PRIMIS

Coding Conundrums

PRIMIS

Fifth Annual Conference 11 – 12 May 2005

Piecing Together the Future

Dr Dougal Darvill(PRIMIS Clinical Adviser)

PRIMIS

Coding Conundrums:

Substance Misuse/Learning Disabilities

Dr Dougal DarvillPRIMIS Clinical Adviser

PRIMIS

Substance Misuse

• Background– Enhanced service– No NSF but DoH ‘Orange’ Book 1999

Guidelines on clinical management– Size of problem unknown but over 2% in 12

London boroughs and Liverpool 2000/1– My practice 130/7500 heroin users (1.7%)

PRIMIS

Heroin

• Focus on heroin– Usually multiple drug misuse, often chaotic– Methadone substitute available– Involves misusers with GPs because

controlled drug prescribing– Enhanced service appears to focus on heroin

(specific maintenance payment)

PRIMIS

Enhanced service specification• Register• Sequential review• 6 monthly

– audit of substitute medication prescribing and adherence to PCT standards

– audit of hepatitis B screening and immunisation• Annual

– attendance rates– Non-attendance– Review against outcomes– Financial review

• Payment: annual retainer+ different rates for patients withdrawing (higher) and on maintenance (lower)

PRIMIS

Create a register-Case finding

• Majority present asking for help

• Some from hospital admissions for drug- related or unrelated problems

• Some referred by community drug agencies/prison/police/probation

• Sharp diagnosis

PRIMIS

Hartcliffe experience

• 130 ‘heroin dependent’– 100 attending for treatment

• Others uncertain situation– Just using street drugs– In prison/bail hostel/lying low– Temporarily off all drugs ‘in remission’– Address often unknown

PRIMIS

Applying a label• E240 (E441) Heroin dependence

– E2400 unspecified opioid dependence– E2401 continuous opioid dependence– E2402 episodic opioid dependence– E2403 opioid dependence in remission– E240Z opioid dependence NOS

• E242% (E441) cocaine dependence• E244% (E442) amphetamine dependence• E241% (E445) benzodiazepine dependence• E243% (E443) cannabis dependence• E23% (E43%) alcohol dependence

PRIMIS

Who is dependent?

• Can be hard to make a definite judgement• Tolerance (increase dose to achieve

original effect)• Physical dependence- withdrawal if

stopped (especially heroin, alcohol)• Psychological dependence- enjoyment

and a feeling of wanting to repeat the experience (especially cocaine, amphetamine, marijuana, hallucinogens)

PRIMIS

Mental and behavioural effects• Eu1% codes: mental and behavioural disorders due to psychoactive

substances: For example-– Eu1A. [X]Mental and behavioural disorders due to use of crack

cocaine– Eu1A0 acute intoxication– Eu1A1 harmful use– Eu1A2 dependence syndrome– Eu1A3 withdrawal state– Eu1A4 withdrawal state with delirium– Eu1A5 psychotic disorder– Eu1A6 amnesic syndrome– Eu1A7 residual and late-onset psychotic disorder– Eu1Ay other mental and behavioural disorders– Eu1Az unspecified mental and behavioural disorder

• Codes in the mental health chapter and focus on the mental effects of substance misuse-not so useful for a register

PRIMIS

Treatment-sequential review

• Being in treatment is worthwhile (NTORS)– improved physical health– reduced drug use– reduced crime

• 9HC0 initial substance misuse assessment

• 9HC1 follow up substance misuse assessment

• 9N4i DNA substance misuse

PRIMIS

Audit of substitute prescribing

• 8B23 (&4Byte) drug addiction therapy

• Unreliable searching for methadone or buprenorphine prescription data-tends to be free text– Handwriting exemption– 14 day prescriptions

PRIMIS

Hepatitis

• Hepatitis A-food poisoning

• Hepatitis B-blood borne-immunisation available

• Hepatitis C-blood borne-no immunisation but treatment available

PRIMIS

Hepatitis B• 68280 Hepatitis B screening required• ZV02B [V]Hepatitis B carrier• 65F1. (&4B) 1st hepatitis B vaccination• 65F2. (&4B) 2nd hepatitis B vaccination• 65F3. (&4B) 3rd hepatitis B vaccination• 65F4. (&4B) Boost hepatitis B vaccination• 65F6. (&4B) 4th hepatitis B vaccination• 65F7. (&4B) 5th hepatitis B vaccination

– Search for bold codes for evidence of immunisation course

– Blood testing can be fiendishly difficult

PRIMIS

Hepatitis B testing codes• 43B1. (&4B) Blood sent: SH-antigen test• 43B2. (&4B) Hepatitis B immune• 43B3. (&4B) SH-antigen negative• 43B4. (&4B) Hepatitis B surface antig +ve• 43B5. (&4B) Hepatitis e antigen present• 43B6. (&4B) Hepatitis B non immune• 43B8. (&4B) Hepatitis B core antigen test• 43B9. (&4B) Hepatitis B e antigen test• 43BZ. (&4B) SH-antigen test NOS• 43dA. (&4B) Hepatitis B core IgM level• 43dB. (&4B) Hepatitis B core antibody level• 43dC. (&4B) Hepatitis B e antibody level • 43jG. (&4B) Hepatitis B nucleic acid detection• 43k0. (&4B) Hepatitis B e antigen level• 43d8. (&4B) Hepatitis B surface antibody level• 43d9. (&4B) Hepatitis B surface antigen level

• Search for them all for evidence of testing. Immunity implies successful immunisation or recovery from natural infection

PRIMIS

Hepatitis C• We need (for practical purposes)

– ‘tested and evidence of hep c infection’– ‘tested and no evidence of hep c infection’– ‘not tested for evidence of hep c’

• We have– 43h3. (&4B) Hepatitis C PCR– 2J11. (&4B) Hepatitis C immune– 2J12. (&4B) Hepatitis C non immune– 6829. (&4B) Hepatitis C screening– 4J3B. (&4B) Hepatitis C viral load– ZV02C [V]Hepatitis C carrier– 43X2. (&4B) Hepatitis C antibody test– 43k1. (&4B) Hepatitis C antigen level– 43X6. (&4B) Hepatitis C antibody level– 43q.. (&4B) Hepatitis C virus RNA assay– 43dD. (&4B) Hepatitis C recombinant immunoblot assay– 43j5. (&4B) Hepatitis C nucleic acid detection– A7040 (A4A3) Viral hepatitis C with coma– A7050 Viral hepatitis C without mention of hepatic coma– A7054 Hepatitis non A non B

• Search for them all for evidence of testing

PRIMIS

HIV testing

• 43C3 (&4B) HIV antibody positive

• 43C2 (&4B) HIV antibody negative

PRIMIS

Outcomes 1• Urine tests (no code for ‘no illegal drugs found in

urine’)• Less IV drug use

– 13c0 (&4B) injecting drug user– 13c1 (&4B) intravenous drug user– 13c2 (&4B) never injecting drug user– 13c3 (&4B) intramuscular drug user

• Reduced drug use (rating scores like CHRISTO)– 13c6 (&4B) substance misuse decreased– 13c5 (&4B) substance misuse increased

PRIMIS

Outcomes 2• Clinical

– Q4852 Neonatal abstinence syndrome– G801E DVT of leg related to IV drug use– M03% (L13%) Cellulitis

• Reduced involvement with legal system– 13HM4 court case pending– 13HQ (&4B) in prison– 13HR (&4B) on probation– 13HS (&4B) on remand

• Deaths especially overdoses

PRIMIS

Outcomes 3• Employment

– 13J7 (&4B) unemployed– 13JA (&4B) full-time employment– 13JB (&4B) part-time employment– 13JJ (&4B) unfit for work (9D11 (&4B) Med3 and 9D21

(&4B) Med5 issued)

• Relapse prevention– ,du2% naltrexone (opiates)– ,du1% disulfiram (alcohol)

• 146C (&4B) failed heroin detoxification

PRIMIS

Financial review-payments

• Enhanced service:

• Retainer +

• £500 withdrawal per patient per year– 9k50 Drug misuse- enhanced service

completed

• £350 maintenance per patient per year– How many successfully withdraw?

PRIMIS

Maintenance treatment• ‘Many patients, despite requesting detoxification are

more suitable for maintenance treatment-the overall goal should be to maximise the patient’s potential health gain’ DoH 1999

• NTORS: service users on reduction programmes were less likely to stay in treatment

• ‘The bulk of evidence shows that the length of time spent in methadone maintenance is a good predictor of outcome: the longer the time, the better the result in terms of reduction of illicit use and psychological adjustment’ National Treatment Agency

PRIMIS

Weblinks

• http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SubstanceMisuse/fs/en (Dept of Health substance misuse information/links)

• http://www.drugs.gov.uk/Home (Dept of Health)• http://www.nta.nhs.uk/ (Nat Treatment Agency)• http://www.dh.gov.uk/assetRoot/04/07/81/98/040

78198.pdf (Orange Book)

PRIMIS

Learning Disabilities

PRIMIS

Defining our terms

• Learning disabilities– A state of arrested or incomplete development

of mind (WHO)– Significant impairment of intellectual

functioning and of social functioning – Previously ‘mental handicap’– WHO use term ‘intellectual disability’

PRIMIS

Learning difficulties

– Specific problems with learning in children (e.g. dyslexia)

– Preferred by many people with learning disabilities

PRIMIS

Learning Disabilities

• Impairment present from childhood– Prenatal/congenital (eg Down’s syndrome)– Birth hypoxia (cerebral palsy)– Postnatal

• IQ is usually a measure of severity

• More difficult to measure social functioning– Level of support needed

PRIMIS

IQ scoring• ICD10 uses ‘mental retardation’ rather than learning disability • IQ mean is 100• Mild Mental Retardation• Approximately IQ range 50 – 69 (in Adults, mental age from 9 to under 12 years).

Likely to result in some learning difficulties in school. Many adults will be able to work and maintain good social relationships and contribute to society.

• Moderate Mental Retardation• Approximate IQ range 35 – 49 (in Adults, mental aged from 6 to under 9 years).

Likely to result in marked developmental delays in childhood but most can learn to develop some degree of independence in self care and acquire adequate communication and academic skills. Adults will need varying degrees of support to live and work in the community.Severe Mental Retardation

• Approximate IQ range 20 – 34 (in Adults, mental age from 3 to under 6 years). Likely to result in continuous need of support.

• Profound Mental Retardation• IQ under 20 (in Adults, mental age below 3 years). Results in severe limitation in self

care, continence, communication and mobility.

PRIMIS

Valuing People

• Previous White Paper 1971: Better Services for the Mentally Handicapped– Developing services in the community

• Focus on rights, independence, choice and inclusion

• Section on improving health

PRIMIS

Valuing People 2

• People with learning disabilities are more at risk of mental illness, chronic health problems, epilepsy, physical and sensory disabilities– Health care designed around their needs =

‘health action plan’

• All to be registered with a GP • Practices to have identified all patients

with learning disabilities by June 2004

PRIMIS

Labels

• E3% (E51%) mental retardation– E30 (E511) mild mental retardation (IQ 50-70)– E310 (E512) moderate mental retardation (IQ 35-49)– E311 (E513) severe mental retardation (IQ 20-34)– E312 profound mental retardation (IQ <20)– E31z}– E3y } other specified mental retardation– E3z (E51z) mental retardation NOS

PRIMIS

Labels 2• Best not to use Eu81z (E4JD) learning disability

NOS from chapter Eu81% (specific developmental disorders of scholastic skills)– Eu810 specific reading disorder– Eu811 specific spelling disorder

• ‘Identification will enable appropriate support to enable patients to access the full range of primary care provision and the monitoring of access to a range of routine health screening opportunities such as cervical and breast screening’

PRIMIS

To make a register

• Look in P% congenital abnormalities– But includes many conditions with no mental

impairment

• Particularly PJ% chromosomal abnormalities– Even then not all have learning difficulties

(e.g. PJ8 balanced translocation in normal individual)

PRIMIS

To make a register 2

• F23 (F32) Congenital cerebral palsy– Birth hypoxia

• E2A Nonpsychotic mental disorders following organic brain damage

• Needs clinician review of each set of notes before adding a label

PRIMIS

Health Action Plan

• By June 2005: a personal written guide on how to stay healthy

• Health facilitators, primary care nurses and GPs should be involved– 9HB0 Learning disabilities health action plan declined– 9HB1 Learning disabilities health action plan offered– 9HB4 Learning disabilities health action plan

completed– 9HB2 Learning disabilities health action plan reviewed

PRIMIS

GP involvement

• All GPs have a system for ensuring that patients with learning disabilities are invited to attend for health screening if they have not visited surgery in the last 3 years– 9HB3 Learning disabilities health assessment

PRIMIS

Health review contents-global• Review of Systems:• Mental health

– Prevalence of mental health needs in people with LDs is high– 9H8/9H6 on severe mental illness register– Anxiety/depression

• Dysphagia – Specific questioning: respiratory disease is a leading cause of death in people

with LDs but smoking rate is lower– R072% (R72%) dysphagia

• Coronary heart disease– Increased risk in people with LDs– G3% (G4%) ischaemic heart disease

• Cancers– Gastrointestinal higher proportion of cancers

• Epilepsy– F25% (F34%)

PRIMIS

Health review 2

• Smears• Mammography• Vision screening• Hearing problems• Dementia• Osteoporosis• Dental problems• Obesity

PRIMIS

Health review contents 3

• Condition specific e.g. Down’s syndrome– Leukaemia (childhood)– Congenital heart problems in 50%– Neck instability (N1488 Atlanto-axial

instability)– Vision and hearing problems– Thyroid problems

PRIMIS

Outcomes

• 9HB4 health action plan completed

• 9HB2 health action plan reviewed

• 4K2% cervical smear results– 6853 ca cervix screen not wanted– 685L cervical smear refused

• 537% mammography

PRIMIS

• http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/LearningDisabilities/LearningDisabilityPublications/fs/en?CONTENT_ID=4032080&chk=w%2Bvo48

(Valuing People)

• www.learningdisabilities.org.uk/

• www.bild.org.uk/