F0 (‘CT declined’) or 9h21. (‘stroke: patient unsuitable’). Note that the latter is an expiring code.
Top tips for stroke coding:
- Get your strokes coded correctly – run a report of those coded ‘Unspecified’ and look for a CT scan record
- Ensure your clinicians know the criteria to successfully exempt a patient from blood thinners
- When deciding not to make an intervention, e.g. for CT scanning, or deciding against higher dose statins when cholesterol is not up to target, always consider whether exception coding that patient is possible and defensible.
For information on Dr Clay’s QOF resources, go to http://tinyurl.com/dy9cea8
Dr Simon Clay is a GP in Erdington, Birmingham.