Hugh Tynan explains the positive and negative nuances of the outpatient procedure coding changes in 2016-17 NHS national tariffs
When the NHS national tariff payment by results system is considered by operational managers, the focus is on high value admitted patients while outpatient procedures (OPROC), with their relatively low proportion of income, suffer undeserved neglect. Such neglect being self-fulfilling as this category of hospital activity is woefully under recorded.
An exaggeration? As a sense check get your clinical income team to report OPROC activity for the orthopaedic non-trauma procedures HRG subchapter. Not many, I dare say. Yet there are six such national tariffs out of a total of 94 national OPROC tariffs. And trauma and orthopaedics is the major surgical specialty.
An OPROC occurs when, during an outpatient attendance, one from a list of OPCS (Office of Population Censuses and Surveys) procedure codes ‘groups’ to a Healthcare Resource Group (HRG) with a national tariff.
OPROC coding depends on a clinician making a clear record of care provided. It also depends on a clerical colleague reading an ‘outcome form’, then inputting appropriate codes into the electronic patient record. Usually an OPROC has a higher tariff value than the default outpatient attend tariff.
The future of the NHS is predicated on fewer admitted patients. And through best practice tariffs the 2015-16 national tariff points providers towards increased OPROC activity. For instance, the commonplace HRG LB72A -Diagnostic Flexible Cystoscopy has an OPROC tariff of £381, in contrast to the much lower inpatient tariff of £218. Also commissioner QIPPs or productivity savings focus on OPROC to daycase ratios for particular OPCS codes.
The August 2015-released 2016-17 engagement tariffs and related grouper signals a massive change around OPROC activity. As already said, the number of HRGs with a national tariff in 2015-16 is 94. In 2016-17 the equivalent number is 191.
Drilling-down to the OPCS codes in the 2016-17 grouper driving OPROC HRGs reveals major challenges for recording codes for OPROC tariff in the new financial year.
As noted already, the clerical adjunct to the outpatient clinician, inputs to the electronic patient record codes from outcome forms. These forms require major updating because not only are there 1,291 new OPROC-relevant OPCS codes in 2016-17, there are also 323 OPCS codes which in 2015-16 generated an OPROC that in 2016-17 no longer so do.
Arguably there is a shifting of goalposts in the 2016-17 OPROC grouper. Suddenly all these OPCS codes are relevant or not. In an ideal world all OPCS codes would be recorded – not least for medical research purposes. However, the reality is that coding in the outpatient setting, which does not come under the control of the highlyn audited provider clinical coding departments, endures undeserved neglect.
Much to welcome
Undoubtedly there is much for providers to welcome in 2016-17 OPPROC proposals. For instance, there are many new ‘chargeable’ codes in OPCS chapters Ear and Eye, whose related specialties are outpatient intensive.
However, the average OPPROC tariff in 2016-17 is 10 per cent lower than 2015-16 and because provider OPROC coding is so deficient, when undertaking for a client, 2016-17 tariff “Impact Assessment” analysis, I observed a decimation of OPROC income in some HRG subchapters.
In contrast, the November 2015 release of reference costs data for 2013-14 clearly evinces the efficacy of focusing on OP coding improvement. Two London acute trusts where I previously advised operational managers saw a massive increase in orthopaedic non trauma OPPROCS. These trusts can be identified from the data.
The coding ‘secret’ for Orthopaedic Non Trauma HRG subchapter is that recording a single OPCS procedure is not sufficient for an OPPROC. The Grouper also requires a second relevant code from the OPCS subchapter Subsidiary Classification of Sites of Operation.
Typically next year’s commissioner contract baseline is derived from current year months 1-6 activity, doubled. However, given the huge change in OPROC grouper it would be wise for providers to upgrade their coding in the remaining months of the current year, to build the case for a more realistic OPROC plan for 2016-17.
Remember, if it is not coded then it does not count for reimbursement. And if it is not in the plan, commissioners will not want to pay.
Hugh Tynan, Conhab Associates