My April blog is all about coding and validation of heart failure registers in primary care.
Over the years I have found so many common themes of coding mishaps and I thought it would be good to share these with you.
As many of you will know, in General Practices in England, a heart failure register is compiled to fulfil the Quality & Outcomes Framework (QOF) requirements with a focus on improving patient outcomes and management.
Working across several practices currently, I have noticed all practice heart failure registers require validation before any medication optimisation can be undertaken.
Validation is important, firstly to find missing patients but also as I have found recently to remove patients from the heart failure register who have been incorrectly coded as heart failure.
In some cases patients with no heart failure diagnosis confirmed have also been started on medications for heart failure.
When patients present in the consultation room with possible heart failure – what can go wrong with coding?
The first hurdle for many is where patients are inadvertently coded in the clinical consultation notes as “Heart Failure” before objective evidence is obtained; i.e. echocardiogram results, such as patients coded “suspected heart failure”.
On SystmOne, if “Heart Failure” is entered into the diagnosis field during a consultation the system offers the user the preferred code and if selected the patient will be added onto the heart failure register.
As a result of these user errors the patient is placed on the heart failure register.
This can lead to the following mistakes in clinical practice:
- A patient is recalled for a heart failure annual review inappropriately.
- The label of heart failure continues for several years in the record and medications can be initiated when not indicated.
- The patient thinks they have heart failure when they don’t.
Investigating the diagnosis
“Does the patient have HF” is the first question.
Look for objective evidence of cardiac dysfunction, this includes echocardiogram, cardiac MRI and even information gleamed from coronary angiography reports.
If NO objective evidence can be found, look for NTproBNP/BNP blood results in the patient record.
Are there any symptoms that are concerning within the latest consultations over the last 3-6 months (e.g. breathlessness, cough, orthopnoea, paroxysmal nocturnal dyspnoea, reduced exercise tolerance or peripheral oedema).
When considering NTProBNP/BNP results, please don’t forget those in atrial fibrillation will have a much higher level – look for signs of heart failure in these patients and risk stratify accordingly.
Chest X-ray may document fluid on the lungs or describe an enlarged heart known as cardiomegaly. This helps to build a clinical picture.
So, if you have NO objective evidence, the patient has signs and symptoms of heart failure and they have NOT had a NTproBNP/BNP blood test, start here with a blood test, do NOT code what you think they may have, hold fire, wait for the diagnosis to be confirmed or refuted.
If objective evidence IS found, in addition to the primary Read code “Heart Failure” you must add the sub category code; EITHER heart failure with reduced ejection fraction (HFrEF) (previously known as left ventricular systolic dysfunction) OR is it heart failure with preserved ejection fraction (HFpEF) (previously known as left ventricular diastolic dysfunction (LVDD)).
Don’t forget some patients will have neither of these and may have valvular heart failure, right ventricular failure or even a restrictive cardiomyopathy.
Why are sub-category codes crucial?
The reasons are twofold, one is linked to QOF, patients with HFrEF fall into the HF QOF indicators for medication initiation and optimisation with ACE inhibitors/ARB/ARNI and beta-blockers.
If the sub category is not added the patient may not receive the appropriate medication optimisation, symptom burden may not be well controlled.
Conversely, a patient may be started on treatment for HFrEF, for example when they have HFpEF, which is treated differently.
I would like to finish on a positive note and share with you some heart failure disease register validation results following my work in a practice recently.
Practice list size: 7,380 patients
Heart failure register
Prevalence increased from 1.04% to 1.48%, additional 32 patients added.
Sub Category Coding – 46 additional patients categorised
37 additional patients coded as HFrEF
9 additional patients coded with HFpEF
In summary
- Validation of the existing HF register is the key to improving outcomes in heart failure patients
- Add the “heart failure” code to EVERY patient with heart failure IN ADDITION to the “sub category code”.
- Add additional findings that are related to valvular dysfunction or right ventricular function, if identified.
- Train clinical and non-clinical staff on coding specifically for heart failure registers.
- Use a system such as the Oberoi Disease Management Audit Platform for Heart Failure (oberoi-dm.co.uk) to identify mis-coded patients in your practice.
Each day working within heart failure I learn something different, the impact of this work is tremendous, every practice needs to do this.
Please feel free to email me if I can be of any help, we have coding sets available free of charge to ensure the correct codes are used for patients with heart failure register and sub categorisation: Amanda.Crundall@oberoi-consulting.com
