There always tends to be a rush towards the end of the financial year to tidy up the codes entered for the QOF. There is a natural tendency in busy practices to put off anything that can be seen to wait while there are more urgent priorities. Here, I provide some tips on where to focus your attention in your end-of-year QOF housekeeping.
1 Make your codes count twice
Fortunately, procrastination can actually be an advantage in the QOF – codes entered in January, February and March can count towards achievement in two QOF years. This can be a particular advantage with exception reporting – especially where only one set of letters is required.
You should send three invitations to patients in enough time to receive a response. I would suggest leaving an interval of a fortnight between each invite. These are relatively simple to code. The main exception Read codes for each area start with 9h, and non-response to letters is classified as informed dissent. True dissent – for example, by telephone – should be coded with the same codes.
These codes are expiring – they only last 15 months – and cover all of a single disease area. In a perfectly organised practice a patient with both diabetes and coronary heart disease would be invited for a single comprehensive review. If a patient declined or did not respond, then a separate code would be needed in each area.
2 Take care with diagnostic codes
One common mistake is failing to code secondary diagnoses. Many patients with type 2 diabetes, heart disease and stroke are treated for associated hypertension and should be coded as such (H3). Miscoding could reduce prevalence and the value of points. Certain Read codes are designated as diagnosis codes in the depression area – for instance, ‘depression’ is a diagnostic code, while ‘depressed’ is a symptom and is not counted towards the indicator.
The other area where diagnosis codes can be tricky is cancer. The prevalence is based on the number of cases of cancer diagnosed since April 2003. Old codes can be valuable as they carry no responsibility, but add value to your points.
Malignancy should be coded (carcinoma in situ does not count) and it is important to use a diagnostic code rather than a histological one. The valid codes all start with a ‘B’, but the histology codes start ‘BB’. To illustrate how similar these can look, BB5a is a histology code for renal adenoma and carcinoma while B4A0 is a valid diagnostic code for malignant neoplasm of the kidney.
In diabetes, the diagnostic codes are C10E and C10F for type 1 and type 2 respectively. Codes C108 and C109 are nearly synonymous with these and don’t count towards the register. Although they have been invalid for a couple of years, it can be all too easy for them to sneak back in.
Another area to watch out for are smoking codes. The code 137L for ‘current non-smoker’ no longer counts, but if the patient has been coded previously as
being a current or former smoker then an ‘ex-smoker’ code could be added alongside 137L.
3 Watch your timing
With all indicators looking for a specific value, such as the one for lithium, only the last measurement is assessed. The timescale for lithium is only four months and so patients should be called in as early as possible to make sure you have a counting measurement in the period. The same is true for most other measurements. Taking a blood pressure reading or blood test early allows changes to be made, and also allows for patients who were previously out of range to be retested.
The new dementia 3 (DEM3) indicator requires a battery of tests six months before or after the diagnosis of dementia. This can mean care is required when entering the diagnosis date. At our practice we do the blood tests before referral, so it can become quite easy for more than six months to pass by between blood tests and the formal secondary care diagnosis.
4 Keep up to date with mental health codes
In previous years patients who had a diagnosis of psychosis or bipolar disorder but who had recovered for some time had to be given an annual exception code if the various reviews were not required. That has changed this year for patients who have had five years without medication, symptoms or the involvement of secondary care services. The patient needs to be coded as being in remission – resolution codes do not apply. However, as long as the patient does not have a relapse, these are persisting exception codes – they do not need to be repeated annually.
5 Get your prevalence up
Exceptions can’t be much use on their own and records of achievement are needed too. I probably bore people by going on about the need to raise practice prevalence, but at least their boredom will be tempered by an increase in income! It is certainly worth running a few searches to ensure that all of your patients are coded correctly – searching against medication is useful.
Almost all patients taking antipsychotics should have some sort of mental health code and there are few indications for sulphonylureas other than diabetes.
6 Focus on small groups
There are several indicators – for instance, for palliative care and lithium prescriptions – where the number of patients may be quite small.
If no patients qualify for an area, you will not receive any points – missing the target for a single patient could have a large effect on your QOF score.
Palliative care can have few patients and requires regular work with meetings throughout the year. It sounds macabre, but it is essential there is a patient alive on your register at the end of March to ensure you get the points.
It is obviously not reasonable to start a patient on lithium just to get the points. The situation does sometimes arise that a lithium level outside of the standard range of 0.4-1.0mmol/l is advised after specialist assessment. The code 44W80 – ‘lithium level therapeutic’ – is valid and useful in these circumstances.
7 Watch out for exceptional exceptions
There are more specific exception codes for some indicators. These are generally in the form of maximum tolerated doses (these codes start 8BL) or patient dissent (starting 8I). The rules do not try to catch you out. Most codes that sound like they should be exceptions actually do work. Code 8I3Y (blood pressure measurement refused) is a valid exception code for blood pressure measurement.
While most of the codes last for 15 months, the exception codes for cervical cytology will last for a full five years. This year, however, two codes (9O8S and 9NiT) no longer count and you may have to go back up to five years and add the codes that still do count (6853, 685L, 8I6K, 9O8Q).
The most common exclusion from cervical cytology is having had a hysterectomy. Unfortunately, the structure of Read codes in this area is confusing. The code should be explicit that this has been a total hysterectomy – for instance, code 7E043, or 7E049 if there is also a bilateral salpingoophorectomy.
Some systems use synonyms for codes, which may be misleading. A supposed synonym of 7E045 might be ‘total abdominal hysterectomy’, but as the base code does not it does not count for the QOF. I would recommend removing this code entirely to avoid confusion.
Dr Gavin Jamie is a GP in Swindon, Wiltshire