Dr Simon Clay provides a guide to this complex area of QOF coding – including advice on what happens if a patient recovers from depression before the end of the QOF year.
The rules underpinning the depression ruleset continue to be gradually altered and made more complex, but here is a guide to maximise your points.
For DEP2, (new depression needing a PHQ-9 severity assessment), the time window for patients being included in this group now extends back 15 months from the reference date (1 April 2011) instead of only 12 months.
So patients from January to March 2010 will be in the depression register count at end of this QOF year. In previous years, they wouldn’t have been included.
Note that since last year, we also have only 28 days to do the assessment, not ‘a month’. However, completed PHQ-9’s count only if done in 12 months before the reference date.
This is to prevent us getting paid twice in two consecutive QOF years for depression assessments done in the first three months of the calendar year.
In consequence, depression diagnosed from January to March 2010 with an assessment done between January and March 2010 and within the 28 day window will ‘score’ in the QOF year 2009-2010, but will be ignored in this QOF year.
Diagnoses for January to March with an assessment not done within 28 days will count against the practice, either in one year or the next, but not both, depending on when the depression was diagnosed.
Depression diagnosed in March 2010 with assessment done in April and within 28 days will count for the practice this QOF year.
DEP 3 indicator
DEP3 requires that a second assessment is done five to 12 weeks after the first (not five to 12 weeks after initial diagnosis being added.)
From January to March each year there is no penalty if the second depression assessment is not completed by the reference date (but it will count against you the following year if it is not done!).
Can you score DEP3 if the first assessment wasn’t done, or if it was done, but too late? Since Version 16.0 of the rules, the following holds.
If a first depression assessment (PHQ-9) is not done at all, then the patient will not score DEP2, but to avoid penalising the practice in two separate indicators for one error, the patient is removed from the denominator for DEP3 and hence does not bring the practice score for DEP3 down due to not having had any PHQ-9’s completed.
However, if the PHQ-9 is completed on the patient, but too late (more than 28 days after the date of the diagnosis), then this exemption does not apply and the patient is included in the denominator for DEP3.
Unfortunately, since one of the criteria for scoring DEP3 is that the first assessment was done on time, the patient automatically ‘fails’ DEP3!
The practical consequence of this is that if you don’t get an initial PHQ-9 done within the correct time window, its best, in QOF terms, not to do one at all, or at least to not code it, as it paradoxically penalises you for DEP3, which you can then never score for that particular patient.
It’s clearly rather unfair that this is how the logic has been written and I suspect that this is not how it was intended.
A final trick
Many practices have struggled with (particularly) DEP3 in the first year – not helped by the Department of Health only informing us of the changes to the rules unforgivably late.
So, there is one trick I recommend to you, which may mitigate the lost thousands of pounds practices may potentially lose.
One of the criteria for being included in the depression denominator at all for DEP2 and DEP3 is that the patient’s depression has not resolved by the reference date.
If a patient does recover from their depression before the end of the QOF year and therefore has a 212S (depression resolved) code added to their record, they are removed from both the DEP2 and DEP3 denominator groups.
This applies to all those patients who were diagnosed with depression from the 1 January 2010, including ones that you ‘missed’ for either their first or their second PHQ-9 questionnaire.
So if those patients who recover have that read code added – which is a recognised QOF exception code – then any indicators they were ‘failing’ will cease to count against you, because the patient will no longer be listed in the depression register.
This therefore has the effect that the patients on whom you did score the questionnaires will now make up a bigger proportion of your target group – improving your scores.
So, if you have patients who have ‘failed’ DEP2 or DEP3, or both and they happen to have got better by 31st March (e.g. a comment in the notes that they’ve recovered, or they’ve stopped needing repeat scripts for anti-depressants or a phone call from interested clinician to see how they are reveals that they’re better) then you might feel able to add 212S (depression resolved).
This exercise can be undertaken in March next year, if you’re struggling to achieve a big enough proportion of your depression register of patients scoring DEP2 and DEP3.
N.B. This article is based on the December 2009 version 16.0 rulesets.
Dr Simon Clay is a GP in Erdington, Birmingham
Depression coding More on QOF coding
For DEP3, two separate criteria need to be fulfilled:
1) DEPAS needs to be present (first depression assessment) and added within 28 days of the depression code going on. If it was done, but outside that valid window, the patient automatically fails DEP3 as well
2) DEPAS2 needs to be present using another PHQ-9 assessment or depression severity questionnaire. This should be added between five and 12 weeks after the first assessment
But because of criterion 1) adding a PHQ-9 assessment out of the required time window automatically causes the patient to miss out on DEP3 too.
Also, do not forget to note if patients have recovered from their depression or stopped needing repeat scripts, as this could improve your QOF scores.