Dr Simon Clay continues his series of articles on navigating the absurdities of QOF coding with advice on how to record smoking status and when it is best not to ask.
There have been a number of changes to the rules underpinning the assessment of smoking status in QOF, adding extra levels of complexity to the way they should be recorded. This article will look at these Rule sets and exception codes and will explain how they work in practice.
Firstly let’s look at the Ruleset looks at the smoking status of patients with one or more of eight qualifying diseases – CHD, CVA/TIA, asthma (if aged 20+ on Reference date), COPD, hypertension, diabetes (if aged 17+ on the Reference date), CKD (if aged 18+ on Reference date), and mental health disorders.
We are charged with recording the smoking status of all patients with any of these diseases every 15 months. (within 15 months of each ‘Reference date’ – 1 April, each QOF year).
However there are a few exceptions:
Never smokers over 26 years
Where the ‘never smoked’ code is added at any time from the patient’s 26th birthday and also on the same day or later than the date of the first qualifying diagnosis code: such patients never need smoking status adding again, presumably due to the assumption that someone who confirms ‘never smoker’ status after they’re 26 is unlikely to start.
If they are ex-smokers, with one or other of the following two criteria, then they are permanently exempted from being asked about their smoking status:
1) The last smoking status is ‘ex-smoker’ and was added in last 15 months before Ref date OR
2) a) the last Smoking code is Ex-Smok (ex-smoker), AND b) Ex-Smok1 (ex-smoker) code was also recorded between a year and a day and two years before the date of ‘Ex-Smok’, AND c) a further ‘ex-smoker’ code (Ex-Smok2) was recorded between two years and a day and three years before the date of ‘Ex-Smok’.
For ex-smokers, these criteria above are fulfilled, the authors of the rulesets have presumably decided that this person is probably a long term ex-smoker and so they permit this patient to be permanently exempted from further requirements to be asked about their smoking status.
You can see that the dates for the three ex-smoker codes all hinge on the most recent ex-smoker code and then look at two further previous time windows, each of which is in relation to this last ex-smoker code.
The date of the last ex-smoker code therefore becomes critical.
For example, say the patient was documented as being an ex-smoker on 25 Sept 2006 (Ex-Smok), also on 24 Sept 2005 (Ex-Smok1), also on 24 September 2004 (Ex-Smok2). The patient has not been asked about smoking status this QOF year, but because he fulfils the second set of criteria above, he not only scores for this QOF year, but as long as there are no further smoking or ex-smoker codes added, he’s permanently exempted.
A keen clinician now sees the patient on 30 November 2008 and decides to ask him his smoking status again. He records this as ex-smoker and the patient scores for the 2008-09 QOF year, (although he was actually scoring already). Now, the last ex-smoker code date is 30/11/08 (Ex-Smok) and the previous one (Ex-Smok1) is more than two years ago (26 Sept 2006). So, the following QOF year (2009-10) the patient will have to be asked again, or will fail the test.
So the moral is, if the patient is already scoring Smok3 due to 2) above, it’s best never to ask again.
What happens if a patient has had several ex-smoker codes added within the three year time window back from the ‘Ex-Smok’ date? Answer – that’s fine.
As long as there are three ex-smoker codes within the required time windows, further ex-smoker codes added before the critical most recent ex-smoker code don’t harm things at all.
Neither do never-smoked codes which seem to creep in occasionally. Neither do codes implying ‘current non-smoker’ such as 137L. For the purposes of QOF, 137L (current non-smoker) is an ex-smoker code.
However, if anyone is also documented as any sort of smoker during the dates between ‘Ex-Smok’ code and ‘Ex-Smok2′ code, then this mucks everything up and the patient can’t count.
There are two exception codes available for the Smoking ruleset, however it’s quite difficult to conceive of a situation where one could reasonably argue for their use, except in the unlikely scenario that a patient simply declines to give you their present smoking status.
These are listed in my spreadsheet of all exception codes at www.poplarssurgery.co.uk/upload/qof
The Records 23 rules
Records 23 now charges GPs with recording the smoking status of everyone from the QOF year during which they become 15 onwards, every 27 months.
However, again, there are variations and exceptions:
1. Never-smokers continue their exemption from further recording provided that the last smoking status is ‘never smoked’ AND the patient was aged 26 years and when recorded as a ‘never smoker’.
2. Patients aged 15-25 who are never-smokers need to have that status re-confirmed and recorded every 15 months, (not even every 27 months) in order to score Records 23.
3. As in the smoking Rulesets above, Patients aged 15+, whose last recorded smoking status at any age is ‘ex-smoker’, are exempted further documentation, provided that either:
a) Last smoking status is ‘ex-smoker’ and was added in last 15 months before Ref date OR
b) i) Last Smoking code is ‘Ex-Smok ‘ (ex-smoker) AND
ii) ‘Ex-Smok1′ (a further ex-smoker code) was recorded between a year and a day and two years before the date of ‘Ex-Smok’, AND
iii) A further ex-smoker code (Ex-Smok2) was recorded between two years and a day and three years before the date of ‘Ex-Smok’
Summary of the Records 23 Rules:
1. You don’t have to collect smoking status for anyone <15 next 1 April
2. If the patient is a current smoker, you only need to record that within 27 months of next April
3. If the patient is 26+ and you have recorded ‘never smoker’ after they reached 25, then you just need to record it once
4. If the patient is aged 15-25, and a ‘never smoker’ then you need to record smoking status (assuming that status continues) every 15 months
5. If the patient is an ex-smoker then you need to:
(a) have the ex-smoking status recorded within the last 15 months,
(b) have a record of ex-smoker status in THREE consecutive years in their history (see above for the gory details of the criteria to be achieved)
There are no exception codes for this, other than the exemption offered to all patients registered within three months before the Reference date and for those under age 15 at the reference date.
Two useful tricks
For both the Smoking Ruleset AND the Records 23 Ruleset, there are two tricks I would commend to you.
Firstly, say you ask a patient if they smoke and they say ‘Oh yes, I gave up in 1980′ (as some patients do). There’s therefore nothing to stop you adding three ex-smoker codes consecutively.
Leave one dated today, and change the date of the second to a year and a day before today. Change the date of the third to two years and a day before today. For example, say today is 24 October 2008. Add three codes dated 24 October 2008, 23 October 2007 and 23 October 2006.
These three records are all an honest account of what the situation was at each date, and you have just permanently exempted the patient from any further recording of their smoking status and will permanently score for that patient in QOF, as long as some keen clinician doesn’t add any more smoking data (see above).
Secondly, you may have patients with an ex-smoker code as their last smoking status code, who gave up several years ago and a keen clinician has added some free text documenting that fact – for example ‘they quit in 1982′ – but perhaps this ex-smoker code was added more than a year ago. If so, then these patients will probably not count for the smoking or Records 23 indicator at present.
We ran a report, looking for patients aged 15 plus with ‘ex-smoker’ as their last smoking status code, added before 1 April 2008, which had any free text added to the entry which might indicate a quit date some time before.
Codes we searched were: 1377 to 137B plus 137F, plus 137K and 137L, plus 137N and 137O and finally 137S and 137T. Most of these patients will not be count for us this QOF year, as they won’t have had three ex-smoker codes added with the correct time frames.
We then printed these out and looked at each one. We found over 200 patients.
Many of these had free text which allowed the addition of two additional ex-smoker codes, back dated as described above, so that the patient was made to count for us this year and also in every subsequent year. For the more organised or obsessive practices, this may be an idea worth looking at!.
These are the depths to which we have now sunk in our efforts to satisfy the absurdities of the QOF.
Dr Simon Clay is a GP in Erdington, Birmingham
Smoking status and the QOF More on QOF coding
This is part of a series of QOF coding tips from Dr Simon Clay. Read the other articles here.