CCC Ref. 2015/02 Date of Issue: 30th April 2015 Clinical Coding Communication Subject: Interpretation of NHS England Data Definitions for the Purposes of Clinical Classification Coding Introduction This notice formally advises NHS Wales clinical coding staff how to interpret specific terms relating to NHS England organisations and data definitions, which are referenced in National Coding Standards The national standards for the application of clinical classifications codes are produced and released by the Clinical Classifications Service (CCS), part of the Health and Social Care Information Centre (HSCIC) within NHS England. These standards are released as the: National Clinical Coding Standards ICD-10 4 th Edition (2014) reference manual National Clinical Coding Standards OPCS-4 reference manual, and its supplementary documents: o High Cost Drugs clinical coding standards and guidance o Chemotherapy Regimens clinical coding standards and guidance Coding Clinic Having been created within NHS England, these standards products contain terms which, while being similar to those used in NHS Wales have a different scope and meaning, and are not directly equivalent. This has led to queries from the Welsh clinical coding service as a number of standards rely on an understanding of the meaning of these terms in order for classifications codes to be correctly assigned. For example, some standards instruct that a specific code must only be assigned to a patient s record once per hospital provider spell. Though this term is used in both NHS Wales and NHS England, its meaning differs between the two organisations thus affecting when the code can be assigned. The following instruction is provided to clinical coders in Wales in order to clarify these issues. Clarification Statement The table below sets out those terms used within National Standards publications which are not used within NHS Wales, or have a differing meaning, and identifies the appropriate NHS Wales terminology into which to translate them to allow clinical coding staff to accurately interpret the given standards and assign the correct
classifications codes: NHS England 1 NHS Wales 2 Hospital Provider Spell Consultant Episode Trust Hospital Provider Spell Finished Consultant Episode Hospital Due to differences between the organisation and operation of the NHS in Wales and its counterpart in England, these terms are not direct equivalents of each other. The table above therefore allows clinical coding staff in NHS Wales to apply the national standards consistently, despite their different meanings, for the purposes of clinical classification coding only. The use of the above guidance will ensure consistency across Wales in the application of clinical classifications codes relying on the use of the listed terms. In addition, it will ensure that on an individual episode-by-episode basis the application of clinical classifications codes will be comparable with those assigned to episodes within organisations in NHS England. Appendix A provides explanations of the differences between the meanings of the NHS England and NHS Wales term Hospital Provider Spell listed above. Appendix B provides examples of the application of the above cross-mappings to specific coding scenarios. These have been chosen to highlight scenarios that clinical coding staff are encountering and are finding problematic due to the different terminology in use in NHS England and Wales. The majority of these are in relation to the assignment of codes for myocardial infarctions and atherosclerotic heart disease, as this area in particular requires clinical coding staff to assign codes based on the status of a patient within the Hospital Provider Spell in which they are treated. However, the requirement to assign codes based on the Hospital Provider Spell in which they occur can be found throughout ICD-10 and OPCS-4; therefore, further examples highlighting code assignments in some of these areas have also been provided for reference. Approval This has been approved out of committee by the Clinical Coding Advisory Group and ratified by the Welsh Information Standards Board (WISB) on the 18th March 2015 1 Links are to the NHS England Data Dictionary definition 2 Links are to the NHS Wales Data Dictionary definition CCC 2015/01 Page 2 of 12
Appendix A Note: In the following examples discharges and admissions are represented by: and transfers of care are represented by: A spell is represented by a coloured box and an episode within it by a white box. The following examples highlight and explain the differences between the NHS England Hospital Provider Spell and the NHS Wales Hospital Provider Spell, using a scenario of a single patient having 4 Finished Consultant Episodes (FCEs) across a number of hospital sites. NHS England Hospital Provider Spell Within NHS England, individual hospitals are part of an NHS Trust (the hospital provider ). A Trust may have any number of hospitals within it. Consecutive time spent by a patient within any number of hospitals that are a part of the same Trust is considered a single Hospital Provider Spell. Patients moving between hospitals as part of their treatment are NOT discharged from one hospital and re-admitted to the next (as is the case in Wales). Instead, in Wales the hospital provider is regarded as being an individual hospital site, rather than an equivalent of an English NHS Trust (i.e. a Health Board). Therefore, a patient may have one or more individual episodes of care making up a single Hospital Provider Spell. A Hospital Provider Spell ends each time a patient is discharged from the Trust (either home, or to be admitted to a different Trust). Example 1: CCC 2015/01 Page 3 of 12
Example 2: NHS Wales Hospital Provider Spell These are continuous periods of inpatient care within the same hospital. Unlike in NHS England, patients are not transferred between hospitals within the same organisation (Health Board). Rather they are discharged from the first (ending the Hospital Provider Spell) and readmitted to the next hospital (starting a new Hospital Provider Spell). Example 1: Example 2: CCC 2015/01 Page 4 of 12
Appendix B Example 1: MI and Atherosclerosis 1 Hospital Provider spell (1 LHB), Multiple FCEs The patient was admitted to Morriston Hospital with crushing chest pain and a diagnosis of an Acute MI was made. The patient was then transferred to a new consultant (creating a 2 nd episode in the same Hospital Provider Spell) for investigation of the coronary arteries. During the procedure the most severely atherosclerotic arteries were treated with 2 drug eluting stents under fluoroscopic control. The patient was then transferred back to the original consultant for continuing care of his MI creating a third episode of care in the same Hospital Provider Spell. CCC 2015/01 Page 5 of 12
Example 2: MI and Atherosclerosis 2 Hospital Provider Spells (1 LHB), multiple FCEs The patient was admitted to Singleton Hospital with crushing chest pain and a diagnosis of an Acute MI was made. The patient was discharged and immediately admitted to Morriston Hospital (which is part of the same Health Board), creating a second Hospital Provider Spell for investigation of the coronary arteries. During the procedure the most severely atherosclerotic arteries were treated with 2 drug eluting stents under fluoroscopic control. The patient was then transferred to a different consultant at the same hospital for ongoing treatment of his MI, creating a 2 nd episode in this second Hospital Provider Spell. CCC 2015/01 Page 6 of 12
Example 3: MI and Atherosclerosis 3 Hospital Provider Spells (2 LHBs), 1 FCE in each The patient was admitted to Prince Phillip Hospital with crushing chest pain and a diagnosis of an acute MI was made. The patient was discharged and immediately admitted to Morriston Hospital (which is in a different Health Board), creating a second Hospital Provider Spell, for investigation of their coronary arteries. During the procedure the most severely atherosclerotic arteries were treated with 2 drug eluting stents under fluoroscopic control. The patient was then discharged and immediately admitted back to the original hospital (and original Health Board) creating a third Hospital Provider Spell for ongoing treatment of the MI. CCC 2015/01 Page 7 of 12
Example 4: MI and Atherosclerosis 1 Hospital provider spell (1 LHB), 4 FCEs The patient was admitted to Morriston Hospital with crushing chest pain and a diagnosis of an acute MI was made. The patient was then transferred to a different consultant for investigation of their coronary arteries, creating a new consultant episode. During the coronary arteriography (which was carried out under fluoroscopic control) it was discovered that the patient had arteriosclerosis of multiple coronary arteries. Unfortunately the arteriosclerosis in the anterior descending coronary artery was too severe to be stented and the patient was booked for an urgent coronary artery bypass graft (CABG). The patient was then transferred back to the admitting consultant for continuing care, creating a third finished consultant episode. Two days later the patient was transferred to a cardiac surgeon creating a fourth finished consultant episode and was taken to theatre. The patient was placed on cardiopulmonary bypass and an anastomosis of mammary artery to left anterior descending coronary artery was performed. The patient recovered well and after a short stay in cardiac ITU was transferred back to the ward. The patient continued to recover and was discharged with a follow up appointment with the Cardiac Surgery Outpatient Department. CCC 2015/01 Page 8 of 12
Example 5: MI and Atherosclerosis 2 Hospital Provider Spells (1 LHB), Multiple FCEs The patient was admitted to Singleton Hospital with crushing chest pain and a diagnosis of an acute MI was made. The patient was then transferred to a different consultant for investigation of their coronary arteries, creating a new finished consultant episode. During the coronary arteriography (which was carried out under fluoroscopic control) it was discovered that the patient had arteriosclerosis of multiple coronary arteries. Unfortunately the arteriosclerosis in the anterior descending coronary artery was too severe to be stented and the patient was referred for an urgent CABG. The patient was then transferred back to the admitting consultant for continuing care creating a third consultant episode. Two days later the patient was discharged and then immediately admitted to Morriston Hospital (which is part of the same Health Board) as they had a cardiac surgery unit and the patient and was taken to theatre. The patient was placed on cardiopulmonary bypass and an anastomosis of mammary artery to left anterior descending coronary artery was performed. The patient recovered well and after a short stay in cardiac ITU was transferred back to the ward. The patient continued to recover and was discharged with a follow up appointment for Cardiac Surgery OPD. CCC 2015/01 Page 9 of 12
Example 6: Larvae Therapy 2 Hospital Provider Spells (1 LHB), multiple FCEs The patient was admitted to the Singleton Hospital under the care of an A&E consultant. They diagnosed a necrotic pressure ulcer to the left heel and began treatment with larvae therapy. The patient was then transferred to a General Medicine consultant creating a new episode of care in the same Hospital Provider Spell, in which the larvae therapy was continued. The patient was then discharged from Singleton and immediately admitted to Morriston Hospital (within the same Health Board) as it was nearer to their family home, thus creating a new Hospital Provider Spell. This Hospital Provider Spell had only one episode of care, during which the larvae therapy was continue. The patient was then discharged home under the care of the district nurse. CCC 2015/01 Page 10 of 12
Example 7: HCD use 2 Hospital Provider Spells (1 LHB), 1 FCE in each The patient was admitted with generalised arthritis to Morriston Hospital for treatment with the high cost drug Infliximab. The patient was then discharged from Morriston Hospital and immediately admitted to Prince Phillip Hospital in Hywel Dda UHB in order to continue treatment closer to their family home creating a new Hospital Provider Spell and episode of care. The treatment with Infliximab continued during this admission. Following treatment they were discharged home. CCC 2015/01 Page 11 of 12
Appendix C: CCCN Distribution List Julie Harris Yvette Lloyd- Ann Wathan Tracey Francis Christine Thomas Helen Thomas Chris Bird Tim Holt Cath Jones Paul Kelly Jean Edgeley Dafydd Ap Gwyn Richard Walker James Webb Alan Roderick Steve Thomson Lisa Cartwright Graham Crooks Katherine Harrison Shan Simkins Debbie Croft Anthony Tracey Sheila Davies Michelle Williams Ann Marie Stockdale Sarah Norman David Howells Janet Warlow Joy McRae Bethan Davies Sally Greenway David Hawes Richard Burdon Helen Dennis Raynor Kellett Mike Norton Abertawe Bro Morgannwg University LHB Abertawe Bro Morgannwg University LHB Abertawe Bro Morgannwg University LHB Abertawe Bro Morgannwg University LHB Abertawe Bro Morgannwg University LHB Abertawe Bro Morgannwg University LHB Aneurin Bevan University LHB Aneurin Bevan University LHB Aneurin Bevan University LHB Betsi Cadwaladr University LHB Betsi Cadwaladr University LHB Betsi Cadwaladr University LHB Betsi Cadwaladr University LHB Cardiff &Vale University LHB Cardiff &Vale University LHB Cardiff &Vale University LHB Cwm Taf University LHB Cwm Taf University LHB Hywel Dda LHB Hywel Dda LHB Hywel Dda LHB Hywel Dda LHB Powys Teaching LHB Powys Teaching LHB Velindre NHS Trust Velindre NHS Trust Velindre NHS Trust WCISU WCISU WCISU Welsh Government NWIS NWIS NWIS 3M 3M CCC 2015/01 Page 12 of 12