The NHS Information Centre is England s central, authoritative source of health and social care information The Casemix Service designs and refines classifications that are used by the NHS in England to describe healthcare activity The NHS Information Centre www.ic.nhs.uk 0845 300 6016 enquiries@ic.nhs.uk The Casemix Service www.ic.nhs.uk/casemix Glossary of Terms www.ic.nhs.uk/jargon-buster Department of Health - Payment by Results www.dh.gov.uk/pbr NHS Connecting for Health www.cfh.nhs.uk
Contents Background 4 Coding 4 Grouping patient activity 4 The Reference Costs collection 5 Funding and the tariff 5 How does this apply to Pain Management? 5 What is the Clinician s role in coding? 6 What to do now? 6 Useful Websites 8 NHS Information Centre 8 Department of Health 8 Connecting for Health 8 Appendix 9 Cognitive Behavioural Therapy & Outpatients 9
Background Coding Coding of interventions: The NHS uses OPCS-4 (the Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (4 th revision)) to document the operations, procedures and interventions carried out on a patient during an episode of secondary health care in the NHS. The current version of this classification is OPCS-4.6 which was released in April 2011. Coding of diagnoses: The NHS uses ICD-10 (International Classification of Diseases 10 th Revision) for coding diagnoses, which is owned by the World Health Organisation (WHO) and is managed in England by NHS Connecting for Health (NHS CfH). NHS CfH expects to update the version of ICD-10 England uses in 2012. How coding happens: This coding of activity is done by trained clinical coders based in specific coding departments. They translate information in the patients notes into alphanumeric codes representing diagnoses and procedures that can then be entered onto the hospital s Patient Administration Systems (PAS). In some trusts, clinical or administrative staff may do their own coding for standard outpatient clinics as coding of outpatient activity has only been taken up in recent years and there are usually not enough trained clinical coders to code both inpatient and outpatient activity. Why does coding matter? The combinations of ICD-10 diagnostic code(s) and OPCS-4 intervention code(s) are used to describe episodes of care. For example a primary diagnosis of a fractured neck of femur together with a total hip replacement procedure provides a way of describing many episodes of patient care with the same key features. Using this approach, thousands of episodes can be grouped together with the expectation that resource consumption will be similar. Grouping patient activity Healthcare Resource Groups (HRGs) are standard groupings of clinically similar diagnoses or interventions which use common levels of healthcare resource and so should cost a similar amount. HRGs offer organisations the ability to understand their activity in terms of the types of patients they care for and the treatments they undertake. They enable the comparison of activity within and between different organisations and provide an opportunity to benchmark treatments and services. It also allows for monitoring of patient management changes over time. Just as diagnostic and intervention codes develop over time, HRG design is revised yearly to ensure activity is mapping to the most appropriate HRG and that new interventions are incorporated. The current HRG design is known as HRG4. 4
HRGs are used as consistent 'units of currency' to support standardised healthcare commissioning, costing and funding across the service. HRGs support the Payment by Results system in two ways: the Reference Costs collection and the National Tariff. The Reference Costs collection HRG4 has been in use for the Department of Health s (DH) Reference Cost exercise since April 2006 (for financial year 2006/7 onwards). This mandatory exercise requires each NHS Provider to group a full year s activity to its respective HRGs. This aggregated HRG activity is then costed (per HRG) within the NHS Provider s finance team. The results are then submitted to the DH by pre-determined deadlines, via a system called UNIFY2. The DH Reference Cost team then gathers all of the information (which comprises of HRG level data for each trust by specialty and admission method) and a national average unit cost for each HRG is calculated using the submitted data from each provider. Funding and the tariff HRG4 has been used for Payment by Results (PbR) funding since April 2009 (for financial year 2009/10 onwards). The tariff for 2009/10 was calculated using the data gathered from Reference Costs 2006/2007 exercise. The time lag between collecting costs and developing a tariff is required in order to adequately test the impact of changes to the funding structure. There are mandatory tariffs for most HRGs with some having different prices for elective and non elective admissions and outpatient attendances. These are very important distinctions when it comes to how much a PCT will be charged. This is to reflect the difference in resource consumption in these settings. Where a mandatory tariff is not set, prices are agreed locally. Payment is usually made per patient based on the HRG that they group to. How does this apply to Pain Management? Most OPCS-4 codes initially related to surgery and interventions that applied to admitted patients only and, therefore, those specialties that require stays in hospital tend to be more familiar with clinical coding. However, as surgery and intervention techniques advance, so the work moves to different settings (e.g. Daycase, Outpatients). The majority of activity carried out by Pain Management specialists is delivered in Outpatients. However, the focus for clinical coding in the NHS has been concentrated on admitted patients, because there are both time and resource implications in coding significant amounts of outpatient activity. Pain Management services need to understand if and how their data is coded and ensure that their activity is correctly recorded on PAS. The Expert Working Group (EWG) for Pain Management which is owned and managed by the NHS Information Centre and includes representatives from the British Pain Society and has 5
responsibility for the design and development of HRGs, have been examining the data currently reported by NHS organisations for their pain management clinical activity. By reviewing national patient activity, it appears that some Pain Management services are unaware that their activity could and should be captured in a more appropriate way. This could be due to a lack of awareness of the coding systems and the reasons why coding is important. This inaccuracy could lead to underreporting of the actual total costs submitted as part of the Reference Cost exercise and in turn lead to inaccurate tariffs. It is important that Pain Management Services record their activity appropriately so that it can be captured nationally and also reported to the Department of Health through the annual Reference Cost exercise. If all services report their activity correctly then reported reference costs and consequently the tariff will be more representative of the resources consumed in delivering Pain Management services. The EWG have worked closely with the DH PbR team to ensure appropriate tariffs are published but the long term solution is to encourage detailed and correct coding, which will provide more accurate reference costs, leading to more representative tariffs. This approach is also being introduced in other Specialties to good effect. What is the Clinician s role in coding? Ensuring that the patient s diagnosis is clearly documented in the notes Identifying co morbidity as this may attract a co morbidity tariff premium Accurate documentation of intervention performed Liaising with clinical coding department and providing clinical guidance to ensure that there is an understanding of intervention in order to ensure that the right OPCS codes are applied for interventions What to do now? Each Provider will have a Clinical Coding Manager. Find out who they are and ask them about the activity they are coding. The Clinical Coding Manager receives regular updates from NHS Connecting For Health on the revised OPCS codes and guidance on how and where these codes should be used and so will be able to explain more about the process of coding and what you may need to do in terms of patients notes to enable coders to find the information they need in order to code appropriately. For many Pain Management Services there will be a very small range of relevant codes and it may be possible to discuss the coding of this activity with the clinical coding staff to make best use of the available coding resources. Your Clinical Coding Manager and Information Manager should be able to explain more about HRGs and grouping of your patient activity and how the grouped data is used by your organisation. 6
Once you have an understanding of the coding and the HRGs, your Finance Department should help you identify what cost information is being submitted as part of the National Reference Costs collection for your activity. The activity levels and associated costs may not be what you believe you are doing and so this is a great opportunity to discuss how your activity and spend can be properly represented. It has been proven that the Reference Cost exercise benefits greatly by having clinical input to ensure that any anomalies are identified and rectified before your organisation s Reference Costs are submitted to the DH Reference Cost team. Your Finance colleagues will also have the results of previous years Reference Cost exercises, which are distributed each year by the DH Reference Cost team. These results, called the National Schedules of Reference Costs (NSRC), show national averages for the HRGs to compare against your organisation. As part of the results that are sent out, a useful tool for measuring your organisation s cost effectiveness is the Reference Cost Index (RCI). The RCI score shows how each organisation is fairing when compared to the national average score of 100. Therefore, if your score is less than 100, you can see the costs of providing your service are lower than the national average for the activity you reported. However, if your RCI score is greater than 100, you need to investigate why it appears to be costing more than the national average to provide your service. Your organisation s Finance Department should also be able to explain the income you receive from the national tariff for your activity and how the income is apportioned across departments. If you have any specific questions regarding HRGs, Casemix, clinical coding and this document in general please contact the lead for this HRG chapter at the NHS Information Centre, Kathryn Knight: Kathryn.knight@ic.nhs.uk 01132542432 You can also contact the joint chairs of the EWG below: Ola Olukoga ola.olukoga@ghnt.nhs.uk Catherine Maddock Catherine.Maddock@bnhft.nhs.uk 7
Useful Websites NHS Information Centre The NHS Information Centre is England's central, authoritative source of health and social care information for frontline decision makers. Our aim is to revolutionise the use of information to improve decision making, deliver better care and realise increased productivity. The Casemix Service designs and refines classifications that are used by the English NHS to describe healthcare activity. These classifications underpin PbR from costing through to payment, and support local commissioning and performance management. www.ic.nhs.uk/casemix Department of Health The Department of Health Reference Costs provide details of how, and on what, almost 51 billion of NHS expenditure was used in the 2009-10 financial year. As in previous years, the main purpose is to provide a basis for comparison within (and outside) the NHS between organisations, and down to the level of individual treatments NHS Reference Costs 2009/10 Publication: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidanc e/dh_123459 NHS Reference Costs 2010/11 Collection Guidance: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyand Guidance/DH_122803 Payment by Results arrangements for 2011/12: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidanc e/dh_124356 Connecting for Health One of Connecting for Health s services is the NHS Classification Service, which is the definitive source of clinical coding guidance and sets the national standards used by the NHS in coding clinical data. On this website you will find essential information on the classifications in use and how to use them effectively. http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding 8
Appendix Cognitive Behavioural Therapy & Outpatients We have taken Cognitive Behavioural Therapy (CBT) as an example of an area of Pain Management where it can be seen nationally that the patient activity and associated costs are not currently well documented. There are four treatment codes for CBT within the OPCS-4 classification (introduced in April 2009): X66.1 Cognitive behavioural therapy by unidisciplinary team Understood to be CBT delivered by one professional. If this member of staff is not a psychologist, it can only 1 be coded as CBT if there is a psychologist overseeing the delivery of this treatment. X66.2 Cognitive behavioural therapy by multidisciplinary team Understood to be CBT delivered by a multidisciplinary team. If this team does not include a psychologist, it can only 1 be coded as CBT if there is a psychologist overseeing the delivery of this treatment. X66.8 Other specified cognitive behavioural therapy X66.9 Unspecified cognitive behavioural therapy These codes exist to retain the structure of the OPCS-4 classification however as they are non-specific, it is not expected that they should be used. Data extracted from the National Hospital Episode Statistics (HES) data for 2009/10 shows the following levels of data recorded against each OPCS code and Treatment Function Code. It is important to note that diagnosis coding is not mandatory in an outpatient setting and is rarely recorded which is why the Treatment Function Code is important to use as a proxy for the patients treatment. A total of 6,452 outpatient attendances were coded nationally during the year, however only 5,901 were directly recorded under Pain Management. This is a believed to be a significant underestimate of the true extent of the work being carried out. 9
Treatment Function Code Dominant Procedure No. Finished Consultant Episodes 191 PAIN MANAGEMENT X66.1 2,319 191 PAIN MANAGEMENT X66.2 3,567 191 PAIN MANAGEMENT X66.9 15 656 CLINICAL PSYCHOLOGY X66.1 40 656 CLINICAL PSYCHOLOGY X66.2 25 713 PSYCHOTHERAPY X66.1 109 713 PSYCHOTHERAPY X66.2 98 OTHER X66.1 24 OTHER X66.2 16 OTHER X66.8 68 OTHER X66.9 171 Total 6,452 The majority of the Outpatient activity is recorded under Pain Management (191) or Psychotherapy (713) but there is also activity attributed to Upper Gastrointestinal Surgery (likely to be re-education for eating disorders) and General Surgery amongst others. Looking at the data in more detail the activity reported during 2009/10 was predominantly carried out in a small number of NHS providers. We are aware that a wide range of NHS providers are carrying out this activity, and so when assessed in more detail, the data reveals some Providers who are recording very little activity, even though we believe there to be CBT services provided. Whether this is due to limited coding resources to code patient activity fully or an unawareness of the ability to record their activity in this way, it supports our view of the paucity of data in this area. It is difficult to define CBT but as discussed in previous sections, if the correct information is provided in patient notes to the clinical coders, then they will select the correct OPCS code and CBT will be recorded on the patient record. Further support is available through the Pain Management Programmes Special Interest Group of the Pain Society: The British Pain Society Churchill House 35 Red lion Square London WC1R 4SG 0207 269 7840 painclinic@britishpainsociety.org 1 Decisions locally suggest that CBT is only coded if there is a psychologist overseeing the delivery of the treatment. However there is currently no national guidance on the use of X66.1 and X66.2. 10