v22 contract codes with scimp suggested codes...salbutamol and ipratropium bromide 33k1. positive...

V22 Contract Codes with SCIMP suggested codesIndex - click on hyperlink Asthma

Atrial Fibrillation

Cancer

Coronary Heart Disease

Chronic Kidney Disease

COPD

CVD Primary Prevention

Dementia

Depression

Diabetes

Epilepsy

Heart Failure

Hypertension

Hypothyroid

Learning Disabilities

Mental Health

Obesity

Osteoporosis

Peripheral Arterial disease (PAD)

Palliative Care

Records

Sexual Health

Smoking

Stroke/TIA

Notes1. All codes are taken from Version 22 of the Dept of Health Dataset and Business Rules (published March 2012). Major changes are highlighted in red.2. In some cases common nomenclature has been used. Codes that end with '%' indicated that this code plus any below it in the heirachy are suitable. Codes connected by a hyphen indicate that any codes between and including the 2 connected codes are suitable.

3. Included are SCIMP suggested codes for use. However in some circumstances it may be more appropriate to use an alternative code that meets the Contract requirements.

4. In the final column we have added some comments to help with coding and to indicate code changes between v21 and v22.

1

ASTHMA To Index

Code Code Breakdown Term

SCIMP Suggested

CodesTerm Comments v22

Diagnosis - Included Codes

H33% Asthma H33zz Asthma NOS Population requires an Asthma code and an asthma related prescription in the last 12 months. V22 - new code added H3120

H3120 Chronic asthmatic bronchitis

Asthma-related Drug Prescription Prescribed in the last year.

Asthma Resolved 21262 Asthma resolved 21262 Asthma resolved212G. Asthma resolved

Exception Codes 9hA%

9hA.. Exception reporting: asthma quality indicators 9hA1. Excepted from asthma quality indicators: Patient unsuitable

9hA1. Excepted from asthma quality indicators: Patient unsuitable 9hA2. Excepted from asthma quality indicators: Informed

dissent

9hA2. Excepted from asthma quality indicators: Informed dissent

9OJ2. Refuses asthma monitoring

Spirometry Codes

33G1. Spirometry reversibility positive 33G1. Spirometry reversibility positive

Patients can be coded with both Asthma and COPD if appropriate. Note that there are differences between the the Asthma and COPD Spirometry Codes, the Asthma spirometry code choice only includes those showing positive reversibility.

33H1. Positive reversibility test to salbutamol 33H1. Positive reversibility test to salbutamol33I1. Positive reversibility test to ipratropium bromide

33J1. Positive reversibility test to a combination of salbutamol and ipratropium bromide

33K1. Positive reversibility test to corticosteroids663J. Airways obstruction reversible745D4 Post bronchodilator spirometry8HRC. Referral for spirometry

Spirometry Exception codes 8I3b. Spirometry test declined Added V22 for Asthma 8 indicator8I6L. Spirometry not indicated8I2j. Spirometry contraindicated33720 Unable to perform spirometry

PEFR Codes

33950 Diurnal variation of peak expiratory flow rate 339g. Serial peak expiratory flow rate339c. Peak expiratory flow rate pre steroids339d. Peak expiratory flow rate post steroids339g. Serial peak expiratory flow rate339n. Serial peak expiratory flow rate abnormal339A. Peak flow rate before bronchodilation339B. Peak flow rate after bronchodilation

66Yc. Number of consecutive days at less than 80% peak expiratory flow rate

66YX. Peak expiratory flow rate monitoring66YY. Peak expiratory flow rate monitoring using diary

2

ASTHMA cont. To Index


SCIMP Suggested


Smoking Habit Codes

137..-137D.

137.. Tobacco consumption 1371. Never smoked tobacco

Required recording for 14 to 19 year olds in the last 15 months. In this age group non-smokers require entry within the previous 15 months. Otherwise asthma patients are included in the Smoking reports. Note - these patients will also require Smoking Cessation advice (QOF Smoking Indicator 2).

1371. Never smoked tobacco 137S. Ex smoker1372. Trivial smoker - < 1 cig/day 137R. Current smoker1373. Light smoker - 1-9 cigs/day1374. Moderate smoker - 10-19 cigs/d1375. Heavy smoker - 20-39 cigs/day1376. Very heavy smoker - 40+cigs/d1377. Ex-trivial smoker (<1/day)1378. Ex-light smoker (1-9/day)1379. Ex-moderate smoker (10-19/day)137A. Ex-heavy smoker (20-39/day)137B. Ex-very heavy smoker (40+/day)137C. Keeps trying to stop smoking137D. Admitted tobacco cons untrue ?

137F.-137H.137F. Ex-smoker - amount unknown137G. Trying to give up smoking137H. Pipe smoker

137J. Cigar smoker137K. Stopped smoking

137M.-137T.

137M. Rolls own cigarettes137N. Ex pipe smoker137O. Ex cigar smoker137P. Cigarette smoker137Q. Smoking started137R. Current smoker137S. Ex smoker137T. Date ceased smoking

137V. Smoking reduced

137X.-137h.

137X. Cigarette consumption137Y. Cigar consumption137Z. Tobacco consumption NOS137a. Pipe tobacco consumption137b. Ready to stop smoking137c. Thinking about stopping smoking137d. Not interested in stopping smoking137e. Smoking restarted137f. Reason for restarting smoking137g. Cigarette pack-years137h. Minutes from waking to first tobacco consumption

137j. Ex-cigarette smoker137l. Ex roll-up cigarette smoker137m. Failed attempt to stop smoking

Review Codes

66YJ. Asthma annual review 66YJ. Asthma annual review66YK. Asthma follow-up66YQ. Asthma monitoring by nurse66YR. Asthma monitoring by doctor8B3j. Asthma medication review9OJA. Asthma monitoring check done

3

ASTHMA cont. To Index


SCIMP Suggested


Asthma Exercise codes

6635. Increasing exercise wheeze

Added V22 for new indicator Asthma9. Codes for Exercise, Sleep and Day symptoms require entry on the same date

663P. Asthma limiting activities663Q. Asthma not limiting activities663e. Asthma restricts exercise663e0 Asthma sometimes restricts exercise663e1 Asthma severely restricts exercise663f. Asthma never restricts exercise663w. Asthma limits walking up hills or stairs663x. Asthma limits walking on the flat

Asthma Sleep codes

663N. Asthma disturbing sleep


663N0 Asthma causing night waking663N1 Asthma disturbs sleep weekly663N2 Asthma disturbs sleep frequently663O. Asthma not disturbing sleep663O0 Asthma never disturbs sleep

663r. Asthma causes night symptoms 1 to 2 times per month

66YP. Asthma night-time symptoms66Ys. Asthma never causes night symptoms

Asthma Day Symptoms

663q. Asthma daytime symptoms


663s. Asthma never causes daytime symptoms

663t. Asthma causes daytime symptoms 1 to 2 times per month

663u. Asthma causes daytime symptoms 1 to 2 times per week

663v. Asthma causes daytime symptoms most days

Asthma Smoking exception code 137k. Refusal to give smoking status Added V22 as exception for Asthma10. Requires entry within the last 15 months.

4

Atrial Fibrillation To Index


SCIMP Suggested


Atrial Fibrillation G573% (excluding G5731)

G573. Atrial fibrillation and flutter G5730 Atrial fibrillationG5730 Atrial fibrillationG5732 Paroxysmal atrial fibrillationG5733 Non-rheumatic atrial fibrillationG5734 Permanent atrial fibrillationG5735 Persistent atrial fibrillationG573z Atrial fibrillation and flutter NOS

Excluded 212R. Atrial fibrillation resolved 212R. Atrial fibrillation resolved

Exceptions 9hF0. Excep atr fib qual ind: Pt uns 9hF0. Excep atr fib qual ind: Pt uns9hF1. Exc atr fib qual ind: Inf diss 9hF1. Exc atr fib qual ind: Inf diss

Salicylate contra-indications:persistent

14LK. H/O: aspirin allergy 14LK. H/O: aspirin allergyZV148 [V]Personal history of aspirin allergy TJ53. Adverse reaction to salicylates

U6051 [X]Salicylates causing adverse effects in therapeutic use

TJ53. Adverse reaction to salicylates

Salicylate contra-indications:expiring

8I24. Aspirin prophylaxis contra-indicated 8I24. Aspirin prophylaxis contra-indicated8I38. Aspirin prophylaxis refused 8I38. Aspirin prophylaxis refused8I66. Aspirin not indicated 8I66. Aspirin not indicated8I70. Aspirin not tolerated 8I70. Aspirin not tolerated

Warfarin contraindications: persistent

14LP. H/O: warfarin allergy 14LP. H/O: warfarin allergy

TJ42% (except TJ420)

TJ42. Adverse reaction to anticoagulants TJ421 Adverse reaction to warfarin sodiumTJ421 Adverse reaction to warfarin sodiumTJ422 Adverse reaction to nicoumaloneTJ423 Adverse reaction to phenindioneTJ42z Adverse reaction to anticoagulants NOS

U6042 [X]Anticoagulants causing adverse effects in therapeutic use

ZV14A [V]Personal history of warfarin allergy

Warfarin contraindications: expiring

8I25. Warfarin contraindicated 8I25. Warfarin contraindicated8I3E. Warfarin declined 8I3E. Warfarin declined8I65. Warfarin not indicated 8I65. Warfarin not indicated8I71. Warfarin not tolerated 8I71. Warfarin not tolerated8I2R. Anticoagulation contraindicated8I3d. Anticoagulation declined8I6N. Anticoagulation not indicated8I7A. Anticoagulation not tolerated

5

Atrial Fibrillation cont. To Index


SCIMP Suggested


Clopidrogel contraindications:persistent

14LQ. H/O: clopidogrel allergy 14LQ. H/O: clopidogrel allergy

U6048 [X]Clopidogrel causing adverse effects in therapeutic use U6048 [X]Clopidogrel causing adverse effects in

therapeutic useZV14B [V]Personal history of clopidogrel allergy

Clopidrogel contraindications:expiring

8I2K. Clopidogrel contraindicated 8I2K. Clopidogrel contraindicated8I3R. Clopidogrel declined 8I3R. Clopidogrel declined8I6B. Clopidogrel not indicated 8I6B. Clopidogrel not indicated8I72. Clopidogrel not tolerated 8I72. Clopidogrel not tolerated

Dipyridamole CI persisting

14LX. H/O: dipyridamole allergy 14LX. H/O: dipyridamole allergyTJC44 Adverse reaction to dipyridamole TJC44 Adverse reaction to dipyridamole

U60C3 [X]Coronary vasodilators causing adverse effects in therapeutic use, not elsewhere classified

Dipyridamole CI expiring

8I2b. Dipyridamole contraindicated 8I2b. Dipyridamole contraindicated8I3n. Dipyridamole declined 8I3n. Dipyridamole declined8I6a. Dipyridamole not indicated 8I6a. Dipyridamole not indicated8I7J. Dipyridamole not tolerated 8I7J. Dipyridamole not tolerated

OTC salicylate codes

67I8. Advice about taking aspirin 8B3T. Over the counter aspirin therapy8B63. Salicylate prophylaxis8B3T. Over the counter aspirin therapy8B6P. Clopidogrel prophylaxis

Salicylate prescriptions

Prescription for antiplatelets or anticoagulants needs to be within last 6 months.

Clopidogrel prescriptionsDipyridamole prescriptions

Warfarin Prescriptions and Code 8B2K. Anticoagulant prescribed by third party

Stroke Risk Assessment using CHAD 38DE. Congestive heart failure, hypertension, age, diabetes, stroke 2 risk score

New code in V22 for AF5. Synonym = CHADS" risk score. Requires a value for result added. Requires entry every 15 months.

6

CANCER To Index


SCIMP Suggested


Cancer Diagnosis

B0…-B32z.

B0% Malignant neoplasm of lip, oral cavity and pharynx Non-melanotic skin cancers excluded. Morphology codes (starting' BB%') also not included.

B1% Malignant neoplasm of digestive organs and peritoneum

B2% Malignant neoplasm of respiratory tract and intrathoracic organs

B3... Malignant neoplasm of bone, connective tissue, skin and breast

B30% Malignant neoplasm of bone and articular cartilage

B31% Malignant neoplasm of connective and other soft tissue

B32% Malignant melanoma of skin

B34..-B6z0

B34% Malignant neoplasm of female breastB35% Malignant neoplasm of male breast

B3y.. Malignant neoplasm of bone, connective tissue, skin and breast otherwise specified

B3z.. Malignant neoplasm of bone, connective tissue, skin and breast NOS

B4% Malignant neoplasm of genitourinary organ

B5% Malignant neoplasm of other and unspecified sites

B6% Malignant neoplasm of lymphatic and haemopoietic tissue

Byu..-Byu41

Byu.. [X]Additional neoplasm classification terms

Byu0. [X]Malignant neoplasm of lip, oral cavity and pharynx

Byu1% [X]Malignant neoplasm of digestive organs

Byu2% [X]Malignant neoplasm of respiratory and intrathoracic organs

Byu3% [X]Malignant neoplasm of bone and articular cartilage

Byu4. [X]Melanoma and other malignant neoplasms of skin

Byu40 [X]Malignant melanoma of other and unspecified parts of face

Byu41 [X]Malignant melanoma of skin, unspecified

Byu5.-ByuE0

Byu5% [X]Malignant neoplasm of mesothelial and soft tissue

Byu6. [X]Malignant neoplasm of breastByu7% [X]Malignant neoplasm of female genital organsByu8% [X]Malignant neoplasm of male genital organsByu9% [X]Malignant neoplasm of urinary tract

ByuA% [X]Malignant neoplasm of eye, brain and other parts of central nervous system

ByuB% [X]Malignant neoplasm of thyroid and other endocrine glands

ByuC% [X]Malignant neoplasm of ill-defined, secondary and unspecified sites

ByuD% [X]Malignant neoplasms of lymphoid, haematopoietic and related tissue

ByuE. [X]Malignant neoplasms of independent (primary) multiple sites

ByuE0 [X]Malignant neoplasms of independent (primary) multiple sites

Cancer exception codes 9h8%

9h8.. Exception reporting: cancer quality indicators 9h81. Excepted from cancer quality indicators: Patient unsuitable

9h81. Excepted from cancer quality indicators: Patient unsuitable 9h82. Excepted from cancer quality indicators: Informed

dissent

9h82. Excepted from cancer quality indicators: Informed dissent

Cancer Care Review 8BAV. Cancer care review 8BAV. Cancer care review For Cancers newly diagnosed in the last 18 months.

7

CHD To Index


SCIMP Suggested


Coronary Heart Disease Codes

G3…-G309.

G3… Ischaemic heart disease G3z.. Ischaemic heart disease NOSG30.. Acute myocardial infarction G340. Coronary atherosclerosisG300. Acute anterolateral infarctionG301% Other specified anterior myocardial infarctionG302. Acute inferolateral infarctionG303. Acute inferoposterior infarctionG304. Posterior myocardial infarction NOSG305. Lateral myocardial infarction NOSG306. True posterior myocardial infarctionG307% Acute subendocardial infarctionG308. Inferior myocardial infarction NOSG309. Acute Q-wave infarct

G30B.-G330z

G30B. Acute posterolateral myocardial infarction

G30X% Acute transmural myocardial infarction of unspecified site

G30y% Other acute myocardial infarctionG30z. Acute myocardial infarction NOS

G31% Other acute and subacute ischaemic heart disease

G32.. Old myocardial infarctionG33.. Angina pectorisG330% Angina decubitus

G33z-G3401G33z% Angina pectoris NOSG34.. Other chronic ischaemic heart diseaseG340% Coronary atherosclerosis

G342-G366.

G342. Atherosclerotic cardiovascular diseaseG343. Ischaemic cardiomyopathyG344. Silent myocardial ischaemiaG34y% Other specified chronic ischaemic heart diseaseG34z% Other chronic ischaemic heart disease NOSG35% Subsequent myocardial infarction

G36% Certain current complications following acute myocardial infarction

G38..-G3z..G38% Postoperative myocardial infarctionG3y.. Other specified ischaemic heart diseaseG3z.. Ischaemic heart disease NOS

Gyu3.% [X]Ischaemic heart diseases

Exception Codes 9h0%

9h0.. Exception reporting: CHD quality indicators 9h01. Excepted from CHD quality indicators: Patient unsuitable

9h01. Excepted from CHD quality indicators: Patient unsuitable 9h02. Excepted from CHD quality indicators: Informed

dissent

9h02. Excepted from CHD quality indicators: Informed dissent

8

CHD cont. To Index


SCIMP Suggested


Myocardial infarction codes

G30% (excluding G30A.)

G30.. Acute myocardial infarction G301z Anterior myocardial infarction NOSG300. Acute anterolateral infarctionG301% Other specified anterior myocardial infarctionG302. Acute inferolateral infarctionG303. Acute inferoposterior infarctionG304. Posterior myocardial infarction NOSG305. Lateral myocardial infarction NOSG306. True posterior myocardial infarctionG307% Acute subendocardial infarctionG308. Inferior myocardial infarction NOSG309. Acute Q-wave infarctG30B. Acute posterolateral myocardial infarction

G30X% Acute transmural myocardial infarction of unspecified site

G30y% Other acute myocardial infarctionG30z. Acute myocardial infarction NOS

G35%

G35.. Subsequent myocardial infarction G304. Posterior myocardial infarction NOSG350. Subsequent myocardial infarction of anterior wall G305. Lateral myocardial infarction NOSG351. Subsequent myocardial infarction of inferior wall G308. Inferior myocardial infarction NOSG353. Subsequent myocardial infarction of other sites G307. Acute subendocardial infarction

G35X. Subsequent myocardial infarction of unspecified site G30z. Acute myocardial infarction NOS

G38%

G38.. Postoperative myocardial infarction

G380. Postoperative transmural myocardial infarction of anterior wall

G381. Postoperative transmural myocardial infarction of inferior wall

G382. Postoperative transmural myocardial infarction of other sites

G383. Postoperative transmural myocardial infarction of unspecified site

G384. Postoperative subendocardial myocardial infarction

G38z. Postoperative myocardial infarction, unspecified

Gyu34 [X]Acute transmural myocardial infarction of unspecified site

Gyu36 [X]Subsequent myocardial infarction of unspecified site

Myocardial Infarction exception codes

9hM.. Exception reporting: myocardial infarction quality indicators

9hM0. Excepted from myocardial infarction quality indicators: informed dissent

9hM1. Excepted from myocardial infarction quality indicators: patient unsuitable

BP Recording Codes246%(Except 2460., 2468., 246H., 246I., 246K., 246L., 246M.)

O/E - blood pressure reading Blood Pressure values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values

BP Recording Exception Codes 8I3Y. Blood pressure procedure refused 8I3Y. Blood pressure procedure refused

Maximal BP therapy 8BL0. Patient on maximal tolerated antihypertensive therapy 8BL0. Patient on maximal tolerated antihypertensive therapy

9

CHD cont. To Index


SCIMP Suggested


Total Cholesterol Codes

44OE. Plasma total cholesterol level

Cholesterol values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values. V22 codes removed.

44P..

Serum cholesterol44P1. Serum cholesterol normal44P2. Serum cholesterol borderline44P3. Serum cholesterol raised44P4. Serum cholesterol very high

44PH. Total cholesterol measurement44PJ. Serum total cholesterol level

Exception from serum cholesterol target persisting

U60CA- [X]Statin causing adverse effect in therapeutic use U60CA [X]Statin causing adverse effect in therapeutic use

TJC24 Adverse reaction to simvastatinTJC25 Adverse reaction to pravastatin

Exception from serum cholesterol target expiring

8BL1. Patient on maximal tolerated lipid lowering therapy 8I3C. Statin declined

8I3C.- Statin declined 8I27. Statins contraindicated8I27. Statins contraindicated 8I63. Statin not indicated8I63. Statin not indicated8I76. Statin not tolerated























Salicylate prescriptions Prescribed in In last 15 monthsClopidogrel prescriptions Prescribed in In last 15 months

Warfarin Prescriptions and Code 8B2K. Anticoagulant prescribed by third party Prescribed in In last 15 months

10

CHD cont. To Index


SCIMP Suggested


Beta Blocker contraindications:persistent

14LL. H/O: betablocker allergy 14LL. H/O: betablocker allergy

TJC6%

TJC6. Adverse reaction to betablockers TJC6. Adverse reaction to betablockersTJC61 Adverse reaction to acebutololTJC62 Adverse reaction to atenololTJC63 Adverse reaction to labetalolTJC64 Adverse reaction to metoprololTJC65 Adverse reaction to nadololTJC66 Adverse reaction to oxprenololTJC67 Adverse reaction to sotalolTJC68 Adverse reaction to timololTJC6z Adverse reaction to betablockers NOS

U60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified

U60B9 [X]Adverse reaction to bisoprololU60BA [X]Adverse reaction to carvedilolU60BB [X]Adverse reaction to nebivololZV14C [V]Personal history of betablocker allergyZVu6i [X]Personal history of allergy to bisoprololZVu6o [X]Personal history of allergy to carvedilolZVu6q [X]Personal history of allergy to nebivolol

Beta Blocker contraindications:expiring

8I26. Beta blocker contraindicated 8I26. Beta blocker contraindicated8I2g. Bisoprolol contraindicated 8I36. Beta blocker therapy refused8I2h. Carvedilol contraindicated 8I62. Beta blocker not indicated8I2i. Nebivolol contraindicated 8I73. Beta blocker not tolerated8I36. Beta blocker therapy refused8IAS. Bisoprolol therapy refused8IAT. Carvedilol therapy refused8IAV. Nebivolol therapy refused8I62. Beta blocker not indicated8I6i. Bisoprolol not indicated8I6j. Carvedilol not indicated8I6k. Nebivolol not indicated8I73. Beta blocker not tolerated8I7K. Bisoprolol not tolerated8I7L. Carvedilol not tolerated8I7M. Nebivolol not tolerated

Beta Blocker prescriptions Prescribed in last 6 months

Ace inhibitor contraindications: persistent

14LM. H/O: angiotensin converting enzyme inhibitor allergy TJC78 Adverse reaction to enalapril

U60C4 [X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic use

ZV14D [V]Personal history of angiotensin-converting-enzyme inhibitor allergy

TJC77 Adverse reaction to captoprilTJC78 Adverse reaction to enalaprilTJC79 Adverse reaction to ramipril

Ace inhibitor contraindications: expiring

8I28. Angiotensin converting enzyme inhibitors contraindicated 8I28. Angiotensin converting enzyme inhibitors

contraindicated

8I3D. Angiotensin converting enzyme inhibitor declined 8I3D. Angiotensin converting enzyme inhibitor declined

8I64. Angiotensin converting enzyme inhibitor not indicated 8I64. Angiotensin converting enzyme inhibitor not indicated

8I74. Angiotensin converting enzyme inhibitor not tolerated 8I74. Angiotensin converting enzyme inhibitor not tolerated

11

CHD cont. To Index


SCIMP Suggested


AII antagonist contraindications: persisting

14LN. H/O: angiotensin II receptor antagonist allergy 14LN. H/O: angiotensin II receptor antagonist allergy

U60CB [X]Angiotensin II receptor antagonists causing adverseeffects in therapeutic use

ZV14E [V]Personal history of angiotensin II receptor antagonist allergy

AII antagonist contraindications: expiring

8I2H. Angiotensin II receptor antagonists contraindicated 8I2H. Angiotensin II receptor antagonists contraindicated

8I3P. Angiotensin II receptor antagonist declined 8I3P. Angiotensin II receptor antagonist declined8I6C. Angiotensin II receptor antagonist not indicated 8I6C. Angiotensin II receptor antagonist not indicated8I75. Angiotensin II receptor antagonist not tolerated 8I75. Angiotensin II receptor antagonist not tolerated

ACE inhibitor prescriptions Prescribed in last 6 months

A II antagonist prescription codes Prescribed in last 6 months.

Statin prescriptions and code 8B3z. Over the counter statin therapy V22 OTC statin code no longer valid

Statin contraindications persistingU60CA [X]Statin causing adverse effect in therapeutic use U60CA [X]Statin causing adverse effect in therapeutic use


Flu vaccine contraindications: persisting

14LJ. H/O: influenza vaccine allergy 14LJ. H/O: influenza vaccine allergy

U60K4 [X]Influenza vaccine causing adverse effects in therapeutic use

ZV14F [V]Personal history of influenza vaccine allergy

Flu vaccine contraindications: expiring

8I2F. Influenza vaccination contraindicated 8I2F1. Seasonal Influenza vaccination contraindicated

Code change in V22 with 9OX5., 8I2F., 8I6D. no longer valid and 9OX51, 8I2F1 and 8I6D1 added.

8I2F0 Seasonal influenza vaccination contraindicated 8I6D1. Seasonal Influenza vaccination not indicated8I6D. Influenza vaccination not indicated 68NE. No consent - influenza imm.8I6D0 Seasonal influenza vaccination not indicated 9OX51 Seasonal influenza vaccination declined68NE. No consent - influenza imm.9OX5. Influenza vaccination declined9OX51 Seasonal influenza vaccination declined

Flu vaccine prescriptions and codes

65E..-65E4.

65E.. Influenza vaccination 65ED. Seasonal Influenza vaccination

Prescribed in the previous 1st September to 31st March. V22 Codes used in 2011-12 season no longer valid and new one available specifying seasonal Flu vaccination.

65E0. First pandemic influenza vaccination65E1. Second pandemic influenza vaccination

65E2. Influenza vaccination given by other healthcare provider

65E3. First pandemic influenza vaccination given by other healthcare provider

65E4. Second pandemic influenza vaccination given by other healthcare provider

ZV048 [V]Influenza vaccination65ED. Seasonal influenza vaccination

65E20 Seasonal influenza vaccination given by other healthcare provider

12

CKD To Index


SCIMP Suggested


Age>=18

CKD Codes Stage 3 - 5

1Z12. Chronic kidney disease stage 3 1Z12. Chronic kidney disease stage 3

See bottom of sheet for classification of CKD.

1Z1B. CKD stage 3 with proteinuria 1Z13. Chronic kidney disease stage 41Z1C. CKD stage 3 wthout proteinuria 1Z14. Chronic kidney disease stage 51Z15. Chronic kidney diseas stage 3A1Z1D. CKD stage 3A with proteinuria1Z1E. CKD stge 3A wthout proteinuria1Z16. Chronic kidney diseas stage 3B1Z1F. CKD stage 3B with proteinuria1Z1G. CKD stge 3B wthout proteinuria1Z13. Chronic kidney disease stage 41Z1H. CKD stage 4 with proteinuria1Z1J. CKD stage 4 wthout proteinuria1Z14. Chronic kidney disease stage 51Z1K. CKD stage 5 with proteinuria1Z1L. CKD stage 5 wthout proteinuria

Excluded CKD codes

1Z10. Chronic kidney disease stage 1 1Z10. Chronic kidney disease stage 1

These codes exclude the patient if dated later than the most recent CKD Codes 3-5.

1Z17. CKD stage 1 with proteinuria 1Z11. Chronic kidney disease stage 21Z18. CKD stage 1 wthout proteinuria1Z11. Chronic kidney disease stage 21Z19. CKD stage 2 with proteinuria1Z1A. CKD stage 2 wthout proteinuria

Exception codes 9hE0. Ex ch kid dis qu ind: Pat uns 9hE0. Ex ch kid dis qu ind: Pat uns9hE1. Ex ch kid dis qua ind: Inf dis 9hE1. Ex ch kid dis qua ind: Inf dis


O/E - blood pressure reading Blood Pressure values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values



Hypertension

G2... Hypertensive disease G2… Hypertensive disease V22 code G24z1 removedG20% Essential hypertension G20.. Essential hypertension

G24..-G2z.. (excluding G24z1)

G240% Secondary malignant hypertension G200. Malignant essential hypertensionG241% Secondary benign hypertension G24.. Secondary hypertensionG244. Hypertension secondary to endocrine disorders G201. Benign essential hypertensionG24z. Secondary hypertension NOS G202. Systolic hypertensionG24z0 Secondary renovascular hypertension NOSG24zz Secondary hypertension NOSG2y.. Other specified hypertensive diseaseG2z.. Hypertensive disease NOS

Gyu2. [X]Hypertensive diseasesGyu20 [X]Other secondary hypertension

Gyu21 [X]Hypertension secondary to other renal disorders

Hypertension resolved 21261 Hypertension resolved 21261 Hypertension resolved212K. Hypertension resolved

Proteinuria

1Z1B. Chronic kidney disease stage 3 with proteinuria R110. [D]Proteinuria1Z1D. Chronic kidney disease stage 3A with proteinuria R1100 [D]Albuminuria1Z1F. Chronic kidney disease stage 3B with proteinuria R1103 [D]Microalbuminuria1Z1H. Chronic kidney disease stage 4 with proteinuria1Z1K. Chronic kidney disease stage 5 with proteinuriaR110. [D]ProteinuriaR1100 [D]AlbuminuriaR1103 [D]MicroalbuminuriaR110z [D]Proteinuria NOS

13

CKD cont. To Index


SCIMP Suggested









contraindicated




Albumin/Creatinine or Protein/Creatinine Ratio

44lD. Urine protein/creatinine ratio 46TC. Urine albumin:creatinine ratio46TC. Urine albumin:creatinine ratio








ACE inhibitor prescriptions Prescribed in last 6 monthsA II antagonist prescription codes Prescribed in last 6 months.

14

To IndexClassification of CRD - From US National Kidney Foundation

GFRStage 1 - Kidney Damage with normal or raised GFR >=90Stage 2 - Kidney Damage with mild decrease GFR 60 - 89Stage 3 - Moderate decrease in GFR 30 - 59Stage 4 - Severe decrease in GFR 15 - 29Stage 5 - Kidney Failure < 15 (or dialysis)Chronic Kidney Disease is defined as either kidney damage or GFR<60mL/min/1.73m2 over a 3 month period

15

COPD To Index


SCIMP Suggested


COPD Diagnosis

H3… Chronic obstructive pulmonary disease H31.. Chronic bronchitisH31% (except H3101, H31y0, H3122)

Chronic bronchitis H32.. Emphysema

H32% Emphysema H3z.. Chronic obstructive airways disease NOS

H36..-H3z..

H36.. Mild chronic obstructive pulmonary diseaseH37.. Moderate chronic obstructive pulmonary diseaseH38.. Severe chronic obstructive pulmonary disease

H39.. Very severe chronic obstructive pulmonary disease

H3y.. Other specified chronic obstructive airways disease

H3y0. Chronic obstructive pulmonary disease with acute lower respiratory infection

H3y1. Chronic obstructive pulmonary disease with acute exacerbation, unspecified

H3z.. Chronic obstructive airways disease NOS

Diagnosis - Exclusion Codes 9h5%

9h5.. Exception reporting: COPD quality indicators 9h51. Excepted from COPD quality indicators: Patient unsuitable

9h51. Excepted from COPD quality indicators: Patient unsuitable 9h52. Excepted from COPD quality indicators: Informed

dissent

9h52. Excepted from COPD quality indicators: Informed dissent

Spirometry exception codes

8I2j. Spirometry contraindicated 8I2M. Spirometry reversibility testing contraindicated8I3b. Spirometry test declined 8I3b. Spirometry test declined8I6L. Spirometry not indicated 8I6L. Spirometry not indicated33720 Unable to perform spirometry

COPD Spirometry Codes745D4 Post bronchodilator spirometry

Patients can be coded with both Asthma and COPD if appropriate.8HRC. Referral for spirometry

16

COPD cont. To Index


SCIMP Suggested

CodesTerm

Codes for FEV1 33971 Forced expired volume in 1 second percentage change 339O. Forced expired volume in 1 second

3398. FEV1/FVC ratio normal3399. FEV1/FVC ratio abnormal339M. FEV1/FVC ratio339O. Forced expired volume in 1 second339O0 Forced expired volume in 1 second reversibility

339R.-339U.

339R. FEV1/FVC percent339S. Percent predicted FEV1

339S0 Percentage predicted forced expiratory volume in 1 second after bronchodilation

339T. FEV1/FVC > 70% of predicted339U. FEV1/FVC < 70% of predicted

339a. FEV1 before bronchodilation339b. FEV1 after bronchodilation339e. FEV1 pre steroids339f. FEV1 post steroids

339j.-339m.

339j. FEV1/FVC ratio pre steroids339k. FEV1/FVC ratio post steroids339l. FEV1/FVC ratio before bronchodilator339m. FEV1/FVC ratio after bronchodilator

339O1 Forced expired volume in one second/vital capacity ratio

MRC Rating

173H. MRC Breathlessness Scale: grade 1173I. MRC Breathlessness Scale: grade 2173J. MRC Breathlessness Scale: grade 3173K. MRC Breathlessness Scale: grade 4173L. MRC Breathlessness Scale: grade 5

COPD Review

66YM. Chronic obstructive pulmonary disease annual review

66YB0 Chronic obstructive pulmonary disease 3 monthly review

66YB1 Chronic obstructive pulmonary disease 6 monthly review










65E..-65E4.









17

t

CVD - Primary Prevention To Index


SCIMP Suggested


Applies to Patients newly diagnosed with Hypertension since 1.4.09. Patients with co-existing CHD, Stroke, TIA, Diabetes, PVD, Familial Hypercholesterolaemia or CKD are excluded from population

Codes for Hypertension, CHD, Stroke, TIA, Diabetes and CKD as detailed in relevant sections within this spreadsheet.

Patients age under 30 or 75 or over, newly diagnosed with hypertension are excluded from requiring risk assessment (PP1) but do still require lifestyle advice (PP2).

PVD

G73.. Other peripheral vascular disease G73z. Peripheral vascular disease NOS

G73z% (excluding G73z1)

G73z. Peripheral vascular disease NOSG73z0 Intermittent claudicationG73zz Peripheral vascular disease NOS

Gyu74 [X]Other specified peripheral vascular diseases

Familial Hypercholesterolaemia

C3200 Familial hypercholesterolaemia C3200 Familial hypercholesterolaemiaC3201 HyperbetalipoproteinaemiaC3204 Fredrickson's hyperlipoproteinaemia, type IIaC3205 Familial defective apolipoprotein B-100

CVD Risk Assessment Exception codes

9hJ0. Excepted from cardiovascular disease quality indicators: patient unsuitable

Codes 8IAK. and 90h9. will only exclude poatient fron the risk assessment indicator. They will still require lifestyle advice.9hJ1. Excepted from cardiovascular disease quality

indicators: informed dissent9Oh9. Cardiovascular disease risk assessment declined8IAK. Cardiovascular disease high risk review declined

CVD Risk Assessment codes

662k.-662n.

662k. JBS cardiovascular disease risk <10 percent over nexten years 38DR. Framingham 1991 cardiovascular disease 10 year

risk score

Requires entry within 3 months of hypertension diagnosis

662l. JBS cardiovascular disease risk 10 - 20 percent over next ten years 38D6. Assessing cardiovascular risk using SIGN score

662m. JBS cardiovascular disease risk 20 - 30 percent over next ten years

662n. JBS cardiovascular disease risk >30 percent over nextten years

38B10 CVD (cardiovascular disease) risk assessment by third party

38DF. QRISK cardiovascular disease 10 year risk score38D6. Assessing cardiovascular risk using SIGN score

38DR. Framingham 1991 cardiovascular disease 10 year risk score

38DP. QRISK2 cardiovascular disease 10 year risk score

Lifestyle Counselling 67H.. Lifestyle counselling Requires entry in the last 15 months for new hypertension since 1.4.0967H8. Lifestyle advice regarding hypertension

18

DEMENTIA To Index


SCIMP Suggested


Dementia

Eu02%

Eu02. [X]Dementia in other diseases classified elsewhere Eu00. [X]Dementia in Alzheimer's disease

Eu020 [X]Dementia in Pick's disease Eu01. [X]Vascular dementiaEu021 [X]Dementia in Creutzfeldt-Jakob disease Eu02z [X] Unspecified dementiaEu022 [X]Dementia in Huntington's disease F110. Alzheimer's diseaseEu023 [X]Dementia in Parkinson's disease

Eu024 [X]Dementia in human immunodef virus [HIV] disease

Eu02y [X]Dementia in other specified diseases classif elsewhere

Eu02z [X] Unspecified dementia

E00%

E00.. Senile and presenile organic psychotic conditionsE000. Uncomplicated senile dementiaE001% Presenile dementia

E002% Senile dementia with depressive or paranoid features

E003. Senile dementia with deliriumE004% Arteriosclerotic dementiaE00y. Other senile and presenile organic psychosesE00z. Senile or presenile psychoses NOS

Eu01%

Eu01. [X]Vascular dementiaEu010 [X]Vascular dementia of acute onsetEu011 [X]Multi-infarct dementiaEu012 [X]Subcortical vascular dementia

Eu013 [X]Mixed cortical and subcortical vascular dementia

Eu01y [X]Other vascular dementiaEu01z [X]Vascular dementia, unspecified

E02y1 Drug-induced dementia

E012% E012. Other alcoholic dementiaE0120 Chronic alcoholic brain syndrome

Eu00%

Eu00. [X]Dementia in Alzheimer's disease

Eu000 [X]Dementia in Alzheimer's disease with early onset

Eu001 [X]Dementia in Alzheimer's disease with late onset

Eu002 [X]Dementia in Alzheimer's dis, atypical or mixed type

Eu00z [X]Dementia in Alzheimer's disease, unspecifiedE041. Dementia in conditions ECEu041 [X]Delirium superimposed on dementia

F110.-F112.

F110. Alzheimer's diseaseF1100 Alzheimer's disease with early onsetF1101 Alzheimer's disease with late onsetF111. Pick's diseaseF112. Senile degeneration of brain

F116. Lewy body disease

Dementia Exclusions 9hD0. Exc demen qual ind: Pat unsuit 9hD0. Exc demen qual ind: Pat unsuit9hD1. Exc demen qual ind: Inform dis 9hD1. Exc demen qual ind: Inform dis

FBC

423.. Haemoglobin estimationRequires entry within time period 6 months before to 6 months after the first diagnosis date

426.. Red blood cell (RBC) count42A.. Mean corpuscular volume (MCV)42H.. Total white cell count

Calcium

44h4. Blood calcium level

Requires entry within time period 6 months before to 6 months after the first diagnosis date

44I8. Serum calcium44h7. Plasma calcium level44IE. Serum ionized calcium (pH 7.4) level44ID. Serum ionised calcium level44IC. Corrected serum calcium level44h9. Plasma corrected calcium level44hD. Blood ionised calcium level

19

DEMENTIA cont. To Index


SCIMP Suggested


Glucose

44TM. Blood glucose series


44f% Serum glucose level44g% Plasma glucose level44T1. Random blood sugar44T2. Fasting blood sugar44T3. 2 hours post food blood sugar44TA. Plasma glucose44TE. 30 minute blood glucose level44TF. 60 minute blood glucose level44TG. 90 minute blood glucose level44TH. 120 minute blood glucose level44TI. 150 minute blood glucose level44TJ. Blood glucose level44TK. Fasting blood glucose level44U% (excluding 44Uz.) Blood glucose result

44V.. Glucose tolerance test44V1. Glucose tolerance test normal44V2. Glucose tol. test impaired44V3. Glucose tol. test diabetic44V6. Extended glucose tolerance testR102. [D]Glucose tolerance test abnormalR10D. [D]Elevated blood glucose levelR1057 [D]Glucose, blood level abnormal

IFCC HbA1c 42W5. Haemoglobin A1c level - IFCC standard V22 New field

Glucose test exception 8IEG. Blood glucose test declined V22 New field

Renal function

44J3. Serum creatinine


44J9. Serum urea level44JA. Plasma urea level44JC. Corrected plasma creatinine level44JD. Corrected serum creatinine level44JF. Plasma creatinine level

Liver function

44E.. Serum bilirubin level

Requires entry within time period 6 months before to 6 months after the first diagnosis date. Codes removed in V22 (SCIMP checking this with UK terminology group)

44E9. Plasma total bilirubin level44EC. Serum total bilirubin level44F3. Total alkaline phosphatase44CU. Plasma alkaline phosphatase level44FA. Plasma alkaline phosphatase liver isoenzyme level44FD. Serum alkaline phosphatase liver isoenzyme level44FH. Alkaline phosphatase liver isoenzyme level44G4. Gamma - G.T. level44G7. Plasma gamma-glutamyl transferase level44G9. Serum gamma-glutamyl transferase level44GA. Plasma alanine aminotransferase level44GB. Serum alanine aminotransferase level

Thyroid function442W. Serum TSH level Requires entry within time period 6 months before to 6 months after the first

diagnosis date442X. Plasma TSH level442A. TSH - thyroid stim. hormone

Vit B12 42T.. Serum vitamin B12 Requires entry within time period 6 months before to 6 months after the first diagnosis date44Le. Plasma vitamin B12 level

Folic acid42U4. Red blood cell folate Requires entry within time period 6 months before to 6 months after the first

diagnosis date. 42U5. Serum folate42UE. Plasma folate level

Dementia review 6AB Dementia Annual Review 6AB.. Dementia Annual Review Requires entry within the previous 15 months and after the Dementia diagnosis date.

20

Depression To Index


SCIMP Suggested


For Dep1 - Population = ALL patients with Diabetes or CHD (ie. they may not have a current diagnosis of depression)

Age>=18 (for Dep2 only)

Depression (For Dep2)

E0013 Presenile dementia with depressionE0021 Senile dementia with depressionE112% Single major depressive episode Eu32. [X]Depressive episodeE113% Recurrent major depressive episode Eu33. [X]Recurrent depressive disorderE118. Seasonal affective disorderE11y2 Atypical depressive disorderE11z2 Masked depressionE130. Reactive depressive psychosisE135. Agitated depressionE2003 Anxiety with depressionE291. Prolonged depressive reactionE2B.. Depressive disorder NECE2B1. Chronic depressionEu204 [X]Post-schizophrenic depressionEu251 [X]Schizoaffective disorder, depressive type

Eu32% (excluding Eu32A, Eu32B, Eu329)

Eu32. [X]Depressive episodeEu320 [X]Mild depressive episodeEu321 [X]Moderate depressive episode

Eu322 [X]Severe depressive episode without psychotic symptoms

Eu323 [X]Severe depressive episode with psychotic symptoms

Eu324 [X]Mild depressionEu325 [X]Major depression, mildEu326 [X]Major depression, moderately severe

Eu327 [X]Major depression, severe without psychotic symptoms

Eu328 [X]Major depression, severe with psychotic symptoms

Eu32y [X]Other depressive episodesEu32z [X]Depressive episode, unspecified

Eu33%

Eu33. [X]Recurrent depressive disorder

Eu330 [X]Recurrent depressive disorder, current episode mild

Eu331 [X]Recurrent depressive disorder, current episode moderate

Eu332 [X]Recurrent depressive disorder, current episode severe without psychotic symptoms

Eu333 [X]Recurrent depressive disorder, current episode severe with psychotic symptoms

Eu334 [X]Recurrent depressive disorder, currently in remission

Eu33y [X]Other recurrent depressive disordersEu33z [X]Recurrent depressive disorder, unspecified

Eu341 [X]DysthymiaEu412 [X]Mixed anxiety and depressive disorder

Depression resolved 212S. Depression resolved 212S. Depression resolved

Depression exceptions 9hC0. Exc depr qual: ind: Pat unsuit 9hC0. Exc depr qual: ind: Pat unsuit9hC1. Exc depressi qual ind: Inf dis 9hC1. Exc depressi qual ind: Inf dis

Depression question codes 68910 Assessment using Whooley depression screen6896. Depression screen using quest 6896. Depression screen using quest

Depression Assessment tool codes388f. Pt health quest (PHQ-9) score First entry required within the timeframe of depression diagnosis + 1 month.

2nd assessment code required within 2 to 12 weeks after the first assessment code.

388g. BDI second edition score388P. HAD scale: depression score

21

DIABETES To Index


SCIMP Suggested


Age >=17

Diabetes diagnosis

C10.. Diabetes mellitus C10E. Type 1 diabetes mellitus

V22, range of codes expanded

C109J Insulin treated Type 2 diabetes mellitus C10F. Type 2 diabetes mellitus

C109K Hyperosmolar non-ketotic state in type 2 diabetes mellitus

C10C. Diabetes mellitus autosomal dominantC10D. Diabetes mellitus autosomal dominant type 2C10E% Type 1 diabetes mellitus

C10F% (except C10F8) Type 2 diabetes mellitus

C10G% Secondary pancreatic diabetes mellitusC10H% Diabetes mellitus induced by non-steroid drugsC10M% Lipoatrophic diabetes mellitusC10N% Secondary diabetes mellitus

Diagnosis Resolved 21263 Diabetes resolved 21263 Diabetes resolved212H. Diabetes resolved

Diabetes Exception reporting codes9h4%

9h4.. Exception reporting: diabetes quality indicators 9h41. Excepted from diabetes quality indicators: Patient unsuitable

V22 code 9h43. no longer recognised as an exception code9h41. Excepted from diabetes quality indicators: Patient

unsuitable 9h42. Excepted from diabetes quality indicators: Informed dissent

9h42. Excepted from diabetes quality indicators: Informed dissent

9h43. Excepted from diabetes quality indicators: service unavailable

BMI Codes 22K% (excluding 22K9.) Body Mass Index

Codes for maximum tolerated diabetes treatment 8BL2. Patient on maximal tolerated therapy for diabetes 8BL2. Patient on maximal tolerated therapy for diabetes

IFCC HbA1c levels 42W5. Haemoglobin A1c level - IFCC standardised V22. IFCC results only ones now accepted for HbA1c

Retinal screening codes

2BB% O/E - retinal inspection 31280 Fundoscopy normal

3128%

3128. Fundoscopy 31281 Fundoscopy abnormal31280 Fundoscopy normal 66AD. Fundoscopy - diabetic check31281 Fundoscopy abnormal 68A7. Diabetic retinopathy screening31282 Dilated fundoscopy normal 68A8. Digital retinal screening31283 Camera fundoscopy31284 Indirect fundoscopy following mydriatic3128Z Fundoscopy NOS

3129. Eye fundus photography

312E.-312G.312E. Direct fundoscopy following mydriatic312F. Camera fundoscopy312G. Indirect fundoscopy following mydriatic

58C1. Retinal photography68A7. Diabetic retinopathy screening68A8. Digital retinal screening66AD. Fundoscopy - diabetic check8HBD. Retinopathy follow up8HBG. Diabetic retinopathy 12 month review8HBH. Diabetic retinopathy 6 month review9N1v. Seen in diabetic eye clinic9N2U. Seen by optician9N2V. Seen by optometrist9N2e. Seen by ophthalmologist9N2f. Seen by retinal screener9NNC. Under care of retinal screener

22

DIABETES cont. To Index


SCIMP Suggested


Retinal exclusion codes

8I6F. Diabetic retinopathy screening not indicated 8I6F. Diabetic retinopathy screening not indicated8I3X. Diabetic retinopathy screening refused 8I3X. Diabetic retinopathy screening refused

9OLD. Diabetic patient unsuitable for digital retinal photography

9m0A. Declined diabetic retinopathy screening

Foot examination exception codes

8I6G. Diabetic foot examination not indicated 8I6G. Diabetic foot examination not indicatedThese codes can be used for DM29 but codes 8IAo. And 8IB6. will not exclude from DM10

8I3W. Diabetic foot examination declined 8I3W. Diabetic foot examination declined8IAo. Foot pulse check declined8IB6. Patient unsuitable for foot pulse check

Neuropathy testing codes

311A. Monofilament foot sensation test 29BB. 10g monofilament sensation R foot normal29B7.-29BV. 29B7. 10g monofilament sensation present 29B9. 10g monofilament sensation R foot abnormal and other codes in range for monofilament test result.

29B1.-29B3.

29B1. O/E - tactile sensation normal 29BC. 10g monofilament sensation L foot normal29B2. O/E - anaesthesia present 29BA. 10g monofilament sensation L foot abnormal29B20 O/E - anaesthesia in legs 29H4. O/E - Vibration sense of right foot abnormal29B21 O/E - anaesthesia of extremities 29H5. O/E - Vibration sense of right foot normal29B3. O/E - hypoaesthesia present 29H6. O/E - Vibration sense of left foot abnormal

29H1.-29HB. O/E - vibration sense normal 29H7. O/E - Vibration sense of left foot normal and other codes in range for side and result of vibration test.

66Ac. Diabetic peripheral neuropathy screening66Aq. Diabetic foot screen9NND. Under care of diabetic foot screener8H7r. Refer to diabetic foot screener

Neuropathy testing exception codes

8I6G. Diabetic foot examination not indicated

These codes can be used for both DM10 and DM298I3W. Diabetic foot examination declined8IAn. Neuropathy assessment declined8IB5. Patient unsuitable for neuropathy assessment

Foot risk classification

2G5E. O/E - Right diabetic foot at low risk2G5F. O/E - Right diabetic foot at moderate risk2G5G. O/E - Right diabetic foot at high risk2G5H. O/E - Right diabetic foot - ulcerated2G5I. O/E - Left diabetic foot at low risk2G5J. O/E - Left diabetic foot at moderate risk2G5K. O/E - Left diabetic foot at high risk2G5L. O/E - Left diabetic foot - ulcerated

Right foot amputation 2G42. O/E - Amputated right leg2G44. O/E - Amputated right above knee2G46. O/E - Amputated right below knee

Left foot amputation2G43. O/E - Amputated left leg2G45. O/E - Amputated left above knee2G47. O/E - Amputated left below knee


O/E - blood pressure reading Blood Pressure values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values.



23



SCIMP Suggested


Proteinuria Diagnosis

R110. [D]Proteinuria R1100 [D]Albuminuria

Care should be taken only to use these codes for persistant proteinuria and not for dipstick test results

R1100 [D]AlbuminuriaR110z [D]Proteinuria NOS

C10EK Type 1 diabetes mellitus with persistent proteinuria

C10FL Type 2 diabetes mellitus with persistent proteinuria

K190X Persistent proteinuria, unspecifiedKyu5G [X]Persistent proteinuria, unspecified

Microalbuminural Testing

44lD. Urine protein/creatinine ratio 46W.. Urine microalbumin467A. 24 hour urine protein output 46W0. Urine microalbumin positive467E. Urine protein level 46W1. Urine microalbumin negative467H. Random urine protein level 46TC. Urine albumin:creatinine ratio

46W%

46W.. Urine microalbumin 46N5. 24 hour urine protein excretion test46W0. Urine microalbumin positive46W1. Urine microalbumin negative46W2. Microalbumin excretion rate

46TC. Urine albumin:creatinine ratio

46N5.-46N8.

46N5. 24 hour urine protein excretion test46N6. 24 hour urine albumin output46N7. Urine protein/creatinine index46N8. Urine microalbumin profile

46N3. Urine total protein46N4. Urine albumin

Serum Creatinine

44J3% Serum creatinine44JC. Corrected plasma creatinine level44JD. Corrected serum creatinine level44JF. Plasma creatinine level

Estimated Glomerular Filtration rate

451E. GFR calculated abbreviated MDRD

An alternative to Creatinine.451F. Glomerular filtration rate

451G. GFR calculated abbreviated MDRD adj for African Americ orign

Microralbuminuria

R1103 [D]Microalbuminuria R1103 [D]Microalbuminuria

C10EL Type 1 diabetes mellitus with persistent microalbuminuria

C10FM Type 2 diabetes mellitus with persistent microalbuminuria








contraindicated











24



SCIMP Suggested




Total Cholesterol Codes 44OE. Plasma total cholesterol level

Cholesterol values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values. V22 codes removed

44P..-44P4.

44P.. Serum cholesterol44P1. Serum cholesterol normal44P2. Serum cholesterol borderline44P3. Serum cholesterol raised44P4. Serum cholesterol very high

















65E..-65E4.









25

EPILEPSY To Index


SCIMP Suggested


Age >=18

Epilepsy Diagnosis

F25% (excluding F2501, F2504, F2511, F2516, F25y4, F256%, F258.-F25A.)

F25.. Epilepsy F25.. EpilepsyF250. Generalised nonconvulsive epilepsyF2500 Petit mal (minor) epilepsyF2502 Epileptic seizures - atonicF2503 Epileptic seizures - akineticF2505 Lennox-Gastaut syndrome

F250y Other specified generalised nonconvulsive epilepsy

F250z Generalised nonconvulsive epilepsy NOSF251. Generalised convulsive epilepsyF2510 Grand mal (major) epilepsyF2512 Epileptic seizures - clonicF2513 Epileptic seizures - myoclonicF2514 Epileptic seizures - tonicF2515 Tonic-clonic epilepsyF251y Other specified generalised convulsive epilepsyF251z Generalised convulsive epilepsy NOSF252. Petit mal statusF253. Grand mal status

F254% Partial epilepsy with impairment of consciousness

F255% Partial epilepsy without mention of impairment of consciousness

F257. Kojevnikov's epilepsyF25B. Alcohol-induced epilepsyF25C. Drug-induced epilepsyF25D. Menstrual epilepsyF25E. Stress-induced epilepsyF25F. Photosensitive epilepsyF25X. Status epilepticus, unspecifiedF25y. Other forms of epilepsyF25y0 Cursive (running) epilepsyF25y1 Gelastic epilepsy

F25y2Localization-related(focal)(partial)idiopathic epilepsy and epileptic syndromes with seizures of localised onset

F25y3 Complex partial status epilepticusF25y5 Panayiotopoulos syndromeF25yz Other forms of epilepsy NOS

F25z. Epilepsy NOSF1321 Progressive myoclonic epilepsySC200 Traumatic epilepsy

Epilepsy medication Prescription Prescribed in the previous 6 months.

Epilepsy resolved 21260 Epilepsy resolved 21260 Epilepsy resolved212J. Epilepsy resolved

Epilepsy Exception codes 9h6%

9h6.. Exception reporting: epilepsy quality indicators 9h61. Excepted from epilepsy quality indicators: Patient unsuitable

9h61. Excepted from epilepsy quality indicators: Patient unsuitable 9h62. Excepted from epilepsy quality indicators: Informed

dissent

9h62. Excepted from epilepsy quality indicators: Informed dissent

Seizure Frequency

6675. Fit frequency 667F. Seizure free >12 months667F. Seizure free >12 months 667Q. 1 to 12 seizures a year

667P.-667V.

667P. No seizures on treatment 667R. 2 to 4 seizures a month667Q. 1 to 12 seizures a year 667S. 1 to 7 seizures a week667R. 2 to 4 seizures a month 667T. Daily seizures667S. 1 to 7 seizures a week 667V. Many seizures a day667T. Daily seizures667V. Many seizures a day

Maximum anticonvulsant therapy 8BL3. Patient on maximal tolerated anticonvulsant therapy 8BL3. Patient on maximal tolerated anticonvulsant therapy

Seizure Free > 12 months 667F. Seizure free >12 months 667F. Seizure free >12 months

26

EPILEPSY cont. To Index


SCIMP Suggested


Females aged under 55

Contraceptive counselling 6110. Contraceptive advice for patients with epilepsyPatients require all three codes entered within the last 15 month to meet the new Epilespy9 indicator. It is not necessary for these all to be on the same day

Preconception advice 67IJ0 Pre-conception advice for patients with epilepsy

Pregnancy advice 67AF. Pregnancy advice for patients with epilepsy

Contraceptive advice exceptions8IAg. Contraceptive advice for patients with epilepsy

declined

To exception code from any one of these items the patient must have either an exception code or a code to meet the indicator for each of the 3 types of advice.

8IB2. Contraceptive advice for patients with epilepsy not indicated

Pre-conception advice exceptions8IAh. Pre-conception advice for patients with epilepsy

declined

8IB3. Pre-conception advice for patients with epilepsy not indicated

Pregnancy advice exceptions8IAi. Pregnancy advice for patients with epilepsy declined

8IB4. Pregnancy advice for patients with epilepsy not indicated

Hysterectomy codes

7E04% (excluding 7E04D) Abdominal excision of uterus

7E05% Vaginal excision of uterus7F1A0 Caesarean hysterectomy7L0A% Clearance of pelvisZV6G8 [V]Acquired absence of uterus

Sterilisation codes

7E10% Bilateral excision of adnexa of uterus

Permanent exclusion from indicator Epilepsy 9

7E111 Salpingoophorectomy of remaining solitary fallopian tube and ovary

7E113 Salpingectomy of remaining solitary fallopian tube NEC

7E115 Oophorectomy of remaining solitary ovary NEC7E15% Open bilateral occlusion of fallopian tubes7E160 Open ligation of remaining solitary fallopian tube7E162 Open clipping of remaining solitary fallopian tube7E1C. Endoscopic bilateral occlusion of fallopian tubes

7E1C3 Endoscopic bilateral placement of intrafallopian implants

7E1D0 Endoscopic occlusion of remaining solitary fallopian tube

159A. H/O: tubal ligationZV25x [V]Other sterilisationZV252 [V]Sterilisation

27

Heart Failure To Index


SCIMP Suggested


Heart Failure

G58%

G58.. Heart failure G58.. Heart failure

Heart Failure is no longer secondary to CHD (as for 2005-06). This population applies to Indicators HF1 and HF2.

G580. Congestive heart failure G581. Left ventricular failureG5800 Acute congestive heart failureG5801 Chronic congestive heart failureG5802 Decompensated cardiac failureG5803 Compensated cardiac failureG581. Left ventricular failureG5810 Acute left ventricular failureG582. Acute heart failureG583. Heart failure with normal ejection fractionG58z. Heart failure NOS

G1yz1 Rheumatic left ventricular failure

662f.-662i.

662f. New York Heart Assoc. classification - class I662g. New York Heart Assoc. classification - class II662h. New York Heart Assoc. classification - class III662i. New York Heart Assoc. classification - class IV

LVD

G581% G581. Left ventricular failure G581. Left ventricular failure

This population applies to indicator HF3 and HF4. Patients need both a 'Heart Failure' code and a 'LVD' code to qualify. V22. Codes removed

G5810 Acute left ventricular failure

585f. Echocardiogram shows left ventricular systolic dysfunction

585g. Echocardiogram shows left ventricular diastolic dysfunction

G5yy9 Left ventricular systolic dysfunctionG5yyA Left ventricular diastolic dysfunction

662f.-662i.

662f. New York Heart Assoc. classification - class I662g. New York Heart Assoc. classification - class II662h. New York Heart Assoc. classification - class III662i. New York Heart Assoc. classification - class IV

Heart Failure Exceptions 9hH%

9hH.. Exception reporting: heart failure quality indicators 9hH0. Excepted from heart failure quality indicators: Patient unsuitable

9hH0. Excepted from heart failure quality indicators: Patient unsuitable 9hH1. Excepted from heart failure quality indicators:

Informed dissent

9hH1. Excepted from heart failure quality indicators: Informed dissent

Echocardiogram

5853. U-S heart scan 5853. U-S heart scan

V22. New code added

58531 Echocardiogram abnormal 58531 Echocardiogram abnormal

585f. Echocardiogram shows left ventricular systolic dysfunction 33BD. Echocardiogram requested

585g. Echocardiogram shows left ventricular diastolic dysfunction 8HQ7. Referral for echocardiography

5C20. Echocardiogram equivocal 5531. Angiocardiography awaited33BD. Echocardiogram requested 5533. Angiocardiography abnormal8HQ7. Referral for echocardiography 8H44. Cardiological referralR1320 [D]Echocardiogram abnormalR1322 [D]Ultrasound cardiogram abnormal5531. Angiocardiography awaited5533. Angiocardiography abnormal5538. Angiocardiography equivocal

79380 Angiocardiography of both right and left sides of heart

79382 Angiocardiography of left side of heart NEC8H4R. Ref to cardio spec interest GP8HVJ. Private referral to cardiologist8H44. Cardiological referral

8H7o0 Fast track heart failure referral for transthoracic two dimensional echocardiogram

Echo Declined 56F1. Echocardiogram declined 56F1. Echocardiogram declined5534. Angiocardiography declined 5534. Angiocardiography declined






28

Heart Failure cont. To Index


SCIMP Suggested




contraindicated













Beta Blocker contraindications:persistent

14LL. H/O: betablocker allergy 14LL. H/O: betablocker allergy

TJC6%

TJC6. Adverse reaction to betablockers TJC6. Adverse reaction to betablockersTJC61 Adverse reaction to acebutololTJC62 Adverse reaction to atenololTJC63 Adverse reaction to labetalolTJC64 Adverse reaction to metoprololTJC65 Adverse reaction to nadololTJC66 Adverse reaction to oxprenololTJC67 Adverse reaction to sotalolTJC68 Adverse reaction to timololTJC6z Adverse reaction to betablockers NOS

U60B7 [X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not elsewhere classified

U60B9 [X]Adverse reaction to bisoprololU60BA [X]Adverse reaction to carvedilolU60BB [X]Adverse reaction to nebivololZV14C [V]Personal history of betablocker allergyZVu6i [X]Personal history of allergy to bisoprololZVu6o [X]Personal history of allergy to carvedilolZVu6q [X]Personal history of allergy to nebivolol

Beta Blocker contraindications:expiring

8I26. Beta blocker contraindicated 8I26. Beta blocker contraindicated

8I2g.-8I2i8I2g. Bisoprolol contraindicated 8I36. Beta blocker therapy refused8I2h. Carvedilol contraindicated 8I62. Beta blocker not indicated8I2i. Nebivolol contraindicated 8I73. Beta blocker not tolerated

8I36. Beta blocker therapy refused

8IAS. - 8IAV8IAS. Bisoprolol therapy refused8IAT. Carvedilol therapy refused8IAV. Nebivolol therapy refused

8I62. Beta blocker not indicated

8I6i. - 8I6k.8I6i. Bisoprolol not indicated8I6j. Carvedilol not indicated8I6k. Nebivolol not indicated

8I73. Beta blocker not tolerated

8I7K.-8!7M.8I7K. Bisoprolol not tolerated8I7L. Carvedilol not tolerated8I7M. Nebivolol not tolerated

Prescription codes for licensed Beta blocker

BISOPROLOL FUMARATEPrescribed in last 6 monthsCARVEDILOL

NEBIVOLOL

Prescription codes for unlicensed Beta blocker

All other Beta-Adrenoceptor Blockers apart for licensed ones above

Patient can remain on an unlicensed B-blocker if they were on this in the 6 months prior to Heart Failure diagnosis (ie. it may not be clinically appropriate to change to a licensed brand)

29

HYPERTENSION To Index


SCIMP Suggested


Hypertension

G2... Hypertensive disease G2… Hypertensive diseaseG20% Essential hypertension G20.. Essential hypertension

G24..-G2z.. (Except G24z1)

G24% Secondary hypertension G200. Malignant essential hypertensionG2y.. Other specified hypertensive disease G201. Benign essential hypertensionG2z.. Hypertensive disease NOS G202. Systolic hypertension

Gyu2. [X]Hypertensive diseases G24.. Secondary hypertensionGyu20 [X]Other secondary hypertension

Gyu21 [X]Hypertension secondary to other renal disorders

Hypertension resolved 21261 Hypertension resolved 21261 Hypertension resolved212K. Hypertension resolved

Hypertension Exception Codes 9h3%

9h3.. Exception reporting: hypertension quality indicators 9h31. Excepted from hypertension quality indicators: Patient unsuitable

9h31. Excepted from hypertension quality indicators: Patient unsuitable 9h32. Excepted from hypertension quality indicators:

Informed dissent

9h32. Excepted from hypertension quality indicators: Informed dissent





30

HYPOTHYROID To Index


SCIMP Suggested


Hypothyroid C04% Acquired hypothyroidism C03z. Acquired hypothyroidismC03% Congenital hypothyroidism C04.. Congenital hypothyroidism

Hypothyroid Medication prescription Prescribed in the previous 6 months

Hypothyroid Exception Codes 9h7%

9h7.. Exception reporting: thyroid quality indicators 9h71. Excepted from thyroid quality indicators: Patient unsuitable

9h71. Excepted from thyroid quality indicators: Patient unsuitable 9h72. Excepted from thyroid quality indicators: Informed

dissent

9h72. Excepted from thyroid quality indicators: Informed dissent

Thyroid function test codes 442% Thyroid hormone tests

31

Learning disabilities To Index


SCIMP Suggested


Age>=18

Learning disabilities

E3% Mental retardation 918e. On learning disability register

Eu7%

Eu7.. [X]Mental retardation Eu814 [X]Moderate learning disabilityEu70% [X]Mild mental retardation Eu815 [X]Severe learning disabilityEu71% [X]Moderate mental retardationEu72% [X]Severe mental retardationEu73% [X]Profound mental retardationEu7y% [X]Other mental retardationEu7z% [X]Unspecified mental retardation

Eu814 [X]Moderate learning disabilityEu815 [X]Severe learning disabilityEu816 [X]Mild learning disabilityEu817 [X]Profound learning disability

Eu81z [X]Developmental disorder of scholastic skills, unspecified

918e. On learning disability register

Learning disabilities Exception Codes 9hL%

9hL.. Exception reporting: learning disability quality indicators

9hL0. Excepted from learning disability quality indicators: informed dissent

9hL1. Excepted from learning disability quality indicators: patient unsuitable

Downs Syndrome PJ0%

PJ0.. Down's syndrome - trisomy 21PJ00. Trisomy 21, meiotic nondisjunctionPJ01. Trisomy 21, mosaicismPJ02. Trisomy 21, translocationPJ0z. Down's syndrome NOS

Hypothyroid C04% Acquired hypothyroidism C03z. Acquired hypothyroidismA previous diagnosis of hypothyroidism + on medication will exclude patient from indicator LD2 unless the hypothyroid diagnosis has been made within the last 15 months. Prescription of levothyroxine requires to be in the previous 6 months

C03% Congenital hypothyroidism C04.. Congenital hypothyroidism

Hypothyroid Medication prescription

Thyroid function test codes 442% Thyroid hormone tests Required in the last 15 months

32

Mental Health To Index


SCIMP Suggested


Psychosis, Schizophrenia + bipolar affective disease codes

E10% Schizophrenic disorders E104. Acute schizophrenic episode

Patients are in the Mental Health population if they have one of these diagnosis codes or they are on Lithium.

E110% Manic disorder, single episode E10z. Schizophrenia NOSE111% Recurrent manic episodes E12z. Paranoid psychosis NOS

E1124 Single major depressive episode, severe, with psychosis E130. Reactive depressive psychosis

E1134 Recurrent major depressive episodes, severe, with psychosis Eu220 [X]Delusional disorder

E114.-E117z

E114% Bipolar affective disorder, currently manic Eu300 [X]HypomaniaE115% Bipolar affective disorder, currently depressed Eu31. [X]Bipolar affective disorderE116% Mixed bipolar affective disorderE117% Unspecified bipolar affective disorder

E11y% (excluding E11y2)

E11y. Other and unspecified manic-depressive psychoses

E11y0 Unspecified manic-depressive psychosesE11y1 Atypical manic disorderE11y3 Other mixed manic-depressive psychoses

E11yz Other and unspecified manic-depressive psychoses NOS

E11z. Other and unspecified affective psychosesE11z0 Unspecified affective psychoses NOSE11zz Other affective psychosis NOSE12% Paranoid states

E13% (excluding E135.)

E13.. Other nonorganic psychosesE130. Reactive depressive psychosisE131. Acute hysterical psychosisE132. Reactive confusionE133. Acute paranoid reactionE134. Psychogenic paranoid psychosisE13y% Other reactive psychosesE13z. Nonorganic psychosis NOS

E2122 Schizotypal personality

Eu2%

Eu2.. [X]Schizophrenia, schizotypal and delusional disorders

Eu20% [X]SchizophreniaEu21. [X]Schizotypal disorderEu22% [X]Persistent delusional disordersEu23% [X]Acute and transient psychotic disordersEu24. [X]Induced delusional disorderEu25% [X]Schizoaffective disordersEu26% [X]Nonorganic psychosis in remissionEu2y. [X]Other nonorganic psychotic disordersEu2z. [X]Unspecified nonorganic psychosis

Eu30%

Eu30. [X]Manic episodeEu300 [X]HypomaniaEu301 [X]Mania without psychotic symptomsEu302 [X]Mania with psychotic symptomsEu30y [X]Other manic episodesEu30z [X]Manic episode, unspecified

Eu31%

Eu31. [X]Bipolar affective disorder

Eu310 [X]Bipolar affective disorder, current episode hypomanic

Eu311 [X]Bipolar affective disorder, current episode manic without psychotic symptoms

Eu312 [X]Bipolar affective disorder, current episode manic with psychotic symptoms

Eu313 [X]Bipolar affective disorder, current episode mild or moderate depression

Eu314 [X]Bipolar affective disorder, current episode severe depression without psychotic symptoms

Eu315 [X]Bipolar affective disorder, current episode severe depression with psychotic symptoms

Eu316 [X]Bipolar affective disorder, current episode mixed

Eu317 [X]Bipolar affective disorder, currently in remissionEu318 [X]Bipolar affective disorder type IEu319 X]Bipolar affective disorder type IIEu31y [X]Other bipolar affective disordersEu31z [X]Bipolar affective disorder, unspecified

Eu323 [X]Severe depressive episode with psychotic symptoms

Eu328 [X]Major depression, severe with psychotic symptoms

Eu329 [X]Single major depressive episode, severe, with psychosis, psychosis in remission

Eu32A [X]Recurrent major depressive episodes, severe, with psychosis, psychosis in remission

Eu333 [X]Recurrent depressive disorder, current episode severe with psychotic symptoms

33

Mental Health cont. To Index


SCIMP Suggested


Lithium Prescription codes d6% LITHIUM SALTS 665B. Lithium stopped prescribed in the last 6 monthsStopped Lithium (excluded) 665B. Lithium stopped Excludes patient if entered after the last prescription date

Remission from severe Mental Illness

E1005 Schizophrenia in remission

Exception codes patients permanently from the indicators but not from the MH overall population. If a later dated MH code is added this will over-ride the remission code

E1015 Hebephrenic schizophrenia in remissionE1025 Catatonic schizophrenia in remissionE1035 Paranoid schizophrenia in remissionE1055 Latent schizophrenia in remissionE1075 Schizo-affective schizophrenia in remissionE1106 Single manic episode in full remissionE1116 Recurrent manic episodes, in full remission

E1146 Bipolar affective disorder, currently manic, in full remission

E1156 Bipolar affective disorder, currently depressed, in full remission

E1166 Mixed bipolar affective disorder, in full remission

E1176 Unspecified bipolar affective disorder, in full remission

Eu223 [X]Paranoid state in remissionEu26. [X]Nonorganic psychosis in remissionEu317 [X]Bipolar affective disorder, currently in remission

Eu329 [X]Single major depressive episode, severe, with psychosis, psychosis in remission

Eu32A [X]Recurrent major depressive episodes, severe, with psychosis, psychosis in remission

Mental Health Exception codes 9h9%

9h9.. Exception reporting: mental health quality indicators 9h91. Excepted from mental health quality indicators: Patient unsuitable

9h91. Excepted from mental health quality indicators: Patient unsuitable 9h92. Excepted from mental health quality indicators:

Informed dissent

9h92. Excepted from mental health quality indicators: Informed dissent

MH Care plan 8CM2. Psychiatry care plan 8CM2. Psychiatry care plan8CR7. Mental health personal health plan

Lithium level test44W8% Serum lithium level Lithium level values should also be recorded for the Contract and your

software system will have a system to deal with Read coding of Values. Requires entry within previous 4 months

44vE. Lithium level therapeuticR1053 [D]Lithium, blood level abnormal

Lithium level Therapeutic 44W80 Lithium level therapeutic 44W80 Lithium level therapeutic This code is not required if Lithium values are within the therapeutic range (0.4 - 1.0).44vE. Lithium level therapeutic

Serum Creatinine

44J3% Serum creatinine Creatinine test results required in the last 9 months44JC. Corrected plasma creatinine level44JD. Corrected serum creatinine level44JF. Plasma creatinine level

TSH test

442A% TSH - thyroid stim. hormone TSH test results required in the last 9 months442K.-442T. 30 minute plasma TSH level There are others in this range for different times of testing442W. Serum TSH level442X. Plasma TSH level442e. Blood spot TSH level

34



SCIMP Suggested


Alcohol consumption136% (excluding 1368., 1369., 136M., 136W, 136Y., 136b.)

136.. Alcohol consumption 1361. Teetotaller

1361. Teetotaller 136L. Alcohol intake within recommended sensible limits

1362. Trivial drinker - <1u/day 136K. Alcohol intake above recommended sensible limits

1363. Light drinker - 1-2u/day1364. Moderate drinker - 3-6u/day1365. Heavy drinker - 7-9u/day1366. Very heavy drinker - >9u/day1367. Stopped drinking alcohol136A. Ex-trivial drinker (<1u/day)136C. Ex-moderate drinker - (3-6u/d)136C. Ex-moderate drinker - (3-6u/d)136D. Ex-heavy drinker - (7-9u/day)136E. Ex-very heavy drinker-(>9u/d)136F. Spirit drinker136G. Beer drinker136H. Drinks beer and spirits136I. Drinks wine136J. Social drinker

136K. Alcohol intake above recommended sensible limits

136L. Alcohol intake within recommended sensible limits

136N. Light drinker136O. Moderate drinker136P. Heavy drinker136Q. Very heavy drinker136R. Binge drinker136S. Hazardous alcohol use136T. Harmful alcohol use136V. Alcohol units per week136X. Alcohol units consumed on heaviest drinking day136Z. Alcohol consumption NOS136a. Increasing risk drinking136c. Higher risk drinking136d. Lower risk drinking

Alcohol Consumption screening declined

8IA7. Alcohol consumption screening test declinedRequires entry in the previous 15 months

8IAt. Extended intervention for excessive alcohol consumption declined

BMI 22K% (excluding 22K9.)

22K.. Body Mass Index22K1. Body Mass Index normal K/M222K2. Body Mass Index high K/M222K3. Body Mass Index low K/M222K4. Body mass index index 25-29 - overweight22K5. Body mass index 30+ - obesity22K6. Body mass index less than 2022K7. Body mass index 40+ - severely obese22K8. Body mass index 20-24 - normal



BP Recording Exception Codes 8I3Y. Blood pressure procedure refused Requires recording within the previous 15 months

Total Cholesterol:HDL

44PF. Total cholesterol:HDL ratio Applies only to patients age 40 and over. Patients with pre-existing, hypertension, diabetes, CHD, PVD, Stroke or TIA, familial hypercholesterolaemia, or CKD are excluded from requiring Tot Chol/HDL test.

44l2. Cholesterol/HDL ratio44lF. Serum cholesterol/HDL ratio44lG. Plasma cholesterol/HDL ratio

Familial Hypercholesterolaemia

C3200 Familial hypercholesterolaemia C3200 Familial hypercholesterolaemia

Excludes from requiring Tot Chol/HDL test.C3201 HyperbetalipoproteinaemiaC3204 Fredrickson's hyperlipoproteinaemia, type IIaC3205 Familial defective apolipoprotein B-100

35



SCIMP Suggested


Glucose

44TM. Blood glucose series

Applies only to patients age 40 and over. Patients with diabetes diagnosed more that 12 months ago are excluded.

44f% Serum glucose level44g% Plasma glucose level

44T1. - 44T3.

44T1. Random blood sugar44T10 Random blood sugar normal44T11 Random blood sugar low44T12 Random blood sugar raised44T2. Fasting blood sugar44T3. 2 hours post food blood sugar

44TA. Plasma glucose

44TE. - 44TK.

44TE. 30 minute blood glucose level44TF. 60 minute blood glucose level44TG. 90 minute blood glucose level44TH. 120 minute blood glucose level44TI. 150 minute blood glucose level44TJ. Blood glucose level44TK. Fasting blood glucose level

44U% (except 44Uz.) Blood glucose result

44V.. - 44V3.

44V.. Glucose tolerance test44V1. Glucose tolerance test normal44V2. Glucose tol. test impaired44V3. Glucose tol. test diabetic

44V6. Extended glucose tolerance testR102. [D]Glucose tolerance test abnormalR10D. [D]Elevated blood glucose levelR1057 [D]Glucose, blood level abnormal

IFCC HbA1c levels 42W5. Haemoglobin A1c level - IFCC standardised V22.Added as an alternative to Glucose test

Glucose test exception code 8IEG. Blood glucose test declined V22 added

Hysterectomy and equivalent codes

685H. No smear - benign hysterectomy

Permanent exclusion from indicator MH16

685I. No smear-amputation of cervix685K. No smear - no cervix9O8Y. No cervical smear required - no uterus7E05% Vaginal excision of uterus

7E040 Abdominal hysterocolpectomy and excision of periuterine tissue

7E042 Abdominal hysterocolpectomy NEC7E043 Total abdominal hysterectomy NEC7E046 Radical hysterectomy

7E049 Total abdominal hysterectomy and bilateral salpingoophorectomy

7E04B Laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy

7E04G Total abdominal hysterectomy with conservation of ovaries

7L0A% Clearance of pelvis26L3. Uterine cervix absent

Cervical Smear

4K22. - 2K29.

4K22. Cervical smear: negative

In Scotland for females age 20 - 60. Requires entry within the previous 5 yrs.

4K23. Cerv.smear: mild dyskaryosis4K24. Cerv.smear: severe dyskaryosis4K25. Cerv.smear:severe dysk.?inv.ca4K26. Cervical smear: ? gland neopl.4K27. Cervical smear:atrophic change4K28. Cerv.smear: mod.dyskaryosis4K29. Cerv.smear: borderline changes

4K2C. Smear NAD - no endocervical cells4KA1. Vaginal vault smear negative4KA3. Vaginal vault smear-atrophic4KA4. Vaginal vault smear abnormal6856. Ca cervix screen - up to date6859. Ca cervix - screen done

685B. - 685D.685B. Ca cervix screen normal685C. Ca cervix screen abnormal685D. Ca cervix screen + fee claim

685R. Liquid based cervical cytology screening7E2A2 Papanicolau smear NEC7E2A3 Vaginal vault smearZV762 [V]Screening for malignant neoplasm of cervix

7E2A0 Examination of female genital tract under anaesthetic and Papanicolau smear

36



SCIMP Suggested


Cervical cytology exceptions

6853. Ca cervix screen - not wanted

Requires entry within the previous 5 years685L. Cervical smear refused8I6K. Cervical smear not indicated9O8Q. Cerv.smear disclaimer received

37

Obesity To Index


SCIMP Suggested


Age >=16

Obesity

22K5. Body mass index 30+ - obesity Need to be recorded in the last 15 months22K7. Body mass index 40+ - severely obese

22K.. (If has attached value of >=30) Body Mass Index only if value attached of >=30 and recorded in the last 15 months

38

Osteoporosis: Secondary prevention of Fragility fractures To Index


SCIMP Suggested


New Area for 2012-13There are two populations for osteoporosis 1. age 50-74, require codes for fragility fracture after 1.4.12 and diagnosis of osteoporosis and DEXA scan code. 2. Those age 75+ require code for fragility fracture.

Fragility fracture N331N Fragility fracture N331N Fragility fractureN331M Fragility fracture due to unspecified osteoporosis

Osteoporosis

N330% (excluding N3305, N3307, N3308, N3309, N330A, N330D)

N330. Osteoporosis N330. OsteoporosisN3300 Osteoporosis, unspecifiedN3301 Senile osteoporosisN3302 Postmenopausal osteoporosisN3303 Idiopathic osteoporosisN3304 Dissuse osteoporosisN3306 Postoophorectomy osteoporosisN330B Vertebral osteoporosisN330C Osteoporosis localized to spine

N3312 Postoophorectomy osteoporosis with pathological fracture

N3313 Osteoporosis of disuse with pathological fractureN3316 Idiopathic osteoporosis with pathological fracture

N3318 - N331B

N3318 Osteoporosis + pathological fracture lumbar vertebrae

N3319 Osteoporosis + pathological fracture thoracic vertebrae

N331A Osteoporosis + pathological fracture cervical vertebrae

N331B Postmenopausal osteoporosis with pathological fracture

N331H - N331M

N331H Collapse of cervical vertebra due to osteoporosisN331J Collapse of lumbar vertebra due to osteoporosisN331K Collapse of thoracic vertebra due to osteoporosisN331L Collapse of vertebra due to osteoporosis NOSN331M Fragility fracture due to unspecified osteoporosis

NyuB0 [X]Other osteoporosis with pathological fractureNyuB1 [X]Other osteoporosis

NyuB8 [X]Unspecified osteoporosis with pathological fracture

Osteoporosis exception codes 9hP%

9hP.. Exception reporting: osteoporosis quality indicators

9hP0. Excepted from osteoporosis quality indicators: patient unsuitable

9hP1. Excepted from osteoporosis quality indicators: informed dissent

DEXA scan (without score)

58E4. Forearm DXA scan result osteoporotic58EA. Heel DXA scan result osteoporotic58EG. Hip DXA scan result osteoporotic58EM. Lumbar DXA scan result osteoporotic58EV. Femoral neck DEXA scan result osteoporotic

Dexa scan (with T score value < -2.5)

58E2. Forearm DXA scan T score58E8. Heel DXA scan T score58EE. Hip DXA scan T score58EK. Lumbar spine DXA scan T score58ES. Femoral neck DEXA scan T score

39

Osteoporosis cont. To Index


SCIMP Suggested


Bone sparing agents Category1 contra-indicated, persisting

14LT. H/O: bisphosphonate allergy To exception codes from bone sparing agents there needs to be an entry from each of the 4 categories of medication.

ZV14K [V]Personal history of bisphosphonate allergy

Bone sparing agents Category 1 contra-indicated, expiring

8I3e. Bisphosphonates declined

requires entry within the last 15 months8I6R. Bisphosphonates not indicated8I7E. Bisphosphonates not tolerated8I2V. Bisphosphonates contraindicated

Bone sparing agents Category2 contra-indicated, persisting 14La. H/O: raloxifene allergy

Bone sparing agents Category2 contra-indicated, expiring

8I6p. Raloxifene not indicated

requires entry within the last 15 months8I7P. Raloxifene not tolerated8IEH. Raloxifene declined8I2l. Raloxifene contraindicated

Bone sparing agents Category3 contra-indicated, persisting 14Lb. H/O: teriparatide allergy


8I6q. Teriparatide not indicated

requires entry within the last 15 months8I7Q. Teriparatide not tolerated8IED. Teriparatide declined8I2m. Teriparatide contraindicated

Bone sparing agents Category4 contra-indicated, persisting

14LW. H/O: strontium ranelate allergyZV14H [V]Personal history of strontium ranelate allergy


8I3h. Strontium ranelate declined

requires entry within the last 15 months8I6V. Strontium ranelate not indicated8I7H. Strontium ranelate not tolerated8I2Y. Strontium ranelate contraindicated

Bone sparing agent prescriptions

fo1% DISODIUM ETIDRONATE

Requires prescription in the last 6 months

fo4% ALENDRONIC ACIDfo6% RISEDRONATE SODIUMfv1% RALOXIFENE HYDROCHLORIDEfu3% TERIPARATIDEfu5% STRONTIUM

40

Peripheral Arterial Disease To Index


SCIMP Suggested


New Area for 2012-13

PAD

G73.. Other peripheral vascular disease G73z. Peripheral vascular disease NOS

G73z% (excluding G73z1)

G73z. Peripheral vascular disease NOSG73z0 Intermittent claudicationG73zz Peripheral vascular disease NOS

Gyu74 [X]Other specified peripheral vascular diseases

PAD Exception codes

9hS.. Exception reporting: peripheral arterial disease quality indicators

9hS0. Excepted from peripheral arterial disease quality indicators: patient unsuitable

9hS1. Excepted from peripheral arterial disease quality indicators: informed dissent



BP Recording Exception Codes 8I3Y. Blood pressure procedure refused Requires recording within the previous 15 months


Total Cholesterol Codes 44OE. Plasma total cholesterol levelCholesterol values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values.

44P.. Serum cholesterol44PH. Total cholesterol measurement44PJ. Serum total cholesterol level






Requires recording within the previous 15 months8I3C.- Statin declined 8I27. Statins contraindicated8I27. Statins contraindicated 8I63. Statin not indicated8I63. Statin not indicated8I76. Statin not tolerated

41

Peripheral Arterial Disease cont. To Index


SCIMP Suggested


Salicylate prescriptions Prescribed in In last 15 monthsClopidogrel prescriptions Prescribed in In last 15 months

Warfarin Prescriptions and Code 8B2K. Anticoagulant prescribed by third party Prescribed in In last 15 months. Warfarin acts as an exclusion for being given aspirin or other anti-platelet medication. Therefore there are no exception








8I24. Aspirin prophylaxis contra-indicated 8I24. Aspirin prophylaxis contra-indicated

Requires recording within the previous 15 months8I38. Aspirin prophylaxis refused 8I38. Aspirin prophylaxis refused8I66. Aspirin not indicated 8I66. Aspirin not indicated8I70. Aspirin not tolerated 8I70. Aspirin not tolerated






8I2K. Clopidogrel contraindicated 8I2K. Clopidogrel contraindicated

Requires recording within the previous 15 months8I3R. Clopidogrel declined 8I3R. Clopidogrel declined8I6B. Clopidogrel not indicated 8I6B. Clopidogrel not indicated8I72. Clopidogrel not tolerated 8I72. Clopidogrel not tolerated

42

Palliative Care To Index


SCIMP Suggested


1Z01. Terminal illness - late stage ZV57C [V]Palliative care2JE.. Last days of life 8CM1. On gold standards palliative care framework8BA2. Terminal care 8HH7. Referred to community specialist palliative care

8BAP.team

Specialist palliative care8BAS. Specialist palliative care treatment - daycare8BAT. Specialist palliative care treatment - outpatient8BAe. Anticipatory palliative care8BJ1. Palliative treatment

8CM1%

8CM1. On gold standards palliative care framework

8CM10 Gold standards framework supportive care stage 1 - advancing disease

8CM11 Gold standards framework supportive care stage 2 - increasing decline

8CM12 Gold standards framework supportive care stage 3 - last days: category C - weeks prognosis

8CM13 Gold standards framework supportive care stage 3 - last days: category D - days prognosis

8CM14 Gold standards framework supportive care stage 3 - last days: category B - months prognosis

8CM4. Liverpool care pathway for the dying8CME. Has end of life advanced care plan8H6A. Refer to terminal care consult8H7L. Refer for terminal care8H7g. Referral to palliative care service

8HH7. Referred to community specialist palliative care team

8IEE Referral to community palliative care team declined

9EB5. DS 1500 Disability living allowance (terminal care) completed

9Ng7. On end of life care registerZV57C [V]Palliative care

43

Records (Smoking, BP, Summaries) To Index


SCIMP Suggested




Clinical Summaries Recording Codes

9348. Computer summary updated 9348. Computer summary updated9344. Notes summary on computer 9344. Notes summary on computer9311. Lloyd George+problem summary9313. Lloyd George culled+summarised

44

SEXUAL HEALTH To Index


SCIMP Suggested


Women age >54

Emergency Contraception prescriptions and codes

61F1. Prescribed post-coital OCP In last 13 months and after 1.4.0961A1. Morning after pills given

Combined Oral Contraception prescription and code 6147. Combined oral contraceptive In last 15 months and after 1.4.09

Progestogen only pill prescription and code 6148. Progestagen only oral contrac. In last 15 months and after 1.4.09

Contraceptive patch prescription In last 15 months and after 1.4.09

Contraceptive Diaphram prescription and code 6161. CAP fitted In last 15 months and after 1.4.09

IUD Insertion prescription and codes

6151. IUD fitted

In last 10 yrs and after 1.4.097E090 Introduction of intrauterine contraceptive deviceZV251 [V]Intrauterine contraceptive device insertion

61511 Insertion of T shaped 375 millimetres squared copper coated intrauterine contraceptive device

IUD / IUS Removal

6152. IUD removed

Dated after latest IUS or IUD code or prescription

615B. IUD expelled

615Q. Intrauterine contraceptive device removed by other healthcare provider

7E092 Removal of intrauterine contraceptive device NEC

7E093 Removal of displaced intrauterine contraceptive device

7E095 Removal of Mirena coil

IUS Insertion prescription and code7E094 Introduction of Mirena coil

In last 5 yrs and after 1.4.09. 61R.. Intrauterine system contraception

Contraceptive Implant - prescription and codes

7G2AG Insertion of Implanon

In last 3 yrs and after 1.4.09.

61KC. Insertion of subcutaneous contraceptive implant by other healthcare provider

7G2AH Reinsertion of subcutaneous contraceptive

7G2AJInsertion of etonogestrel radiopaque contraceptive implant

9kr.. Subdermal etonogestrel implant insertion enhanced services administration

Contraceptive implant removal

7G2H7 Removal of subcutaneous contraceptive

Dated after latest Implant insertion code or prescription.

7G2HA Removal of Implanon

7G2HBRemoval of etonogestrel radiopaque contraceptive implant

61KF. Removal of subcutaneous contraceptive implant by other healthcare provider

Contraceptive injectable - prescriptions only Injection prescriptions are detected if prescribed in the last 12 months

Sexual Health Exception codes 9hK0. Except.sexual health indic.: pt. unsuitable9hK1. Except. sexual health indic.: informed dissent

LARC advice

8CAw. Advice about long acting reversible contraception Dated in last 15 months for pts on oral or patch contraceptives. Dated within 1 month of most recent Emergency contraception code or prescription. Advice requires both written AND verbal advice. If one of these codes used then assume both given679K2 Education for intrauterine system

LARC Verbal advice 8CAw1 Verbal advice about long acting reversible contraception

If these codes used then required to enterone code from each section to meet indicator, showing that both written and verbal advice given.

LARC written advice

8CAw2 Written advice about long acting reversible contraception

8CEF. Intrauterine device contraception leaflet given

45

8CEG. Long acting reversible contraception leaflet given

46

SMOKING To Index


SCIMP Suggested


Patients with any one of CHD,Stroke or TIA, PAD, Hypertension, Diabetes (Age>=17), COPD, Asthma (with medication in the last year and age >=20), CKD (age >=18) or on the Mental health Register (Schizophrenia, Psychosis or Bipolar disorder) count for this indicator

Smoking Habit Codes

137..-137D.

137.. Tobacco consumption 1371. Never smoked tobacco1371. Never smoked tobacco 137S. Ex smoker1372. Trivial smoker - < 1 cig/day 137R. Current smoker1373. Light smoker - 1-9 cigs/day1374. Moderate smoker - 10-19 cigs/d1375. Heavy smoker - 20-39 cigs/day1376. Very heavy smoker - 40+cigs/d1377. Ex-trivial smoker (<1/day)1378. Ex-light smoker (1-9/day)1379. Ex-moderate smoker (10-19/day)137A. Ex-heavy smoker (20-39/day)137B. Ex-very heavy smoker (40+/day)137C. Keeps trying to stop smoking137D. Admitted tobacco cons untrue ?

137F.-137H.137F. Ex-smoker - amount unknown137G. Trying to give up smoking137H. Pipe smoker

137J. Cigar smoker137K. Stopped smoking

137M.-137T

137M. Rolls own cigarettes137N. Ex pipe smoker137O. Ex cigar smoker137P. Cigarette smoker137Q. Smoking started137R. Current smoker137S. Ex smoker137T. Date ceased smoking


137X.-137h.

137X. Cigarette consumption137Y. Cigar consumption137Z. Tobacco consumption NOS137a. Pipe tobacco consumption137b. Ready to stop smoking137c. Thinking about stopping smoking137d. Not interested in stopping smoking137e. Smoking restarted137f. Reason for restarting smoking137g. Cigarette pack-years137h. Minutes from waking to first tobacco consumption

137j. Ex-cigarette smoker137l. Ex roll-up cigarette smoker137m. Failed attempt to stop smoking

Never Smoked 1371. Never smoked tobacco 1371. Never smoked tobacco Requires entry in 15months if aged 15 to 25. If aged over 25 requires entry once ever dated after patients 25th birthday and after their diagnosis date

Ex-Smoker

1377-137B

1377. Ex-trivial smoker (<1/day) 137S. Ex smoker

Complex. Requires entry in last 15 months (but note for records is required in last year) OR, if entered more than a 15 months ago, requires 3 ex-smoker entries dated over a 3 year period with no 'smoker' code subsequently entered.

1378. Ex-light smoker (1-9/day)1379. Ex-moderate smoker (10-19/day)137A. Ex-heavy smoker (20-39/day)137B. Ex-very heavy smoker (40+/day)

137F. Ex-smoker - amount unknown137K. Stopped smoking

137N. - 137O. 137N. Ex pipe smoker137O. Ex cigar smoker

137S. - 137T. 137S. Ex smoker137T. Date ceased smoking

137j. Ex-cigarette smoker137l. Ex roll-up cigarette smoker

47

SMOKING cont. To Index


SCIMP Suggested


Current Smoker Code

1372.-1376.

1372. Trivial smoker - < 1 cig/day 137R. Current smoker1373. Light smoker - 1-9 cigs/day

Requires entry within last 15 months.

1374. Moderate smoker - 10-19 cigs/d1375. Heavy smoker - 20-39 cigs/day1376. Very heavy smoker - 40+cigs/d

137C.-137D. 137C. Keeps trying to stop smoking137D. Admitted tobacco cons untrue ?

137G.-137H. 137G. Trying to give up smoking137H. Pipe smoker

137J. Cigar smoker137M. Rolls own cigarettes

137P.-137R.137P. Cigarette smoker137Q. Smoking started137R. Current smoker


137X.-137f.

137X. Cigarette consumption137Y. Cigar consumption137Z. Tobacco consumption NOS137a. Pipe tobacco consumption137b. Ready to stop smoking137c. Thinking about stopping smoking137d. Not interested in stopping smoking137e. Smoking restarted137f. Reason for restarting smoking

137h. Minutes from waking to first tobacco consumption137m. Failed attempt to stop smoking

Smoking Exception reporting codes

9hG0. Except smok qual ind: Pt uns 9hG0. Except smok qual ind: Pt unsNote - overall exception codes for the individual disease areas will not exclude patients from the Smoking criteria and these codes will also need entry.

9hG1. Except smok qual ind: Inf diss 9hG1. Except smok qual ind: Inf diss

9Ndg. Declined consent for follow-up by smoking cessation team

Support and Refer Stop Smoking Service/ Adviser

8CAL. Smoking cessation advice

V22 New field. Currently records need both a code for both support / referral AND for pharmacotherapy (code or prescription). This is being reviewed for V23.

8HTK. Referral to stop-smoking clinic8HkQ. Referral to NHS stop smoking service8H7i. Referral to smoking cessation advisor8IAj. Smoking cessation advice declined8IEK. Smoking cessation programme declined9N2k. Seen by smoking cessation advisor

13p50 Practice based smoking cessation programme start date

9Ndf. Consent given for follow-up by smoking cessation team

9Ndg. Declined consent for follow-up by smoking cessation team

Pharmacotherapy (prescriptions + codes)

745H%

745H. Smoking cessation therapy

V22 New field. Currently records need both a code for both support / referral AND for pharmacotherapy (code or prescription). This is being reviewed for V23.

745H0 Nicotine replacement therapy using nicotine patches

745H1 Nicotine replacement therapy using nicotine gum

745H2 Nicotine replacement therapy using nicotine inhalator

745H3 Nicotine replacement therapy using nicotine lozenges

745Hy Other specified smoking cessation therapy745Hz Smoking cessation therapy NOS

8B3f. Nicotine replacement therapy provided free8B2B. Nicotine replacement therapy8B3Y. Over the counter nicotine replacement therapy8IEM. Smoking cessation drug therapy declined

48

STROKE / TIA To Index


SCIMP Suggested


Stroke Disease Codes

G61% (Except G617.) Intracerebral haemorrhage G61.. Intracerebral haemorrhage

If known, Strokes should be coded as Ischaemic or Haemorrhagic rather than unspecified.

G63y0 Cerebral infarct due to thrombosis of precerebral arteries G64z. Cerebral infarction NOS

G63y1 Cerebral infarction due to embolism of precerebral arteries G66.. Stroke and cerebrovascular accident unspecified

G64% Cerebral arterial occlusion

G66% (excluding G669.) Stroke and cerebrovascular accident unspecified

G6760 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic

G6W.. Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries

G6X.. Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries

Gyu62-Gyu66

Gyu62 [X]Other intracerebral haemorrhage

Gyu63 [X]Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries

Gyu64 [X]Other cerebral infarction

Gyu65 [X]Occlusion and stenosis of other precerebral arteries

Gyu66 [X]Occlusion and stenosis of other cerebral arteries

Gyu6F [X]Intracerebral haemorrhage in hemisphere, unspecified

Gyu6G [X]Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries

ZV125 [V]Personal history of circulatory system disease

TIA Codes

G65..-G654

G65.. Transient cerebral ischaemia G650. Basilar artery syndrome

V22 code removed

G650. Basilar artery syndrome G65zz Transient cerebral ischaemia NOSG651. Vertebral artery syndromeG6510 Vertebro-basilar artery syndromeG652. Subclavian steal syndromeG653. Carotid artery syndrome hemispheric

G654. Multiple and bilateral precerebral artery syndromes

G656.-G65zz

G656. Vertebrobasilar insufficiencyG65y. Other transient cerebral ischaemiaG65z. Transient cerebral ischaemia NOSG65z0 Impending cerebral ischaemiaG65z1 Intermittent cerebral ischaemiaG65zz Transient cerebral ischaemia NOS

F4236 Amaurosis fugaxZV12D [V]Personal history of transient ischaemic attack

Stroke Exception Codes 9h2%

9h2.. Exception reporting: stroke quality indicators 9h21. Excepted from stroke quality indicators: Patient unsuitable

9h21. Excepted from stroke quality indicators: Patient unsuitable 9h22. Excepted from stroke quality indicators: Informed

dissent

9h22. Excepted from stroke quality indicators: Informed dissent

Non-haemorrhagic Stroke

G63y0 Cerebral infarct due to thrombosis of precerebral arteries G64z. Cerebral infarction NOS

G63y1 Cerebral infarction due to embolism of precerebral arteries

G64% Cerebral arterial occlusionG665. Pure motor lacunar syndromeG666. Pure sensory lacunar syndrome

G6760 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic

G6W.. Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries

G6X.. Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries

Gyu63 [X]Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries

Gyu64 [X]Other cerebral infarction

Gyu65 [X]Occlusion and stenosis of other precerebral arteries

Gyu66 [X]Occlusion and stenosis of other cerebral arteries

Gyu6G [X]Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries

49

STROKE / TIA cont. To Index


SCIMP Suggested


MRI / CT Scan codes

567..-5673.

567.. Computerised axial tomography 569.. Nuclear magnetic resonance

Requires entry within 3 months before to 1 month after a new Stroke or TIA after 1.4.08.

5671. CAT scan requested 5675. CAT scan - brain5672. CAT scan normal 567C. CAT scan brain - abnormal5673. CAT scan abnormal 5694. Magnetic resonance imaging of brain abnormal

569..-5693.

569.. Nuclear magnetic resonance 8HQ3. Refer for NMR scanning5691. Nuclear magn.reson.requested 8HQ4. Refer for CAT scanning5692. Nuclear magn reson normal5693. Nuclear magn.reson. abnormal

5675. CAT scan - brain567C. CAT scan brain - abnormal5694. Magnetic resonance imaging of brain abnormal569F. Magnetic resonance imaging of brain normal569K0 Magnetic resonance imaging of brain5C00. CT scan brain - normal5C12. Computerised tomography brain scan abnormal8HQ3. Refer for NMR scanning8HQ4. Refer for CAT scanning8HBJ. Stroke / transient ischaemic attack referral8HTQ. Referral to stroke clinic

MRI / CT Declined 5695. Magnetic resonance imaging scan declined 5695. Magnetic resonance imaging scan declined56F0. CT scan brain declined 56F0. CT scan brain declined





Total Cholesterol Codes


Cholesterol values should also be recorded for the Contract and your software system will have a system to deal with Read coding of Values.

44P..-44P4.

44P.. Serum cholesterol44P1. Serum cholesterol normal44P2. Serum cholesterol borderline44P3. Serum cholesterol raised44P4. Serum cholesterol very high


Cholesterol code with a value


V22 field added for Stroke844P.. Serum cholesterol44PH. Total cholesterol measurement44PJ. Serum total cholesterol level













50



SCIMP Suggested
















Dipyridamole CI persisting

14LX. H/O: dipyridamole allergy 14LX. H/O: dipyridamole allergyIf exception coding, patients require an exception code for Dypyridamole, Aspirin, Warfarin and Clopidogrel to be excluded.

TJC44 Adverse reaction to dipyridamole TJC44 Adverse reaction to dipyridamole

U60C3 [X]Coronary vasodilators causing adverse effects in therapeutic use, not elsewhere classified

Dipyridamole CI expiring

8I2b. Dipyridamole contraindicated 8I2b. Dipyridamole contraindicated8I3n. Dipyridamole declined 8I3n. Dipyridamole declined8I6a. Dipyridamole not indicated 8I6a. Dipyridamole not indicated8I7J. Dipyridamole not tolerated 8I7J. Dipyridamole not tolerated



Salicylate prescriptions Prescribed in last 15 monthsClopidogrel prescriptions Prescribed in last 15 monthsDipyridamole prescriptions Prescribed in last 15 months

Warfarin Prescriptions and Code 8B2K. Anticoagulant prescribed by third party Prescribed in last 15 months

51



SCIMP Suggested











65E..-65E4.









52

v22 contract codes with scimp suggested codes...salbutamol and ipratropium bromide 33k1. positive...

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