CKD has not changed much for 2013-14 but a number of areas are often not optimally managed, potentially losing practices valuable points.
This article explains the workings of the CKD ruleset to help practices score well in this QOF area.
The CKD denominator
The CKD ruleset hinges on whether patients have CKD of sufficient severity to be further considered. (There are five gradations of CKD but only CKD3,4,or 5 are looked at by QOF).
To be in the denominator a patient should have an eGFR of 60 or less as their last recorded value. However, the rules don’t look at the value of the last eGFR; they look instead at the last code defining the patient’s degree of CKD and use that to determine whether the patient is in the ruleset denominator or not.
For example: a patient has a recorded eGFR of 50 and then has a Read code qualifying for CKD3 added (such as K053 : chronic kidney disease stage 3). Then the patient has U&Es done again and this time the recorded eGFR is 65.
Unless the practice adds a further Read code re-defining the CKD grade as CKD2, the patient will continue to be in the CKD ruleset denominator, despite the last eGFR suggesting that this might not be correct.
Valid CKD codes
The following are valid CKD codes:
- 1Z12. Chronic kidney disease stage 3
- 1Z13. Chronic kidney disease stage 4
- 1Z14. Chronic kidney disease stage 5
- 1Z15. Chronic kidney disease stage 3A (v12)
- 1Z16. Chronic kidney disease stage 3B (v12)
- 1Z1B. Chronic kidney disease stage 3 with proteinuria (v12)
- 1Z1C. Chronic kidney disease stage 3 without proteinuria (v12)
- 1Z1D. Chronic kidney disease stage 3A with proteinuria (v12)
- 1Z1E. Chronic kidney disease stage 3A without proteinuria (v12)
- 1Z1F. Chronic kidney disease stage 3B with proteinuria (v12)
- 1Z1G. Chronic kidney disease stage 3B without proteinuria (v12)
- 1Z1H. Chronic kidney disease stage 4 with proteinuria (v12)
- 1Z1J. Chronic kidney disease stage 4 without proteinuria (v12)
- 1Z1K. Chronic kidney disease stage 5 with proteinuria (v12)
- 1Z1L. Chronic kidney disease stage 5 without proteinuria (v12)
- K053 : Chronic kidney disease stage 3 (Ver 23.0 Oct 2012)
- K054 : Chronic kidney disease stage 4 (Ver 23.0 Oct 2012)
- K055 : Chronic kidney disease stage 5 (Ver 23.0 Oct 2012)
Severity sub-divisions remain, though are not enforced by the rules so sub-division into 3a and 3b is not required. CKD3a is defined as eGFR of 45-59ml/min and CKD3b as eGFR of 30-44 ml/min.
CKD2 requires us to get CKD patients’ BP down to 140/85. For the 2013-14 QOF year we need 81% of these patients to achieve this threshold to get full points for the indicator.
Since this is challenging, don’t forget to use exception coding when you or the patient decides that it is not reasonable to add even more drugs. A full list of the valid codes is available on my QOF disc (see below), but the one you are most likely to use is 8BL0: ‘Patient on maximum-tolerated antihypertensive therapy’.
CKD3 and -4
CKD3 requires us to treat some patients with an ACE inhibitor or ARB and CKD4 requires us to check the urine for ACR annually in order to identify those CKD patients with proteinuria or microalbuminuria.
CKD4 requires that all patients with CKD3 or worse need an albumin to creatinine ratio test (ACR) or a protein to creatinine ratio test (PCR) annually.
This annual obligation remains even if the patient has documented proteinuria or microalbuminuria already.
To record ACR or PCR (ACR is much preferred in renal circles and I understand that labs are supposed to be sorting out the logistics to offer this test) the codes are as follows:
- 46TC. urine albumin : creatinine ratio (ACR)
- 46TD. urine microalbumin : creatinine ratio
- 44lD. urine protein : creatinine ratio (PCR)
These need to be recorded every 12 months (April to April).
Definition of proteinuria
NICE suggests that an ACR of 30mg/mmol should be regarded as positive for proteinuria in either a patient with CKD or a diabetic patient (Blue book 2013, p128). This is equivalent to a PCR of 50 mg/mmol.
As far as I can tell, the only suggestion for a threshold for a diagnosis of significant microalbuminuria is the diabetic one of ≥ 2.5mg/mmol for men and ≥ 3.5 mg/mmol for women.
If any reader has better information than this please add a comment – the blue book is entirely unhelpful on this point.
Testing for proteinuria influences a practice’s score for CKD4 and also, to some extent, CKD3 (the requirement to start ACE inhibitors or ARBs).
If a patient’s urine is never checked for protein (to score CKD4), that patient is not even entered into the denominator for CKD3. This is good news financially but not good clinically as any software a practice is using to help remind them to consider ACE inhibitors will not give such a prompt in hypertensive CKD patients unless they have also been coded as being proteinuric.
Read codes for proteinuria
The following list are all QOF codes for CKD patients with proetinuria:
- R110 : [D]Proteinuria
- R1100 : [D]Albuminuria
- R1103 : [D]Microalbuminuria
- R110z : [D]Proteinuria NOS
- 1Z1B. (CKD stage 3 with proteinuria)
- 1Z1D. (CKD stage 3A with proteinuria)
- 1Z1F. (CKD stage 3B with proteinuria)
- 1Z1H. (CKD stage 4 with proteinuria)
- 1Z1K. (CKD stage 5 with proteinuria)
No time criteria are applied to any of the proteinuria codes. Any presence in the record will count.
Codes that were previously valid, but were removed in 2009 are:
- 4674 : Urine protein test = +
- 4675 : Urine protein test = ++
- 4676 : Urine protein test = +++
- 4677 : Urine protein test = ++++
ACE inhibitors and ARBs
Only those patients who have all three of the following need to be demonstrably on an ACE or ARB:
- a CKD code of CKD3 or worse
- a hypertension code
- a proteinuria code previously entered.
Quite why in CKD a diagnosis of hypertension is a requirement before CKD patients with proteinuria are required to be offered ACE inhibitors or ARBs I do not know.
The guideline QOF document states on p129: ‘ACE-I and ARBs are generally more effective than other anti-hypertensives in minimising deterioration in kidney function and this effect is most marked where there is significant proteinuria. Such treatment is both clinically and cost-effective.’
So I am not clear why the rules do not require us to treat proteinuric CKD patients with ACE inhibitors or ARBs until they have also developed hypertension as well.
Diabetics do not need the co-morbidity of hypertension to be offered ACE inhibitors in this situation. CKD patients do. This seems surprising.
Don’t forget that if a patient can’t take an ACE inhibitor you have to try an ARB or exception code them from both drug families before they are exempted from CKD3.
In summary, to avoid losing money in the QOF CKD area, practices have to do four things:
Ensure that patients with eGFRs of 60 or worse on repeat testing get labelled with a valid CKD code to increase your CKD prevalence.
Be prepared for free use of the ‘hypertension maximal treatment’ code when the BP is as low as you can reasonably get it.
Get the urine tests done and ensure that someone in the practice is acting on the results. The ACR result, whatever the number, will not make the patient proteinuric or microalbuminuric unless someone is adding the required codes if the result is bad enough to warrant it.
Ensure patients are offered ACE inhibitors or ARBs when required or are exception coded from them.
Dr Simon Clay is a GP in Erdington, Birmingham
For details of Dr Clay’s comprehensive QOF Resource disc go to tinyurl.com/qofdisc