chapter introduction - guide to unbundling

Guide to Unbundling of 33

Guide to Unbundling Version No: 4.0 Issue Date: 13 February 2009

Author: The National Casemix Classifications Service Date: February 2009

Copyright © 2009, The Information Centre, Casemix Service. All rights reserved.

Guide to Unbundling Author: The National Casemix Classifications Service Date: February 2009


GUIDE TO UNBUNDLING - CONTENTS

1 INTRODUCTION ..........................................................................................................................3

2 OUTLINE OF UNBUNDLING.....................................................................................................3

3 WHY UNBUNDLE? .....................................................................................................................3

4 WORKED EXAMPLE ..................................................................................................................4

5 WHAT COMPONENTS ARE UNBUNDLED?.........................................................................4

6 WHEN DOES UNBUNDLING HAPPEN IN THE GROUPING PROCESS?.......................5

7 WHICH DATASETS PRODUCE UNBUNDLED HRGS? ......................................................5

8 WHAT HAPPENS WHEN ALL PROCEDURES ARE UNBUNDLED? ...............................5

9 HOW ARE UNBUNDLED HRGS SHOWN IN THE GROUPER OUTPUT? .......................5

10 ON WHAT BASIS ARE UNBUNDLED HRGS ALLOCATED? ............................................6

11 CHAPTER SPECIFIC GUIDANCE ...........................................................................................6 11.1 CHEMOTHERAPY ...................................................................................................................6 11.2 RADIOTHERAPY .....................................................................................................................8 11.3 INTERVENTIONAL RADIOLOGY.............................................................................................11 11.4 DIAGNOSTIC IMAGING..........................................................................................................11 11.5 REHABILITATION ..................................................................................................................13 11.6 SPECIALIST PALLIATIVE CARE ............................................................................................15 11.7 ADULT CRITICAL CARE........................................................................................................19 11.8 PAEDIATRIC AND NEONATAL CRITICAL CARE .....................................................................22 11.9 RENAL DIALYSIS ..................................................................................................................25 11.10 HIGH COST DRUGS ............................................................................................................28

12 APPENDIX 1 – HIGH COST DRUG MAPPING TO OPCS 4.4 CODE AND ASSOCIATED HRG ............................................................................................................................30 Copyright © 2009, The Information Centre, Standards and Classifications. All rights reserved. This work remains the sole and exclusive property of The Information Centre and may only be reproduced where there is explicit reference to the ownership of The Information Centre. This work may be re-used by NHS and government organisations without permission. Commercial re-use of this work must be granted by The Information Centre.



1 Introduction

HRG4 introduces the concept of “unbundling”. This guide explains unbundling and describes how the concept has been applied to specific chapter areas within HRG4. It includes a number of worked examples and notes that will help users to understand how relevant data are collected, coded and grouped to produce unbundled HRGs. 2 Outline of Unbundling

In HRG v3.5 each episode of care would derive a single HRG. In HRG4, some significant elements of cost and activity have been “unbundled” from core HRGs. The impact of unbundling is that under HRG4 a case will be assigned more than one HRG if it includes any unbundled elements. The “unbundled component” becomes an HRG in its own right as an addition to a core HRG. For example, a case could be assigned the following HRGs depending on the components within it: Unbundled Unbundled Unbundled Unbundled

Core HRG +

Renal Dialysis HRGs

+ High Cost Drug HRGs

+Diagnostic Imaging HRGs

+ Rehabilitation HRGs

Unbundled HRGs have been developed to comply with the design rules which apply to all HRGs. Principally, there must be at least 600 cases expected per annum nationally, or the total national cost must be at least £1.5 million per annum. 3 Why Unbundle?

The benefits of unbundling are to:

• Improve the performance of HRGs so that they can better represent activity and costs

• Support service redesign • Support Patient Choice (e.g. choice of scan provider). It is increasingly

likely that patients will attend different providers for different parts of the care pathway.



4 Worked example

Assume a patient is admitted with a head injury and abdominal pain after falling and has a CT scan (head) immediately on admission. A day later they have a further CT scan of the abdomen. In HRG v3.5, this case would be grouped to HRG H64 (Head Injury <70 w/o cc) In HRG4, it is grouped to

Core HRG HD37C Head Injury without CC Unbundled HRG RA08Z Computerised Tomography Scan, one area, no contrast

HRG4 Case

Primary Diagnosis (ICD-10)

Procedure 1 (OPCS-4.4)

Procedure 2 (OPCS-4.4)

HRG v3.5 Core HRG Unbundled

HRG

A

S09.9 Unspecified injury of head

U05.1 Computed tomography of head Y98.1 Radiology of one body area (or <20 minutes)

U08.1 Computed tomography of abdomen NEC Y98.1 Radiology of one body area (or <20 minutes)

H64 HD37C RA08ZRA08Z

5 What components are unbundled?

Unbundled HRGs have been developed for:

• Chemotherapy – procurement and delivery • Radiotherapy – planning and delivery • Diagnostic Imaging • Rehabilitation • Renal Dialysis • Critical Care • Specialist Palliative Care • High cost drugs

The unbundled activity will be identified by data items or codes – typically a new or existing OPCS code. The unbundling of a component or process of care will be applied consistently throughout HRG4, except in the following cases:



• Only one Emergency and Urgent Care HRG will be assigned per attendance and no element of treatment will be unbundled from the accident and emergency CDS.

6 When does unbundling happen in the grouping process?

Unbundling is the first step in the grouping process, following data validation. Unbundled procedures are removed from the data input file and processed separately to derive unbundled HRGs. The grouper then ignores these unbundled components when deriving the core HRG for an episode or spell. 7 Which datasets produce unbundled HRGs?

Unbundled HRGs can be derived from the Admitted Patient Care and Outpatient datasets. The Accident and Emergency dataset does not generate unbundled HRGs; investigation and treatment activity is incorporated in the core HRGs for emergency and urgent care. 8 What happens when all procedures are unbundled?

In some cases, all procedures in an episode may be unbundled, e.g. in an attendance for renal dialysis where no other procedures are performed. Even where there are no procedures remaining after unbundling, the grouper will always allocate a core HRG for the episode or spell in addition to the HRGs for the unbundled components. When all significant procedures in an inpatient Finished Consultant Episode (FCE) or spell are unbundled, diagnosis is used to derive a core HRG for the episode. For non-admitted care, if all procedures are unbundled the episode is allocated one of the eight relevant non-admitted care attendance HRGs as a core HRG. 9 How are unbundled HRGs shown in the grouper output?

Any unbundled components will be shown against the relevant FCE / spell. Unbundled HRGs are shown as the last (right-most) entries in the grouper output for the FCE/spell to which they relate. There is no significance to the order in which unbundled HRGs are listed. For the second iteration of the HRG4 Reference Costs Grouper, released to the NHS in January 2008, unbundled HRGs were also provided in relational



output format, as a separate file, in addition to being included on the output file as the last (most right) entries. This output is also produced from the HRG4 2008/09 Reference Costs grouper. The FCE HRGs in a spell can be linked through the use of a common spell identifier to enable local analysis. 10 On what basis are unbundled HRGs allocated?

All unbundled HRGs are event based, as recorded using appropriate underlying classifications, e.g. OPCS-4.4 codes. The unit of activity for these unbundled HRGs varies according to case type:

Unbundled Component Currency Chemotherapy – regimen 1 HRG per regimen procured Chemotherapy - delivery 1 HRG per cycle of delivery Radiotherapy – planning 1 HRG per planning instance Radiotherapy - treatment 1 HRG per fraction delivered Diagnostic Imaging 1 HRG per imaging activity

Rehabilitation

1 HRG per rehabilitation assessment 1 HRG per diem for each individual recorded delivery of rehabilitation

Renal Dialysis 1 HRG per session of dialysis treatment

Adult Critical Care 1 HRG per critical care period, based on number of organs supported

Paediatric and Neonatal Critical Care 1 HRG for each day of Critical Care

Specialist Palliative Care 1 HRG per diem for each episode of care

High cost drugs 1 HRG per drug prescribed per spell, excluding drugs delivered within Chemotherapy regimens

Users should refer to the Reference Costs guidance issued by the Payment by Results team at the Department of Health for details of the currency used to collect 2008/09 Reference Costs data. These currencies may be reviewed by PbR prior to application for reimbursement. 11 Chapter Specific Guidance

11.1 Chemotherapy

The chemotherapy HRGs for cancer treatment have been unbundled from the medical and the surgical inpatient and non-admitted care HRGs. All patients



will therefore receive a core HRG based on surgical procedures or primary diagnoses and one or more additional chemotherapy HRGs. Trusts will receive multiple delivery HRGs per cycle if the cycle is delivered on multiple attendances. Each time a new chemotherapy cycle starts, a new regimen will be recorded. Under HRG4, chemotherapy groupings are based on cycles and are split between chemotherapy drug procurement (regimen) and delivery. Each patient will be allocated one HRG for the regimen procured per cycle and one HRG for each attendance for treatment, to reflect the complexity of treatment and hence resource usage. Pharmacy costs will be included in the procurement codes as detailed in the 2008/09 Reference Costs guidance. The chemotherapy regimen HRGs are banded into 10 bands, with an additional HRG to accommodate procurement of drugs for regimens not on the national list. The list of regimens has been compiled from lists supplied by members of the Network Pharmacy Group. The chemotherapy delivery HRGs for the first attendance take account of the resources required for the delivery of one cycle of the chemotherapy regimen. The subsequent delivery is a single generic code and this will be further reviewed in the future HRG design. In respect of chemotherapy, “Inpatient Ordinary Admissions”, “Regular day attenders”, “Day cases”, “Same day inpatients” and “Outpatients” are all treated the same from an HRG perspective and all can generate the same HRGs. In most cases there is a straightforward 1 to 1 mapping of OPCS-4.4 codes to HRGs as shown below: Chemotherapy regimen grouping logic OPCS-4.4 HRG HRG Label

X70.1 SB01Z Procure Chemotherapy drugs for regimens in Band 1 X70.2 SB02Z Procure Chemotherapy drugs for regimens in Band 2 X70.3 SB03Z Procure Chemotherapy drugs for regimens in Band 3 X70.4 SB04Z Procure Chemotherapy drugs for regimens in Band 4 X70.5 SB05Z Procure Chemotherapy drugs for regimens in Band 5

X70.8 SB16Z Procure Chemotherapy drugs for regimens not on the national list

X71.1 SB06Z Procure Chemotherapy drugs for regimens in Band 6 X71.2 SB07Z Procure Chemotherapy drugs for regimens in Band 7 X71.3 SB08Z Procure Chemotherapy drugs for regimens in Band 8 X71.4 SB09Z Procure Chemotherapy drugs for regimens in Band 9 X71.5 SB10Z Procure Chemotherapy drugs for regimens in Band 10



Chemotherapy delivery grouping logic OPCS-4.4 HRG HRG Label

X73.1 SB11Z Deliver exclusively Oral Chemotherapy X73.8 SB11Z Deliver exclusively Oral Chemotherapy X73.9 SB11Z Deliver exclusively Oral Chemotherapy X72.3 SB12Z Deliver simple Parenteral Chemotherapy at first attendance

X72.2 SB13Z Deliver more complex Parenteral Chemotherapy at first attendance

X72.1 SB14Z Deliver complex Chemotherapy, including prolonged infusional treatment at first attendance

X72.4 SB15Z Deliver subsequent elements of a Chemotherapy cycle X72.9 SB17Z Deliver chemotherapy for regimens not on the national list

NHS organisations must ensure that they collect appropriate and accurate OPCS-4.4 codes for chemotherapy activity to ensure that they receive the necessary unbundled chemotherapy HRG. If chemotherapy data are collected on a secondary system, organisations must be able to transfer it to their PAS system in order for the necessary grouping to HRG to take place. It is important that coders use the most up to date OPCS code set to record chemotherapy. These codes were not covered by OPCS-4.2. A mapping of the regimens to OPCS 4.4 codes for procurement of chemotherapy drugs can be found at the following website. http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/downloads/chemo This file should be used to determine which band a regimen maps to. 11.2 Radiotherapy

The radiotherapy HRGs have been unbundled from the medical and the surgical inpatient and non-admitted care HRGs. All patients will therefore receive a core HRG based on surgical procedures or primary diagnoses and one or more additional radiotherapy HRGs. Providers will receive multiple delivery HRGs (one per fraction) if a course of radiotherapy is delivered over multiple attendances. HRG4 groups for radiotherapy include one set for pre-treatment (planning) processes and one set for treatment delivered, with a separate code being allocated for each fraction delivered. These groups are: • Radiotherapy planning

http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/downloads/chemo

http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/downloads/chemo



• Radiotherapy treatment (delivery per fraction) The planning HRGs are banded into 9 bands based on increased complexity, with a tenth band intended to capture “Other Radiotherapy Planning”. The planning HRG is intended to cover all attendances required for completion of the planning process. It is not intended that individual attendances for parts of this process will be recorded separately. The planning HRG does not include the consultation at which the patient consents to radiotherapy, nor would it cover any outpatient attendance for medical review required by any change in status of the patient. The treatment HRGs are banded into 8 bands of treatment based on increased complexity, with a ninth band for “Other Radiotherapy Treatment”. For each fraction of treatment delivered, one HRG will be assigned. Radiotherapy HRGs are driven by OPCS-4.4 codes and the majority have a direct mapping. The logic used relies on the coding of a secondary procedure to indicate a general anaesthetic or delivery of a fraction using a megavoltage or orthovoltage machine. The radiotherapy HRGs are listed in the table below. HRG Label

SC01Z Define volume for SXR, DXR, electron or Megavoltage Radiotherapy without imaging and with simple calculation

SC02Z Define volume for simple Radiation Therapy with imaging (Simulator, CT scanner etc) but with simple calculation and without Dosimetry

SC03Z Define volume for simple Radiation Therapy with imaging and Dosimetry

SC04Z Define volume for multiple phases of complex Radiation Therapy with imaging and Dosimetry

SC05Z Define volume for Radiation Therapy with imaging, Dosimetry and technical support e.g. mould room

SC06Z Define volume for Radiation Therapy with imaging and Intensity-modulated Radiation Therapy Dosimetry or equivalent

SC07Z Prepare for Total Body Irradiation SC08Z Prepare for Intracavitary Radiotherapy SC09Z Prepare for Interstitial Radiotherapy SC10Z Other Radiotherapy Planning SC21Z Deliver a fraction of treatment on a superficial or orthovoltage machine SC22Z Deliver a fraction of treatment on a megavoltage machine SC23Z Deliver a fraction of complex treatment on a megavoltage machine

SC24Z Deliver a fraction of Radiotherapy on a megavoltage machine using General Anaesthetic

SC25Z Deliver a fraction of Total Body Irradiation SC26Z Deliver a fraction of Intracavitary Radiotherapy without General Anaesthetic



SC27Z Deliver a fraction of Intracavitary Radiotherapy with General Anaesthetic SC28Z Deliver a fraction of Interstitial Radiotherapy SC29Z Other Radiotherapy Treatment The OPCS-4.4 codes relating to the radiotherapy HRGs are listed in the table below: OPCS-4.4 Label

X63.1 Volume definition for radiotherapy with imaging and intensity-modulated radiation therapy dosimetry

X63.2 Volume definition for radiotherapy with imaging, dosimetry and technical support

X63.3 Volume definition for multiple phases of complex radiotherapy with dosimetry

X63.4 Volume definition for simple radiotherapy with imaging and dosimetry

X63.5 Volume definition for simple radiotherapy with imaging and simple calculation

X63.6 Volume definition for superficial or deep X-ray, electron or megavoltage radiotherapy with simple calculation

X63.8 Other specified radiotherapy volume definition X63.9 Unspecified radiotherapy volume definition X64.1 Preparation for total body irradiation X64.2 Preparation for intracavitary radiotherapy X64.3 Preparation for interstitial radiotherapy X64.8 Other specified radiotherapy preparation X64.9 Unspecified radiotherapy preparation X65.1 Delivery of a fraction of total body irradiation X65.2 Delivery of a fraction of intracavitary radiotherapy X65.3 Delivery of a fraction of interstitial radiotherapy X65.4 Delivery of a fraction of external beam radiotherapy NEC X65.5 Oral delivery of radiotherapy for thyroid ablation X65.8 Other specified radiotherapy delivery X65.9 Unspecified radiotherapy delivery

The mapping of the OPCS-4.4 codes to their respective radiotherapy HRGs can be found in the Code to Group spreadsheet available from the Casemix Service website at http://www.ic.nhs.uk/casemix Notes: • It is important that coders use the most up to date OPCS code sets to

record radiotherapy. This activity was not covered by OPCS-4.2.

http://www.ic.nhs.uk/casemix



A separate OPCS-4.4 code needs to be recorded for each fraction delivered for outpatients and regular day attenders. Local constraints on the number of fields available on PAS may limit the number that can be recorded to a maximum per record. This is unlikely to be an issue for outpatient and regular day attenders treatment as it is improbable that more than 3 fractions are given at a single attendance. • However, for inpatients, there may be insufficient procedure fields

available to enter all the fractions. This is likely to apply to most inpatients who receive radiotherapy treatment. Providers are therefore only required to record one fraction of Radiotherapy delivery in an inpatient setting, regardless the number of total fractions given.

11.3 Interventional Radiology

At present the design of the original unbundled interventional radiology HRGs is under review. Unbundled HRGs are therefore no longer generated for interventional radiology activity. 11.4 Diagnostic Imaging

For the purpose of the 2008/09 reference costs, all diagnostic imaging with the exception of plain film x-ray and obstetric ultrasound scans can be unbundled and will derive HRGs that are additional to a core HRG for the care event. Each imaging procedure other than those for plain-film x-ray should be separately recorded using a valid OPCS-4.4 code and will generate a separate HRG in the reference cost grouper. These HRGs are dependent on imaging activity being coded using OPCS-4.4 and included in the APC or outpatient dataset for input to the grouper. Providers need to ensure that imaging data is collected and coded or they will fail to generate the appropriate diagnostic imaging unbundled HRGs. It is imperative that for the correct HRG for Diagnostic Imaging being generated the OPCS-4 codes recorded follow national clinical coding guidance both in terms of the codes used and the sequencing of these codes. Further information on OPCS-4 codes can be obtained by contact NHS Connecting For Health [email protected] The original intention was to have a one-to-one mapping from the OPCS-4.4 codes to the Diagnostic Imaging HRGs. However, this was not possible within the constraints of the OPCS coding scheme. It has therefore been necessary to use subsidiary codes to improve the fit between the OPCS-4.4 and Diagnostic Imaging HRG codes.

mailto:[email protected]



The OPCS-4.4 code plus the subsidiary codes can then generate the appropriate Diagnostic Imaging HRG code in the grouper. The following example shows the subsidiary code logic and how it affects grouping. For OPCS-4.4 code U05.1 CT of head:

• If subsidiary codes Y97.1 Radiology with pre and post contrast and Y98.1 Radiology of one body area (or <20 minutes) are recorded, then the activity groups to RA10Z CT one area, pre and post contrast

• If subsidiary code Y97.3 Radiology with post contrast and Y98.1

Radiology of one body area (or <20 minutes) are recorded, then the activity groups to RA09Z CT one area, post contrast)

Notes: Radiology Departments generally have their own information systems which may not necessarily be linked to PAS. Providers will need to ensure that there is a mechanism in place to provide relevant information to clinical coders so that imaging procedures can be entered as OPCS-4.4 codes on PAS. Clinical coders will need clinical input and comprehensive documentation of procedures to be able to code this activity. Diagnostic Imaging HRGs are derived wholly from OPCS-4.4 codes and allocation to an HRG is therefore dependent on adequate specificity of coding. Where coding is at the .8 (other specified) or .9 (unspecified) level, this is likely to result in a failure to group. This is because these codes are not specific and do not identify the type of Radiological procedure or the resource used. It is important that coders use the most up to date OPCS code set. 81 new codes (95% of the total for this chapter) have been added through the 4.3 and 4.4 revisions of OPCS. Data collection is a cause of concern for departments who do not have access to good electronic data collection systems. This work has coincided with the implementation programme for PACS (picture archiving and communication systems) across England as part of the work of Connecting for Health. In the interim, it has been recognised that too simplistic a system risks failing to capture the required level of detail for PbR to reimburse departments



accurately but too complex a system risks overloading the coding system, resulting in poor quality data. It is felt that these HRGs achieve the best balance currently possible but will be flexible enough to support improved data collection when better systems become available. 11.5 Rehabilitation

Rehabilitation HRGs are only generated where care is identified as taking place under a specialist rehabilitation consultant or within a discrete rehabilitation ward or unit. They require the recording of OPCS-4.4 U50.- – U54.- codes to generate an unbundled rehabilitation HRG in addition to the core HRG for the care episode. Where a patient is not admitted specifically to a rehabilitation unit or where rehabilitation treatment is undertaken without transfer to a specialist consultant, or without transfer to a rehabilitation unit, such activity will not be coded, according to NHS Connecting for Health coding rules. Thus this will not be identified as discrete rehabilitation and will not generate an unbundled rehabilitation HRG. Rehabilitation assessment is identified by OPCS-4.4 codes X60.- and does not require a rehabilitation diagnosis to generate any of the three rehabilitation assessment HRGs. Derivation of rehabilitation HRGs is dependent on the recording of rehabilitation activity using one of the following OPCS-4.4 codes: OPCS-4.4 Code

Label

U50.1 Delivery of rehabilitation for amputation of limb U50.2 Delivery of rehabilitation for hip fracture U50.3 Delivery of rehabilitation for joint replacement U50.4 Delivery of rehabilitation for rheumatoid arthritis U50.5 Delivery of rehabilitation for osteoarthritis U50.8 Other specified rehabilitation for musculoskeletal disorders U50.9 Unspecified rehabilitation for musculoskeletal disorders U51.1 Delivery of rehabilitation for brain injuries U51.2 Delivery of rehabilitation for spinal cord injury U51.3 Delivery of rehabilitation for pain syndromes U51.8 Other specified U51.9 Unspecified U52.1 Delivery of rehabilitation for drug addiction U52.2 Delivery of rehabilitation for alcohol addiction U52.8 Other specified U52.9 Unspecified U53.1 Delivery of rehabilitation following plastic maxillofacial reconstruction U53.2 Delivery of rehabilitation following other plastic reconstruction U53.3 Delivery of rehabilitation for burns



U53.4 Delivery of rehabilitation for trauma nec U53.8 Other specified U53.9 Unspecified U54.1 Delivery of rehabilitation for acute cardiac disorders U54.2 Delivery of rehabilitation for respiratory disorders U54.3 Delivery of rehabilitation for stroke U54.8 Other specified U54.9 Unspecified X60.1 Rehab. Assessment by multidisciplinary, non-specialised team X60.2 Rehab. Assessment by multidisciplinary, specialised team X60.3 Rehab. Assessment by unidisciplinary team X60.8 Other specified X60.9 Unspecified Example 1 A patient is admitted for a hip replacement. After an initial period of 10 days under the care of the Orthopaedic consultant, they are transferred within the same provider for discrete rehabilitation care under the care of a rehabilitation consultant. A rehabilitation delivery OPCS-4.4 code is recorded on the patient record. They are subsequently discharged after 20 days of rehabilitation. The activity is therefore described as follows:

• 2 finished consultant episodes with an overall length of stay of 30 days • 1 single provider spell

The expected output from the HRG4 Reference Cost grouper would be: HRG Label HA12C Major Hip Procedures Category 1 without CC (Core HRG for the treatment

episode) VC18Z*20 Rehabilitation for joint replacement (Unbundled HRG for discrete rehabilitation). Note: The grouper output will produce an unbundled rehabilitation HRG for each day of an episode that contains an appropriate rehabilitation OPCS-4.4 code. Depending on the output format, this may be detailed in a relational list, or indicated by the use of the multiplier (*) symbol against the number of unbundled rehabilitation HRGs generated (so example one is shown as VC18Z*20). Example 2 A patient is admitted for a hip replacement and subsequently receives rehabilitation care within the same provider, without transfer to a specialist rehabilitation consultant or a discrete rehabilitation unit. No rehabilitation delivery OPCS-4.4 code is recorded on the patient record. The patient is discharged after 30 days.



In this case, the activity is therefore described as follows:

• 1 finished consultant episode with an overall length of stay of 30 days • 1 single provider spell.

The rehabilitation care is regarded as ‘part and parcel’ of the hip replacement procedure. The HRG4 Reference Costs grouper would therefore generate a single HRG for the spell, for Hip replacement, with a length of stay of 30 days. Notes: It is important that coders use the most up to date OPCS code set. 30 new codes specifically for rehabilitation are in OPCS-4.4; these were not covered by OPCS-4.2. Data quality may be variable for these codes because of the difficulties in differentiating between routine and discrete rehabilitation, which may be dependent on historical local practice and individual organisation structure. Allied health professionals should clearly document the rehabilitation activity in the patient casenotes and also specify whether it is assessment or delivery activity. Clear documentation is the key factor in recording rehabilitation activity to ensure generation of an appropriate rehabilitation HRG. 11.6 Specialist Palliative Care

All Specialist Palliative Care [SPC] is unbundled and will generate SPC HRGs that are additional to the core episode HRG. The Hospital Specialist Support HRG will always be in addition to a diagnosis/surgical HRG which covers the FCE and Spell. HRGs SD01A and SD01B for Inpatient Specialist Palliative Care (not Same Day) will be generated on a per diem basis. The grouper output will detail an SPC HRG for each day in an episode of care. Two additional HRGs have been created for Inpatient Specialist Palliative Care Same Day (SD02A and SD02B). This is to facilitate the Expert Working Group requirement that differentiates between same day and multi-day patients where the expected resource use differs. The HRGs are split based on age, with a distinction being made between 19 years and over, and 18 years and under. There are therefore 10 HRGs within the current SPC HRG design:



HRG Label SD01A Inpatient Specialist Palliative Care 19 years and over SD01B Inpatient Specialist Palliative Care 18 years and under SD02A Inpatient Specialist Palliative Care Same Day 19 years and over SD02B Inpatient Specialist Palliative Care Same Day 18 years and under SD03A Hospital Specialist Palliative Care Support 19 years and over SD03B Hospital Specialist Palliative Care Support 18 years and under SD04A Medical Specialist Palliative Care Attendance 19 years and over SD04B Medical Specialist Palliative Care Attendance 18 years and under SD05A Non-Medical Specialist Palliative Care Attendance 19 years and over SD05B Non-Medical Specialist Palliative Care Attendance 18 years and under

Inpatients (including Day Cases) – Six HRGs

Adults (over 19 years)

Adult Inpatients admitted under the care of a Specialist Palliative Medicine consultant excluding patients discharged on the day of admission unless they die on the day of admission and excluding patients who have been admitted for holiday relief/ respite care. Inpatient

SPC

Children (18 or under)

Paediatric Inpatients admitted under the care of a Specialist Palliative Medicine consultant excluding patients discharged on the day of admission unless they die on the day of admission and excluding patients who have been admitted for holiday relief/ respite care.

Adults

Adult Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving support from a member of a Specialist Palliative Care Team as described by NICE Guidance - Improving Supportive and Palliative Care for Adults with Cancer (2004). The specialist support can be given for a patient with a non-malignant or a malignant condition in an inpatient setting. Hospital -

Specialist Support

Children

Paediatric Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving support from a member of a Specialist Palliative Care Team as described by NICE Improving Outcomes Guidance for Children and Young Adults with Cancer (2005). The specialist support can be given for a patient with a non-malignant or a malignant condition in an inpatient setting.

The inpatient SPC HRGs are shown overleaf.



HRG Label Definition

Notes

SD01A Inpatient Specialist Palliative Care 19 years and over

Age on Admission ≥ 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine) AND Length of Stay > 0 OR Discharge Method = 4 (Patient died) AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative care AND NOT Primary Diagnosis (ICD-10) = Z75.5 Holiday relief care

Adult Inpatients under the care of a Specialist Palliative Medicine consultant Excluding patients discharged on the day of admission unless they die on the day of admission Excluding patients admitted for respite care.

SD01B Inpatient Specialist Palliative Care 18 years and under

As above with: Age < 19

Paediatric Inpatients under the care of a Specialist Palliative Medicine consultant

Excluding patients discharged on the day of admission unless they die on the day of admission Excluding patients admitted for respite care.




Notes

SD02A

Inpatient Specialist Palliative Care Same Day 19 years and over

Age on Admission ≥ 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine) AND Length of Stay = 0

AND

Discharge Method ≠ 4 (Patient did not die) AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative care AND NOT Primary Diagnosis (ICD-10) = Z75.5 Holiday relief care

SD02B

Inpatient Specialist Palliative Care Same Day 18 years and under


SD03A

Hospital Specialist Palliative Care Support 19 years and over

Age on Admission ≥ 19 AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative Care AND NOT Main Specialty Code = 315 (Palliative Medicine)

Adult

Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving input from a Specialist Palliative Care specialist support service

SD03B

Hospital Specialist Palliative Care Support 18 years and under


Paediatric

Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving input from a Specialist Palliative Care specialist support service.



Outpatients, Day therapy assessments and Interventions – Four HRGs The HRG designs are:


SD04A Medical Specialist Palliative Care Attendance 19 years and over

Age ≥ 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine)

SD04B Medical Specialist Palliative Care Attendance 18 years and under


SD05A Non-Medical Specialist Palliative Care Attendance 19 years and over

Age ≥ 19 AND Main Specialty Code = 950 (Nursing Episode) OR 960 (Allied Health Profession Episode) AND Treatment Function Code = 315 (Palliative Medicine)

SD05B Non-Medical Specialist Palliative Care Attendance 18 years and under


The Outpatient Attendance CDS can record contacts by Medical, Nursing and Allied Health Professionals (AHPs). Chaplains and Social Workers may record contacts as AHPs as well as Physiotherapists, Speech and Language Therapists, Occupational Therapists, Podiatrists, Dieticians, Clinical Psychologists etc. Patients receiving Chemotherapy and other unbundled interventions such as MRIs, high cost drugs etc will receive additional HRGs for each unbundled component. 11.7 Adult Critical Care

There are seven HRGs defined for Level 2 and Level 3 Adult Critical Care. A single unbundled HRG will be produced per adult critical care period. These ACC HRGs are effectively unbundled from the rest of the patient episode. For reference cost grouping, days in critical care must be deducted from the overall patient length of stay to avoid double counting.



The HRGs are based on the level of support required by the patient as evidenced by the number of organs supported:

Total Organ Groups Supported HRG

6 XC01Z Adult Critical Care - 6 Organs Supported 5 XC02Z Adult Critical Care - 5 Organs Supported 4 XC03Z Adult Critical Care - 4 Organs Supported 3 XC04Z Adult Critical Care - 3 Organs Supported 2 XC05Z Adult Critical Care - 2 Organs Supported 1 XC06Z Adult Critical Care - 1 Organs Supported 0 XC07Z Adult Critical Care - 0 Organs Supported

Fields within the ACCMDS used by this standard are:

CCMDS Field Description Critical Care Unit Function Advanced Respiratory Support Days Basic Respiratory Support Days Advanced Cardiovascular Support Days Basic Cardiovascular Support Days Renal Support Days Neurological Support Days Dermatological Support Days Critical Care Level 2 Days Critical Care Level 3 Days

Note: Liver support is included in ACCMDS but is currently excluded from the Adult Critical Care Levels 2 and 3 HRGs due to lack of available data. Patients Covered By Adult Critical Care HRGs The HRGs XC01Z to XC07Z will be assigned to all patients with an ACCMDS record with the exception of non Level 2 and 3 patients with zero organs supported.

Description Value

Critical care level 2 days Total calendar days during which level two care was provided during the period

Critical care level 3 days Total calendar days during which level three care was provided during the period



Any record calculated as zero total organs supported (see below) which has zero Level 2 or 3 days (i.e. the sum of the two fields) will be assigned the UZ01Z (Data Invalid for grouping) HRG Code rather than “XC07Z”. Organ Support Groups Organ groups supported are taken from the Adult Critical Care Minimum Data Set (ACCMDS) and are: Organ groups Notes

Advanced Respiratory Support

Basic and Advanced Respiratory Support are treated as separate organ groups for the purposes of the HRG definition

Basic Respiratory Support See above

Advanced Cardiovascular support and Basic Cardiovascular Support

Advanced and Basic Cardiovascular Support are treated as one organ group for the purposes of the HRG definition

Basic Respiratory Support and Basic Cardiovascular Support

Basic Respiratory Support and Basic Cardiovascular Support are treated as one organ group for the purposes of the HRG definition

Renal Support Neurological Support Dermatological Support

Notes: • Gastrointestinal Support is treated as a standard component of care and

the cost of providing this care is absorbed into the costs of the other organ support groups so it is not counted as a separate organ support group in the HRG.

• Liver support is excluded from the HRG. • For reference cost purposes, only FCEs that fall within completed spells

should be submitted for grouping, so if the critical care activity is within a spell that is still open at year end this should not be counted.

• Length of Stay in critical care is not used in the HRG assignment but is

calculated by the grouper and included as part of the grouper output for adult critical care.



• Length of Stay may be calculated during pre-processing based on the Critical Care Start Date and the Critical Care Discharge Date with parts of a day counted as whole days.

11.8 Paediatric and Neonatal Critical Care

Grouping of critical care activity is derived from information submitted from the NCC and PCC Critical Care datasets. The unbundled HRGs for these services will be collected for the first time in the 2008/09 Reference Costs collection. Neonatal and Paediatric Critical Care retrieval activity is derived from the APC dataset. Determination of the NCC and PCC retrieval HRGs requires that the correct information regarding Treatment Function Code, admission method, source of admission and neonatal level of care is available in the APC dataset for the corresponding admisison to a paediatric / neonatal critical care unit. Critical Care HRGs are unbundled from the rest of the inpatient episode. For reference cost grouping, there is an additional processing requirement for sites to remove the critical care days from the duration of the overall stay in the APC record so that these are not ‘double counted’. Paediatric and Neonatal Critical Care HRGs are generated per diem, i.e. for each day the patient receives Critical Care, and are unbundled from any other HRGs such as the overall Spell/Episode HRG and separately unbundled HRGs such as MRIs that may be assigned to the Spell/Episode. Critical Care will therefore derive:

• A core HRG for the FCE / spell, for other non critical care aspects of a

child’s care e.g. surgery, underlying medical conditions • A daily ‘Level of Care’ HRG for critical care treatment

The Paediatric ‘Level of Care’ HRGs are:

HRG Label XB01Z Intensive Care - ECMO/ECLS XB02Z Intensive Care Advanced Enhanced XB03Z Intensive Care Advanced XB04Z Intensive Care Basic Enhanced XB05Z Intensive Care Basic XB06Z High Dependency Advanced XB07Z High Dependency



The Neonatal ‘Level of Care’ HRGs are:

HRG Label Abbreviation XA01Z Intensive Care IC XA02Z High Dependency HDC XA03Z Special Care without external carer SC XA04Z Special Care with external carer SC-EC XA05Z Normal Care NC

Note:

• Spell/Episode HRGs for other non critical care aspects of care i.e. surgery and underlying medical conditions, are defined outside of the Critical Care datasets.

• HRGs for unbundled interventions such as MRIs are defined outside of Critical Care.

• HRG bandings for unbundled high cost drugs are defined externally to Critical Care. However, data necessary to generate grouping are included in the PCC and NCC MDS.

Neonatal and Paediatric Critical Care Recovery (Retrieval) HRGs There are two new HRGs for retrieval:

• XA06Z Neonatal Critical Care retrieval • XB08Z Paediatric Critical Care retrieval

Grouping is driven by the following parameters:

• Treatment function code • Admission method • Source of admission • Neonatal level of care

Although the NCC and PCC datasets are predicated on the treatment of patients within Critical Care, these datasets do not include any admission information and so cannot be used to derive retrievals. Information for retrieval HRGs is therefore derived from the APC dataset. The following rules will be applied to generate these HRGs: 1. Check the Admission Method (mandatory field) to ensure that it is a

transfer. This will need to be:



81 "Other Admission, - Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency"

Or 28 "Emergency admission, when admission is unpredictable and at

short notice because of clinical need, - Other Means", which includes "- transfer of an admitted PATIENT from another Hospital Provider in an emergency"

And 2. Check Source of Admission (mandatory field).

For Neonates this should be 52 " NHS other hospital provider - ward for maternity patients or

neonates". This is necessary to confirm that they have come from another hospital as Admission Method 28 can also be for "baby born at home as intended".

Or 87 "Non NHS run hospital" For paediatrics this should be 51 "NHS other hospital provider - ward for general patients or the

younger physically disabled or A & E department". Or 87 "Non NHS run hospital"

And 3. The first FCE in the spell will need to have a suitable TFC (mandatory

field). For Neonates it will be 422 "Neonatology Special Care, High Dependency and Intensive Care." For Paediatrics this is 242 "Paediatric Intensive Care - Only to be used by designated

Paediatric Intensive Care Units". And 4. Because the Neonatal TFC is imprecise, it is also necessary to check the

Neonatal Level of Care (mandatory field) to be: 3 "Level 1 Intensive Care (Maximal Intensive Care): Care given in an

intensive care nursery which provides continuous skilled supervision by qualified and specially trained nursing and medical staff. Such care includes support of the infant's parent(s)."

Or 2 "Level 2 Intensive Care (High Dependency Intensive Care): Care

given in an intensive or special care nursery which provides continuous skilled supervision by qualified and specially trained nursing staff who may care for more babies than in Level 1



Intensive Care. Medical supervision is not so immediate as in Level 1 Intensive Care. Care includes support of the infant's parent(s)."

Age validation will not be applied as there is no facility within the APC dataset to validate neonate age, which must be in days. The use of the relevant Neonate [422] or Paediatric [242] TFC is deemed to be sufficient. 11.9 Renal Dialysis

All renal dialysis is unbundled and identified as a separate HRG, additional to the core HRG. Correct assignment of HRGs is dependent on the collection and entry of:

• Renal dialysis OPCS-4.4 codes • Relevant diagnosis codes for blood borne viruses, if applicable for

patient • Age of patient • OPCS-4.4 codes for specified high cost drugs

There are eight renal dialysis HRGs in the current HRG4 design, as collected in the 2008/09 Reference Costs:-

HRG Label

LC01A Haemodialysis/Filtration on patient with Blood Borne Viruses 19 years and over

LC01B Haemodialysis/Filtration on patient with Blood Borne Viruses 18 years and under

LC02A Haemodialysis/Filtration 19 years and over LC02B Haemodialysis/Filtration 18 years and under LC04A Continuous Ambulatory Peritoneal Dialysis 19 years and over LC04B Continuous Ambulatory Peritoneal Dialysis 18 years and under LC05A Automated Peritoneal Dialysis 19 years and over LC05B Automated Peritoneal Dialysis 18 years and under



Grouping logic is straightforward. Whenever one of the following OPCS-4.4 codes is recorded, an unbundled renal dialysis HRG will be generated:

OPCS-4.4 Label X40.1 Renal dialysis X40.2 Peritoneal dialysis nec X40.3 Haemodialysis nec X40.4 Haemofiltration X40.5 Automated peritoneal dialysis X40.6 Continuous ambulatory peritoneal dialysis X40.7 Haemoperfusion X40.8 Other specified compensation for renal failure X40.9 Unspecified compensation for renal failure

HRGs LC01A and LC01B also require a secondary diagnosis of a blood borne virus as identified by one of the following diagnosis codes being recorded.

ICD-10 code Label

B160 Acute hep B with delta-agent (coinfection) with hep coma B161 Acute hep B with delta-agent (coinfectn) without hep coma

B162 Acute hepatitis B without delta-agent with hepatic coma

B169 Acute hep B without delta-agent and without hepat coma B170 Acute delta-(super)infection of hepatitis B carrier B171 Acute hepatitis C B178 Other specified acute viral hepatitis B180 Chronic viral hepatitis B with delta-agent B181 Chronic viral hepatitis B without delta-agent B182 Chronic viral hepatitis C B188 Other chronic viral hepatitis B189 Chronic viral hepatitis, unspecified B190 Unspecified viral hepatitis hepatic with coma B199 Unspecified viral hepatitis without hepatic coma B200 HIV disease resulting in mycobacterial infection B201 HIV disease resulting in other bacterial infections B202 HIV disease resulting in cytomegaloviral disease B203 HIV disease resulting in other viral infections B204 HIV disease resulting in candidiasis B205 HIV disease resulting in other mycoses B206 HIV disease resulting in Pneumocystis carinii pneumonia B207 HIV disease resulting in multiple infections B208 HIV dis resulting in oth infectious and parasitic dis B209 HIV disease resulting in unspec infectious or parasitic dis



ICD-10 code Label

B160 Acute hep B with delta-agent (coinfection) with hep coma B161 Acute hep B with delta-agent (coinfectn) without hep coma B210 HIV disease resulting in Kaposi's sarcoma B211 HIV disease resulting in Burkitt's lymphoma B212 HIV dis resulting oth types of non-Hodgkin's lymphoma B213 HIV dis result oth mal neo lymphoid haematopoietic rel tis B217 HIV disease resulting in multiple malignant neoplasms B218 HIV disease resulting in other malignant neoplasms B219 HIV disease resulting in unspecified malignant neoplasm B220 HIV disease resulting in encephalopathy B221 HIV disease resulting in lymphoid interstitial pneumonitis B222 HIV disease resulting in wasting syndrome B227 HIV dis resulting in multiple diseases classif elsewhere B230 Acute HIV infection syndrome B231 HIV dis result (persistent) generalized lymphadenopathy B232 HIV dis result haematologic / immunologic abnorm NEC B238 HIV disease resulting in other specified conditions B24X Unspecified human immunodefiency virus [HIV] disease Z21X Asymptomatic human immunodef virus [HIV] infect status

In addition, if specified high cost drugs are used in renal dialysis, these should be recorded and will then be identified as additional unbundled HRGs. The following drug list is not exhaustive but includes a selection which may be relevant for renal patients:

Drug OPCS-4.4

code HRG OPCS-4.4 code label and HRG label

Darbopoetin alfa X90.1 XD23Z Hypoplastic Haemolytic and Renal Anaemia drugs band 1

Epoetin alfa X90.1 XD23Z Hypoplastic Haemolytic and Renal Anaemia drugs band 1

Antilymphocyte globulin X90.2 XD24Z Hypoplastic Haemolytic and Renal

Anaemia drugs band 2

Note: Renal dialysis has been designed as an unbundled component of care for reference costing purposes. Collection of data at this level of detail will enable future payment processes to be applied either to individual sessions or to aggregated courses of treatment, in line with Department of Health Payment by Results Policy decisions.



It is recognised that there may be a large number of sessions for each dialysis patient and that there is a prospective data collection burden if each event needs to be recorded for payment purposes. It is also acknowledged that current systems may not readily support the collection of data at session level and that it may therefore be difficult for trusts to record data at this level for transmission via CDS. However, for reference costing purposes, it is assumed that units will know approximately how many sessions of haemodialysis or days on peritoneal dialysis their patients have had. Future payment arrangements for dialysis will need to be determined by PbR. These may require adjustment to the unbundling approach and to data collection requirements at provider level. 11.10 High Cost Drugs

In HRG4, specific high cost drugs can be recorded within the Admitted Patient Care CDS and the Outpatient CDS using OPCS-4.4 codes. These OPCS-4.4 codes will derive unbundled HRGs that will be additional to the core HRG for the care episode. All high cost drug HRGs are unbundled. Whenever a separate high cost drug OPCS-4.4 code is recorded it will generate a separate unbundled high cost drug HRG in addition to the core HRG for the care episode. To facilitate the Reference Costs requirements, where multiple high cost drugs are recorded, multiple high cost drug HRGs will be generated. Grouping logic is very straightforward. There is a one to one mapping of high cost drug OPCS-4.4 code to high cost drug HRG. The exceptions to this are the 34 residual category .8 and .9 OPCS-4.4 codes, which map to the category UZ06 Poorly Coded Procedures. This is to ensure the coding follows the DH high cost drugs list to support Reference Costs collections and PbR requirements. At the Annex section of the newly published (updated Jan 2009) High Cost Drugs chapter summary, there is a mapping table between drugs, OPCS codes and HRGs. (Please add the hyperlink when it is finalised). Please bear in mind that the mapping will change in the future to reflect the changes made in both of the national drug list and OPCS.



Worked Examples 1. Patient was admitted due to pulmonary hypertension, Bosentan was given. Discharged 3 days later.

Case Age Length of Stay (days)

Primary diagnosis (ICD-10)

Primary Procedure (OPCS-4.4)

HRG4

A 65 3 I27.0 Pulmonary hypertension

X822 Pulmonary hypertension Drugs Band 2

Core HRG EB01Z Non interventional acquired cardiac conditions 19 years and over + High cost drug HRG XD02Z Primary Pulmonary Hypertension drugs band 2

2. Neonatal, 30 weeks gestation, preterm delivery. Suffered from Respiratory distress and Beractant was given. Discharged 5 days later.

Case Age Length of stay (days)

Primary diagnosis (ICD-10)

Secondary diagnoses (ICD-10)

Primary procedure (OPCS-4.4)

HRG4

B

0

5

P22.9 Respiratory distress of newborn, unspecified

P07.3 Other preterm infants

X84.2 Pulmonary surfactant drugs band 1

Core HRG PB02Z Minor Neonatal Diagnoses+XD37Z Pulmonary surfactant drugs Band 1

Analysis of the 2006/07 Hospital Episode Statistics (HES) data for admitted patient care shows that nearly 70% of trusts have not recorded a single high cost drugs OPCS code and thus have not generate a single unbundled high cost drugs HRG for admitted patients during this financial year. Drug names are complex and by their nature, high cost drugs tend to be low volume. There is therefore a high risk of omission errors. It is important that clinicians and pharmacy departments clearly identify the use of specified high cost drugs in clinical notes and ensure that this information is communicated to coding staff. Where organisations currently use the discharge summary to code, they should ensure that the names of the drugs are clearly documented on the summary. Whenever possible, the generic names rather than the brand names should be documented.



Appendix 1 – High Cost Drug mapping to OPCS 4.4 code and associated HRG

Note: This High Cost Drug mapping to OPCS-4.4 code is provided for information purposes only and will be continually updated. Please refer to NHS Connecting for Health for the latest information. Appendix 1 is located overleaf [To note, OPCS X866, Antiviral Drugs Band 1 and HRG XD38Z Antiviral Drugs Band 1 are now amended to read Antiretroviral.] .

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