Last-minute QOF tips: Heart failure (HF), 2012/3

Heart failure versus left ventricular dysfunction.

It is important, for QOF – purposes, to understand the difference between these two concepts. There are a set of codes that signify that a patient has heart failure (HF) under the QOF: These include (but are not confined to):

1. G58.. Heart failure
2. G580. Congestive heart failure
3. G581. Left ventricular failure
4. G58z. Heart failure NOS.

Then there are sub-set of these codes that define HF due to Left Ventricular Dysfunction (LVD). These include (but are not confined to): 

1. G581. Left ventricular failure
2. G5810 Acute left ventricular failure
3. 585f. Echocardiogram shows left ventricular systolic dysfunction
4. 585g. Echocardiogram shows left ventricular diastolic dysfunction

A number of codes then, define the patient as having HF, but do not qualify the patient as having HF due to LVD. These include:

1. G58.. Heart failure
2. G580. Congestive heart failure
3. G58z. Heart failure NOS.

The reason these codes are so important is that only patients with LVD need to be demonstrably prescribed an ACE or ARB (indicator HF3) and (if prescribed an ACE/ARB), also prescribed a Beta blocker (indicator HF4):

HF3: Pts with HF due to LVD need ACE inhibitor

HF4: Pts with HF due to LVD who are prescribed an ACE/ARB, also need to be prescribed a Beta blocker licenced for Heart failure

The consequence of this coding issue for LVD is that if for example you code an HF patient with a G58 code, “Heart failure” or with G580. “CCF”, then the patient does not have HF due to LVD in the QOF definition. Therefore they will not need ACEs/beta blockers for HF3/HF4 indicators.

This can either be an advantage (if your patient is 98 and you judge that clinically the risks outweigh the benefits.

It could also be a disadvantage, if this patient has been started on those drugs but you’re not getting the credit under the QOF analysis, or if you use prompting software to remind you of QOF requirements as such patients won’t get those prompts (because they don’t fulfil the definition of patients with HF due to LVD).

We had some patients coded with G58.. “Heart failure”.  Since this doesn’t imply LVD, their ACE and Beta blocker blocker treatment wasn’t counting for us. By adding an LVF code, if appropriate, the patient drops into the denominator and the numerator groups for HF3 and HF4.

By understanding this, you can choose codes which are an accurate representation of the clinical situation and also maximise patient care and practice profits too.

Licenced and unlicenced beta blockers

Only three beta blockers are valid for HF4: bisoprolol, carvedilol and nebivolol.

If a patient’s in the denominator for HF4 and you prescribe one of the above, you will score the points. If the patient is on a Beta blocker, but it’s an unlicenced one, the patient is completely removed from the denominator group (so they neither score for you, nor against you).

So, providing they’re also on an ACE/ARB, you can increase your scores for this indicator by changing a patient from an unlicenced Beta blocker (like Atenolol) to one that is licenced, (like bisoprolol for example), if you feel that’s appropriate.

Heart failure and echoscardiograms

HF2 requires you to refer patients with HF for an echocardiogram to confirm the diagnosis. This must be from three months before you add the diagnosis to 12 months after.

If you inherit a patient diagnosed with Heart failure but without evidence of an Echo, and apparently stable on treatment you might take the view that it’s inappropriate to retrospectively send them for an Echo – for example if they are very frail or severely demented.

In such a case, you might use the exception code 9hH0. Heart failure: Patient unsuitable. This would exempt the patient from any HF indicators he wasn’t scoring. Note, however, that it’s an expiring code and so would need re-adding the following year (see my previous article on exception coding).

Next, Dr Clay will be covering tips for coding stroke patients. For information on Dr Clay’s QOF resources, go to http://tinyurl.com/dy9cea8

Dr Simon Clay is a GP in Erdington, Birmingham.