Dr Simon Clay continues his series of articles on QOF coding by looking at why some patients are still required to have a mental health review long after they have recovered.
Under QOF rules before April 2006, the only patients who were on the mental health register were deliberately put there by the active addition of one of two Read codes that defined the presence of a mental illness: 9H6 (on NSF mental health register) or 9H8 (on severe mental illness register)
Since December 2006 and in versions thereafter, the whole concept of a mental health register is abandoned in QOF. There is only a list of patients within the mental health ‘denominator group’.
Mental health denominator group
There are now two different ways by which patients may end up in this group:
1. The presence of a ‘psychosis’ Read code (as defined by the mental health ruleset) anywhere in the record and added at any time in the past
2. Having a script for lithium in the six months before each reference date (1 April each year)
The list of Read codes which will ‘trigger’ inclusion into the list of patients who need a mental health review annually under the QOF is as follows:
- E10..%, E110.%, E111.%, E1124, E1134
- E114. – E117z
- E11y.% (excluding E11y2)
- E11z., E11z0, E11zz, E12..%,
- E13..% (excluding E135.)
- E2122, Eu2..%
- Eu30.%, Eu31.%
- Eu323, Eu333
The presence of any of these codes, added at any time in the patient’s clinical record – yes, even 30 years ago – now classifies the patient as being in the list of psychotic patients as far as the QOF is concerned.
Depression Read codes
The depression Read codes are roughly divided into a neurotic depression chapter and a psychotic depression chapter.
In the QOF rules as formulated in April 2006, if GPs have previously added any depression read codes that come from the psychotic depression chapter, they were often accidentally defined as ‘psychotic’ under the QOF rules and would therefore need a mental health care plan and mental health review etc.
The rule changes introduced in version 9.0 (December 2006) and continued subsequently resolve most of this complexity by removing many of the depression codes from the trigger list of psychosis codes under mental health that previously forced the patient into the mental health group as well.
There are now only nine depression codes that also put the patient into the mental health group as well. Luckily these all actually look like psychosis codes so it’s unlikely GP’s will use them accidentally. They are as follows:
- E1124 (single episode major depression with psychosis)
- E1134 (recurrent major depress’ with psychosis)
- E130 (psychotic reactive depression)
- Eu204 [X] (post-schizophrenic depression)
- Eu251 [X] (schizophrenic psychotic depression)
- Eu323 [X] (single episode of psychotic depression)
- Eu333 [X] (recurrent psychotic depression)
- Eu328 : [X] (major depression, severe with psychotic symptoms)
- Eu333 [X] (endogenous depression + psychotic symptoms)
Once a psychosis code is added to the record, there is no easy way to remove the patient from the psychosis register under the mental health disease category.
The Read code 9H7, (removed from mental illness register) originally introduced for this purpose, no longer works under the new rules.
‘Acceptable’ codes (triggering only a ‘depression’ diagnosis under QOF), include:
- E135 (agitated depression)
- Eu32z (reactive depression)
- E2003 (anxiety with depression)
- E2B.. (depressive disorder)
- E112 (agitated or endogenous depression)
- Eu320 / Eu321 / Eu322 (mild/moderate/severe depression)
The following ‘sadness’ codes are neither depression nor mental psychosis codes:
- 13Hc (bereavement)
- E2900 (bereavement reaction)
- Any chapter one ‘symptom’ codes such as 1BT.. (depressed mood)
What you should do with a patient who has long since recovered
Each practice may have a number of patients who have codes on their records which define the patient as psychotic.
If the patient has long since recovered and is well, it may not be appropriate to call the patient up for an annual mental health review and to write a joint care plan!
Such patients had not usually had 9H6 or 8 on their records before April 2006 and were therefore not in the mental health register previously, but would be now, due to the rule changes including any patient with any psychosis code, added ever.
Such codes included:
- E110 (single episode of mania)
- Eu30 (manic episode)
- Eu30z (manic episode unspecified)
Some patients with records containing these codes will have no active psychotic problem and don’t need annual mental health reviews and care plans. Of course, some patients will have an active psychotic problem.
A clinician is probably the only one who can differentiate these two groups, (though evidence of active antipsychotic medication being prescribed might be used as a screening tool perhaps?)
Having derived a list of patients that should not be in the list, you need to identify the code that’s putting them in there (remembering that they may have more than one code triggering insertion).
Again, as the rules stand, there is no code that may be added which would permanently except a patient with these codes from the mental health denominator group. The options on how to deal with these patients seem to be threefold:
1. See the patient, either opportunistically or by calling them in, and do a mental health review, irrespective of the clinical need
2. Add the expiring exception code 9h91 (mental health: patient unsuitable) to the patient’s record: patient stays in mental health denominator group for prevalence purposes, but exception code needs adding again next year unless the QOF rules are altered in the interim
3. Change the old psychosis code to a code from the Read code chapter 146 (history of…): These include 1464 (H/O schizophrenia); 146D (H/O manic depression) and 146H (H/O psychosis). The patient is permanently removed from the mental health register unless another psychosis code added subsequently. This avoids the technical obligation of having to do a mental health care plan on this well patient. Adding some free text to explain why the code was changed might also be advisable.
Dr Simon Clay is a GP in Erdington, Birmingham
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