Practices too often throw away money by making mistakes in claiming for QOF points. Here, Dr Simon Clay warns GPs on common errors
The QOF is becoming more complex and NICE is expected to make even more changes over the coming years. It’s easy to make mistakes in coding – and even small errors can lead to lost income.
But get your QOF coding right now and you will see a financial benefit at year end – and in some cases a benefit for your patients too.
1. Atrial fibrillation diagnosis
It is easy to fail to score for the AF2 indicator for getting an ECG on new cases of atrial fibrillation.
There is only one ECG code that is valid – 3272 (ECG: atrial fibrillation). All the other five valid codes are referral codes, for instance ‘refer to cardiologist’.
2. Measuring cardiovascular risk
The codes for the primary prevention of cardiovascular disease in new cases of hypertension are relatively new, and can be a source of confusion.
You may think that any code for the Framingham risk score would be suitable, but 3888 (Framingham CHD 10-year risk) and 388R (Framingham CHD 10-year adjusted risk) are not valid codes as they are not cardiovascular risk scores.
The two editions of QRISK (QRISK and QRISK2) are valid, as are the JBS CVD and the Framingham CVD 10-year risk scores (662 chapter, 38DF, 38DP and 38DR codes respectively).
3. Stroke treatment
You can code a stroke in three ways – G61 (infarction), G64 (bleed) or G66 (stroke unspecified).
Only the first group get put into the denominator group for Stroke 12 (patient needs anti-platelet or anticoagulant).
If the person inputting the QOF data at your practice uses G66 codes for any cerebral infarctions the aspirin prescriptions will not count for you.
Also, if you use prompting software to help you start useful drugs on such patients, the software will not prompt you to consider aspirin because there is no infarction code present to trigger it.
4. Maximum tolerated treatment
It’s easy to lose points in coding patients as on maximum tolerated treatment. There are four codes that can be used when there is a clinical reason for not stepping up treatment – for instance if you have an 80-year-old on four antihypertensives and you decide that, clinically, that’s sufficient.
The four codes are to be used in patients on lipid-lowering drugs (8BL1), antihypertensives (8BL0), with diabetes (8BL2) or epilepsy (8BL3). But it is important to realise that in the first three, readings should be made annually for total cholesterol, blood pressure and HbA1c.
Even though you’ve decided to add one of these maximum tolerated treatment codes, it still does not exempt the patient from having the reading done every year.
5. Heart failure treatment
There are two sets of codes that determine whether you will receive points under heart failure codes HF3 and HF4.
These codes relate to the obligation to offer ACE-inhibitors/angiotensin receptor blockers and ß-blockers respectively to patients with heart failure caused by left ventricular dysfunction.
There is one list of valid heart failure codes and another list (a sub-fraction of the first), which defines the patient as having heart failure owing to LVD. Only patients with a qualifying code from both lists are in the denominator for HF3 and HF4.
Ten codes from the G58 chapter are valid for heart failure, but only two of these, G581 (LVF) and G5810 (acute LVF), are also LVD codes. So if you code a patient with G58 (heart failure) or G580 (CCF) as G58z (heart failure NOS), that patient will not be in the denominator groups for ACE-inhibitors or ß-blockers, since none of these codes is valid as an LVD code.
Depending on the clinical situation, this may or not be felt to be advantageous, but if you don’t understand the coding, you may not be optimising clinical care or your QOF scores.
6. Lifestyle advice
This has been introduced for new patients with hypertension diagnosed from April 2009. They need an annual coding of having received lifestyle advice on exercise, alcohol, smoking and diet.
Although there are specific codes for these separately, the only two valid codes are 67H (lifestyle counselling) and 67H8 (lifestyle advice regarding hypertension).
Spirometry on COPD patients has to be done once only between three months before to 12 months after the diagnosis code. It must test reversibility, but some spirometry reversibility codes are disallowed.
For example, the whole of the 33G Read code chapter (temptingly titled ‘spirometry reversibility’) is not valid, but the less catchily titled 33H chapter (salbutamol reversibility) is valid, among others.
It is also important to know that repeating an FEV1 annually is required (for COPD10), but also that doing (and coding) a full spirometry is not allowed.
Illogically, a specific code for FEV1 is required – any one of the 16 permitted options listed in the ruleset. We use 339O (FEV in one second).
8. Exception coding
The exception codes divide into persisting and expiring codes.
Sometimes a code from either type would be valid, but choosing a persisting code rather than an expiring one will add to your workload.
Codes such as 8I73 (ß-blocker not tolerated) need repeating annually, but U60B7 (adverse reaction to ß-blocker) can be added once and forgotten about.
9. Mental health reviews
If may seem ridiculous, but you do need at least one mentally ill patient to fail to turn up for their annual review to score under MH7. Two codes are required, 9N4t (this patient did not attend an appointment for a mental health review) and 6A60 (mental health review follow-up).
In addition, the 6A60 code must be added on the same day or within two weeks after the 9N4t code date.
This area is fraught with potential errors, with the time limits on the assessments made under the DEP2 and DEP3 indicators changing recently. Click here to read my article on this.
Dr Simon Clay is a GP in Erdington, Birmingham
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