"Suggested Read Code Lists for Templates, 6 new Enhanced Services, v0"
Suggested Read Code Lists for Templates: Enhanced Services 2008-09 Enclosed are some short lists of codes that practices may wish to include in their templates. The codes are related to payment and / or to quality / activity markers in Enhanced Services that were launched since April 2008. Contents: 1. Version control table 2. Introduction 3. Diabetes LES 4. COPD LES 5. Heart Failure LES 6. Alcohol LES 7. Sexual Health LES 8. Ethnicity LES 9. Ethnicity DES 10. Learning Disabilities LES 11. Care Homes LES 12. IUCDs 13. Minor Surgery 14. Child Protection LES 15. Prevalence Incentive Scheme a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 1 of 12. (1) Version Control Table Version Author Details of Changes Other Comments Number and Date V0.01 R Nicholls First Draft of Read Sent to J Duddle for comments on format. 18/11/2008 code lists, incorporating Needs the following checks (I Patel): selected codes from 1) All descriptions of codes in this match the code Adebayo Akande’s descriptions in the Read code database (or Explanation of ES EMIS LV if database not working) Indicators 2) All read codes listed in this document under an enhanced service are included somewhere in the latest version of the business rules or MIQUEST query set for that service (excluding Ethnicity DES) 3) The extra advice included next to codes / descriptions in this document (e.g. advice on Value prompts or required free text) corresponds to similar advice in ““ES Indicators READ Codes May 2008 v1.0.doc” 4) The numerator of every indicator in the ES Scorecard for the 6 LESs in this document (excluding Ethnicity DES) includes at least one code which is listed in this document. e.g.for the indicator “Blood Sugar 3y in high risk (including BMI>=30)”, the Business rules show that the numerator includes patients with code “44f”, which is in this document. 5) Any comments / suggested changes to wording Also needs brief check by RN. V0.02 I Patel Full checks complete. 18/11/2008 1 erroneous code Correction made. Issues highlighted to RN. V0.03 R Nicholls Issues raised by RN Now ready for circulation at ES Review Event, technical 26/11/2008 reviewed – no further checks complete. action, Correction accepted However, this is a draft work in progress. The following are required to move this forward: 1) Addition of read code categories required for templates as well as example codes and descriptions, in a table with 3 columns.... e.g. sexual health template Column 1(code category): a read code for diagnosis of chlamydia, Column 2 (Read code): Ayu4K, Column 3 (Read code description): [X]Chlamydial infection of genitourinary tract, unspecified 2) Ensure that example read codes tie in with the ones chosen in EMIS QOF templates 3) Review by PCT practice data quality facilitators 4) Ideally review by some practices / GPs before wider circulation a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 2 of 12. Version Author Details of Changes Other Comments Number and Date V0.04 R Nicholls Codes for 06/01/2009 recording First Language in Ethnicity DES – updated and typo corrected. V0.05 I.Patel ‘READ Codes READ Codes for the following combined in this document: 21/01/2009 Summary List for Learning Disabilities LES / Care Homes LES / IUCDs / Minor Surgery / Child Protection LES / Prevalence ES Part 2 Incentive Scheme v0.05.doc’ combined with this list. 14/01/2009 R.Nicholls Altered Blood & pressure codes to 23/01/2009 be compatible with EMIS LV system set up (as per M Clarke’s advice) a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 3 of 12. (2) Introduction: Suggested Read Code Lists for Templates for Enhanced Services Enclosed are some short lists of codes that practices may wish to include in their templates. The codes are related to payment and / or to quality / activity markers in Enhanced Services that were launched since April 2008. Where codes / clinical terms are marked with an asterisk (*) there are alternative codes with similar meanings that are also picked up by the Enhanced Services data collections. There are often many different codes which count towards the same targets in Enhanced Services. It is ultimately up to the practice to decide which codes are most appropriate clinically to include in their data entry templates, and which ones to add to add to each individual patient’s record. Practices have previously been provided with a full list of codes included in Enhanced Services Monitoring (see section 2 of “ES Indicators READ Codes May 2008 v1.0.doc”; Note that a new code has been included in the monitoring since that document was written - 9Oy0 – “Invitation to Diabetes Screening”) While every effort has been made to check these lists of Read codes, they cannot be guaranteed to be accurate or complete. This document is a draft work in progress, with some improvements planned for the future. In addition, we would welcome any comments or suggestions for further improvements to this document, or to any aspect of Enhanced Services Monitoring / other documentation re Enhanced Services, please contact EnhancedServices.Camden@nhs.net . a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 4 of 12. (3) LES For Identification of Diabetes: C10E Type 1 diabetes mellitus* C10F Type 2 diabetes mellitus* C11y2 Impaired Glucose Tolerance* C11y3 Impaired Fasting Glycaemia* 22K Body Mass Index* 2469 O/E – systolic blood pressure reading 246A O/E – diastolic blood pressure reading 44f, 44g Blood Glucose* 9Oy0 Invitation to Diabetes Screening (4) COPD LES: H3 COPD* 68M Spirometry Screening* 8I3b Spirometry Declined 9OOZ Stop Smoking Monitoring NOS (to be used for in-house COPD Smoking Assessments) 173H MRC Breathless Scale: grade 1 173I MRC Breathless Scale: grade 2 173J MRC Breathless Scale: grade 3 173K MRC Breathless Scale: grade 4 173L MRC Breathless Scale: grade 5 339S FEV1 as a percentage of predicted PLUS VALUE (0 to 100) 8A44 Pulse Oximetry Monitoring PLUS VALUE (0 to 100)* 65720 Pneumococcal Vaccination Given* 8I3Q Pneumococcal Vaccination Declined* 8I2E Pneumococcal Vaccination Contraindicated* (5) Heart Failure LES: G58 Heart Failure* 2469 O/E – systolic blood pressure reading 246A O/E – diastolic blood pressure reading 44J3, 44JF Creatinine codes* 65720 Pneumococcal Vaccination Given* 8I3Q Pneumococcal Vaccination Declined* 8I2E Pneumococcal Vaccination Contraindicated* 8I26 Beta blocker contraindicated* 8I36 Beta blocker therapy refused 8I62 Beta blocker not indicated 8I73 Beta blocker not tolerated 68B6 Heart Failure screen (To be used in patients at High Risk of Heart Failure who have been asked regarding symptoms of Heart Failure) 1J60 Suspected Heart Failure (To be used in patients at High Risk of Heart Failure with Symptoms Suggestive of Possible Heart Failure) 44AP Serum pro-BNP level 44AN Plasma pro-BNP level 33BD Echocardiogram requested* 56F1 Echocardiogram declined 58530 Echocardiogram normal* 585g Echocardiogram shows left ventricular diastolic dysfunction 585f Echocardiogram shows left ventricular systolic dysfunction 58531 Echocardiogram abnormal* a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 5 of 12. 5C20 Echocardiogram equivocal (6) Alcohol LES: 9k17 Audit C completed 136 Alcohol Consumption 8CAM Patient advised about alcohol (code for Brief Interventions) 9k11 Alcohol Consumption Counselling (code for Extended Brief Interventions) – Free text needs to be added to this code (see table below) 8BA8 Alcohol Detoxification (add “By Practice” in free text to this code when the Detoxification is carried out by the practice in accordance with Level 3 of the Alcohol LES) Free Text to add to code 9k11 for Extended Brief Interventions: Where and by Whom Extended Brief Intervention Precise Free Text to enter with code 9k11 Carried out: Referral and accepted to outside alcohol service By Outside Agency Delivery by in-house advisor from sensible drinking In House By Sensible Drinking Advisor service Delivery by competent practice staff member By Practice (7) Sexual Health LES: 9kF0 Sexual Health Enhanced Service Completed (add to ALL patients given care under the terms of the Sexual Health LES)* 4JQA. Gonorrhoea test positive* A98 Gonococcal infections* Ayu4K [X]Chlamydial infection of genitourinary tract, unspecified* AD10 Urogenital Trichomonas* A910 Primary genital syphilis* A97z Syphilis NOS* A541 Genital Herpes Simplex* A7881 Asymptomatic HIV infection A788 Acquired Immunodeficiency Syndrome (AIDS)* A788y HIV with other clinical findings* A703 Viral (serum) Hepatitis B* ZV02B [V]Hepatitis B carrier* A70z0 Hepatitis C* ZV02C [V]Hepatitis C carrier* 679S Health education - safe sex* 65X Contact tracing* 9Op0 HIV screening offered 8I3p HIV screening declined a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 6 of 12. (8) Ethnicity LES: 9i% (All codes beginning with 9i but not 9i itself) – 2001 census ethnic categories (9) Ethnicity DES (Language Codes): (The Ethnicity DES, launched in September 2008 by the Department of Health, includes a target related to coding of main spoken language) 13l% (one-three-small-el) (Any code beginning with “13l”) – Main Spoken Language codes 13u% (Any code beginning with “13u”, but not 13u itself!) – More Main Spoken Language codes 13w% (Any code beginning with “13w”, but not 13w itself!) – Yet More Main Spoken Language codes 13ZM Using British Sign Language 13ZP Using Makaton Sign Language Very rarely there will be no read code specifically for the patient’s main spoken language; in such a case the practice should enter the code 13l (one-three-small-el), “main spoken language” and add the patient’s language to this code in free text. (10) Learning Disabilities LES: 918e On learning disability register Body Mass Index: 22K Body Mass Index Smoking Status: 1371 Never smoked tobacco 137R Current smoker 137S Ex-Smoker Lifestyle Advice: 8CAL Smoking cessation advice 8CA4 Patient advised re diet 8CA5 Patient advised re exercise Medication Review: 8B3V Medication review done 8I3V Medication review declined Individual Health Action Plan: 9HB0 Learning disabilities health action plan declined 9HB1 Learning disabilities health action plan offered 9HB2 Learning disabilities health action plan reviewed 9HB4 Learning disabilities health action plan completed a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 7 of 12. (11) Care Homes Codes For Denoting that Patients are In Care Homes: 13FX Lives in care home 8CW Provision of GP intermediate care Blood Pressure: 2469 O/E – systolic blood pressure reading 246A O/E – diastolic blood pressure reading Medication Review: 8B3V Medication review done 8I3V Medication review declined Weight: 22A O/E – weight Influenza vaccination: 65E Influenza vaccination 9OX5 Influenza vaccination declined Pneumococcal vaccination: 65720 Pneumococcal vaccination given 8I3Q Pneumococcal vaccination declined Allergies: 1151 No known allergies U60% Various codes for Adverse reactions to medications SN58% Various codes for food allergies SN59% Various codes for venom / bite / sting allergies (12) IUCDs Contraception Advice: 611 General contraceptive advice 614F Emergency contraception advice (To record that patients have been offered advice on the range of contraceptive options available to them prior to fitting.) Chlamydia Screening: 4JK9 Endocervical chlamydia swab 9Oq0 Chlamydia test offered 8I3T Chlamydia screening declined Successful Fitting of IUCD / IUS: 6151 IUD fitted 6153 IUD re-fitted 61A2 IUD fitted for ‘morning after’ emergency contraception a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 8 of 12. 7E094 Introduction of Mirena coil Unsuccessful IUCD Fitting Attempt: 615J Unsuccessful intrauterine contraceptive device insertion Completion of IUCD Fitting Enhanced Service: 9kA0 IUCD fitting - enhanced service completed (Code 9kA0 should be entered after a successful IUCD fitting carried out by the practice in accordance with the terms of the Enhanced Service). Initial Review of IUCD After Fitting: 615L IUD 6 week check Annual Review of IUCD 615K IUCD annual review Complications of IUCDs K4z Female pelvic inflammatory disease NOS 615E IUCD threads lost SP032 Mechanical Complication of IUCD (includes perforation) (13) Minor Surgery Codes for Injections (muscles, tendons and joints): (This does not include intramuscular injections or local anaesthetic given prior to performing a minor surgery procedure.) Minor surgery done – injection 9877 Injection into joint 7K6Z3 Free text must be added to the above codes with clinical detail for monitoring purposes (not patient identifiable). Codes for Invasive Procedures: (N.B. Cryotherapy, curettage and cauterisation continue to be provided as an additional service and are not payable as part of the Minor Surgery Enhanced Service.) Minor surgery done – aspiration 9878 Minor surgery done – incision 9879 Minor surgery done – excision 987A Minor surgery done – other 987B Free text must be added to the above codes with clinical detail for monitoring purposes (not patient identifiable). Please supply sufficient detail in free text to enable clinical assessors to verify the claim, making clear that the procedure was invasive, this might include details of size of lesion; use of local anaesthetic and suturing can be coded (see supplementary codes below). Consent: Consent given for minor surgery procedure 8923 a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 9 of 12. Supplementary codes: Primary suture of skin 7G210 Local anaesthetic 7M34 Histology: Tissue sent for histology 4K11 Histology normal 4K13 Histology abnormal 4K14 Histology nos 4K1Z Histology nonsp. finding R15 (14) Child Protection LES Name of Primary Carer (To be recorded for all newly registered children): 9180 Carer’s Details OR 918H Primary Carer (Whichever code you use, please add the name of the child’s main carer in free text) (Note: 9180 is the best code to use; 918H can still be used and is included in the LES monitoring; the problem with 918H is that some nationally-written flu searches assume that children with 918H in their record are themselves carers and that they therefore should have flu vaccination!) Name of School (To be recorded for all newly registered children, especially if aged 5+ years): 13Z4 Schooling (please add the name of the school in free text) Child Protection Register: 13Id On Child Protection Register 13IO Child removed from protection register Social Worker: (To be recorded for all children on the Child Protection register): 13G4 Social worker involved (Please add the name and phone number of the social worker / relevant area office in free text) Health Visitor: (To be recorded for all children aged <5 years on the Child Protection register): a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 10 of 12. 13G2 Health Visitor Visits (Please add the name of the child’s health visitor in free text) (15) Prevalence Incentive Scheme CVD risk: 662k JBS CVD risk <10% over next 10 years 662l JBS CVD risk ≥10 to ≤20% over next 10 years 662m JBS CVD risk >20 to ≤30% over next 10 years 662n JBS CVD risk >30% over next 10 years EMISNQFR5 10 year CVD Risk (EMIS systems only) EMISNQFR8 Estimated 10 year CVD Risk (EMIS systems only) CHD Risk: 3888 10 year CHD Framingham Risk 388R 10 year adjusted CHD Framingham Risk EMISFR3 10 year CHD Framingham Risk (EMIS systems only) EMISFR4 Estimated 10 year CHD Framingham Risk (EMIS systems only) Heart Failure: G58 Heart Failure 68B6 Heart Failure screen 1J60 HF suspected 1I10 HF excluded Diabetes: C10E Type 1 Diabetes C10F Type 2 Diabetes Patients who were pregnant at the time of the diagnostic blood tests should have gestational diabetes entered into their record (L1809). Other Relevant Read Codes: C11y2 Impaired Glucose Tolerance C11y3 Impaired Fasting Glycaemia Hypertension G2 Hypertensive Disease a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 11 of 12. a28f43d7-b941-4835-bf06-678e353b30e5.doc / R Nicholls/A Akande/ I Patel, Camden PCT, 09/08/2012, page 12 of 12.