COPD has not changed much for 2013-14; this article covers the changes that have been made and highlights areas where you may be able to optimise scoring of points.
It is permissible for a patient to be in the asthma and the COPD disease groups simultaneously. This is explicitly stated on p96 of the blue book QOF guidance document. So if a patient with pre-existing asthma, perhaps with a history of smoking, seems to be developing symptoms consistent with COPD, spirometry is done and the patient fulfils the COPD criteria but also demonstrates reversibility, it is alright simply to add COPD to the patient’s record. Since most annually-required checks count for both diseases, this enables you to score twice for little extra work.
Spirometry coding requirements
Make sure your coders (including summarisers and respiratory practice nurses) know about the correct codes for documenting spirometry. These have changed over the years. This year there are only two codes which qualify a patient as having had spirometry:
- 745D4 Post bronchodilator spirometry
- 8HRC. Refer for spirometry
Only patients whose diagnosis was added after 1 April 2011 need to have had one of these two codes added. In addition, as has always been the case, the code needs to be added no earlier than three months before the COPD code was added and no later than 12 months after.
After the diagnosis COPD patients need an annual FEV1 check to assess deterioration. The valid code options for this number no fewer than 19. However, it is important to note that the two codes for spirometry, noted above, do not count. So although you would think doing a full spirometry (which includes FEV1 of course) should count, in fact it doesn’t. We use 339O. ‘forced expired volume in one second’.
COPD R/V requirements
Two separate components are still required to score COPD 3. These are the COPD review and the recording of the MRC dyspnoea score.
The review should consist of doing the MRC score, assessing inhaler technique if inhalers are used and the clinician should also be aware of the patient’s current lung function (so do the FEV1).
We then use 66YM (COPD R/V) to code the review. We add to this one of the valid MRC dyspnoea scores (173H to 173L.) as no doubt detailed within your clinical system.
COPD 5, the new oxygen saturation indicator
This year a new indicator has been added – COPD 5. We are to record the oxygen saturations of our COPD patients on air, if their MRC dyspnoea score is 3 or worse.
This is easily done using a finger pulse oximeter (now ridiculously cheap). I bought 10 and distributed them around my colleagues’ rooms and visit bags to capture the saturations of our housebound patients as they will be the ones with the more severe MRC scores. Since there are five points on offer for this indicator, I expect these to pay for themselves in a year.
It is important to ensure that the Read code you use to record the result (44YA0) is a numeric code in your clinical system. If it isn’t, and you add the result as free text, the code won’t count. You should be able to make it a numeric code if it isn’t at present.
The point of the test is that those patients with saturations below 92% on air should be considered for referral for oxygen therapy.
Exception coding for COPD
Throughout the QOF year there are going to be some patients with COPD who have such severe dementia that they can’t comply with an FEV1 test so add a valid exception code and remove them from your denominator group for FEV4.
You can do the same for FEV2 if they have not had spirometry and this works even if you add the exception code after the official window for getting the spirometry test done has closed. There are four valid options to exception code from spirometry and the same four codes also exempt the patient from the COPD4 indicator FEV1 requirement. These are all listed in my collated spreadsheet of exception codes signposted at the end of the article.
Other patients who might validly have such exception codes added to exempt from FEV1 and spirometry testing include some cancer patients where you feel it clinically inappropriate to do the testing.
Dr Simon Clay is a GP in Erdington, Birmingham
For details of Dr Clay’s comprehensive QOF Resource disc go to tinyurl.com/qofdisc