Q&A

It is now possible to record a patient whose illness is in remission by entering one of the ‘in remission’ Read Codes. The patient will remain on the register but will be excluded from MH10-MH16 inclusive.

What constitutes ‘remission’ from serious mental illness can be found on page 21 of the Quality and Outcome Framework guidance book

The following codes are available:

If the therapeutic range is acceptable for the patient you should code the patient with the following code:

44W80  Lithium level therapeutic

This Read Code for both Version 2 and CTV 3 Read Codes

There are exception codes that can be added to the patient’s record but this will remove them from the indicator. The indicator is about prevention of secondary fragility fractures. Unfortunately the two patients on the register both refusing the bone sparing agents, would be removed and the indicator will again be zero for achievement. The patient needs to have had a prescription printed in the last six months of the QOF year (1st October onwards). If the patient has had a script since the 1^st October 2018 then you would have achieved the indicator.

There was a criteria change for the fragility fracture for the 75yrs and over  in 2014/15. The fragility fracture has to have occurred on or after 1st April 2014. See criteria below:

The register is split in to two, the 50-74 year olds and the 75 and over.

For the 50-74 years the patient would require

• A diagnosis at any point in their history of osteoporosis
• A DEXA scan at any point in their history confirming diagnosis
• A fragility fracture after the 1st April 2012.

For the 75yrs and over they only require

• A diagnosis at any point in their history of osteoporosis
• A fragility fracture after the 1st April 2014.

Most elderly people with a fracture in this age group are considered to be a fragility fractures so for the upper age I would do a fracture search and look at those the Hospital have started on the meds such as the calcium and vitamin supplements and discuss with the GP.

Your first step should be:

• Look at all the fractures that have happened after the 1st April 2012. If you have admin staff coding they may not have coded them correctly. The codes required are:

CTV3                                      Version 2

XaNSP                                   N331N

XaIIp                                      N331M

Look at those who have been started on a supplement by the hospital after a fracture.

Once you have ensured the code is correct for the patients fracture  you may need to look back in their history and check a QOF code has been used for the DEXA, as it is at any time in the patients history (If we turn the clock back ten years we used generic codes for diagnostic tests so you may find a DEXA recorded incorrectly)

A number of practices have also found the osteoporosis was not coded just the scan.

Looking at QOF the majority practices have managed to identify patients, the average range is between 1 – 14 patients. I spoke to a practice with 11000 patients yesterday and they have 2 patients. The hardest is ensuring the coding is correct for fractures. This is where the admin staff needs clinical input as not all fragility fractures are clear on the discharge letters.

A fragility fracture is when a fracture is sustained as a result of low trauma or lesser force such as a fall from a standing height. It includes vertebral fractures but usually not fractures of the skull or bones of the hand or feet. For example:

Slipping and breaking a hip is worth investigating depending on the surface / weight of person etc. A break from a very minor event such as turning an ankle, coughing and cracking a rib would almost certainly be included

The register is split in to two, the 50-74 year olds and the 75 and over.

For the 50-74 years the patient would require

• A diagnosis at any point in their history of osteoporosis
• A DEXA scan at any point in their history confirming diagnosis
• A fragility fracture after the 1st April 2012.

For the 75yrs and over they only require a fragility fracture after the 1st April 2012. Most elderly people with a fracture in this age group are considered to be a fragility fractures so for the upper age I would do a fracture search and look at those the Hospital have started on the meds such as the calcium and vitamin supplements and discuss with the GP.

Your first step should be:

• Look at all the fractures that have happened after the 1st April 2012. If you have admin staff coding they may not have coded them correctly. The codes required are:

CTV3                                      Version 2

XaNSP                                   N331N

XaIIp                                      N331M

• Look at those who have been started on a supplement by the hospital after a fracture.

• Once you have ensured the code is correct for the patients fracture  you may need to look back in their history and check a QOF code has been used for the DEXA, as it is at any time in the patients history (If we turn the clock back ten years we used generic codes for diagnostic tests so you may find a DEXA recorded incorrectly)
• A number of practices have also found the osteoporosis was not coded just the scan.

Looking at QOF the majority practices have managed to identify patients, the average range is between 1 – 14 patients. I spoke to a practice with 11000 patients yesterday and they have 2 patients. The hardest is ensuring the coding is correct for fractures. This is where the admin staff need clinical input as not all fragility fractures are clear on the discharge letters.

It is only looking at the newly diagnosed patients as it is about secondary prevention of further fractures.

You need to record each of the follow for the patient to appear on the register.

Diagnosis of Osteoporosis

DEXA Scan confirming the diagnosis

Fragility fracture

Overleaf are the QOF Clusters for each of the areas:

There are 6 points but for 3 you need to enter a ‘yes’ to having regular meeting to discuss the patients -MDT meeting etc. On CQRS if you are unsure how to manually enter the 4 ‘yes’ answers that are required across three areas: palliative, cytology and smoking. The CQRS/GPES help file can be found on this website under EHS.

Yes, the Business Rules were written using SNOMED codes, as discussed at the original training session there are Read codes that will sit within the QOF clusters that do not belong there. NHS Digital  Business Rules team are aware of this and are working hard to sort out the coding issues before the final release which will be used for end of year 18/19.

The issues so far area:

• Post-concussion syndrome – showing on the Dementia Register and showing the need for a Dementia care review. The SNOMED code it is picking up is 492615014, this will be removed from the cluster
• Ankylosing Spondylitis – showing on the Rheumatoid Arthritis register showing the registers indicator alerts. The SNOMED code it is picking up is 9631008, this will be removed from the cluster
• Fragility Fracture – showing in the Osteoporosis diagnosis cluster putting patients on the register due to having a fracture alone

Please let me know if you discover any other coding issues, we can share the information which will save staff unnecessary time investigating why

The exception codes for LVD were removed from the business rules when changes were made to the rules confirming Diagnosis of HF due to LVD a couple of years ago (see question below)

The exception codes are as follows:

XaMJ9   Exception reporting: heart failure quality indicators

XaMJB   Excepted from heart failure quality indicators: Informed dissent

XaMJA   Excepted from heart failure quality indicators: Patient unsuitable