Introduction to Sub-chapter RA Diagnostic Imaging Procedures
Version No: 2.0 Issue Date: 15 January 2008
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SUB-CHAPTER SUMMARY – DIAGNOSTIC IMAGING PROCEDURES Chapter / Sub-chapter name and label Chapter R: Imaging and Interventional Radiology Sub-chapter RA –Diagnostic Imaging Procedures
Scope / coverage Diagnostic Imaging Healthcare Resource Groups (HRGs) are grouped according to examination type and then according to resource use. The examination types are: Magnetic Resonance Imaging Computerised Tomography DEXA Scans Contrast Fluoroscopy Diagnostic Ultrasound Nuclear Medicine
MR CT DX CF US NM
It should be noted that •
DEXA scans have been included here, even though they are not undertaken in Radiology departments, as they are a priority area for government targets on diagnostic procedures and do not easily fit elsewhere.
•
Therapeutic radioiodine (OPCS-4.4 codes U06.5 Scanning of thyroid gland) has been included here as they are commonly undertaken by nuclear medicine departments. They could have been included with radiotherapy but, in order to facilitate more appropriate resource identification, have instead been included within Diagnostic Imaging
The imaging procedures covered in this sub-chapter cover some Radiology procedures and Nuclear Medicine. Interventional radiology procedures are addressed in a separate sub-chapter (RB).
RA. Diagnostic Imaging.doc Author: Casemix Service
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In total, there are 33 HRGs within the sub-chapter, of which 28 relate to Diagnostic Imaging and 5 to Nuclear Medicine. Further details of the five Nuclear Medicine HRGs are below: •
RA35Z Nuclear Medicine Category 1 Procedures requiring no radiation protection, minimal equipment costs and standard staff costs of up to one hour technologist time, including patient explanation and processing.
•
RA36Z Nuclear Medicine Category 2 Procedures requiring diagnostic level radiation protection, basic gamma camera or sample counter, standard technologist time of up to one hour and low to medium isotope costs.
•
RA37Z Nuclear Medicine Category 3 Procedures requiring diagnostic level radiation protection, technologist time of up to two hours, gamma camera with SPECT and/or medium isotope costs. For cardiac procedures, cardiology supervision is included.
•
RA38Z Nuclear Medicine Category 4 Procedures requiring diagnostic level radiation protection, technologist time of up to three hours, gamma camera with CT and high isotope costs.
•
RA39Z Nuclear Medicine Category 5 – Procedures requiring diagnostic level radiation protection, technologist time of up to three hours, high equipment costs and/or very high isotope costs.
Differences from HRG v3.5? Prior to HRG4, a collaborative exercise between The Casemix Service and a group of experts nominated by the Royal College of Radiologists had developed groupings for plain films, contrast procedures and fluoroscopy, ultrasound, CT and MRI. However, implementation of these HRGs was deferred pending further work to include Nuclear Medicine and Interventional Radiology. The principal development work for HRG4 has therefore been to design HRGs for these additional areas. One of the main benefits of introducing diagnostic imaging HRGs is the ability to more accurately report activity.
RA. Diagnostic Imaging.doc Author: Casemix Service
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Prior to the introduction of these codes diagnostic imaging activity was reported via an annual return that was filled in manually. The scope of the new OPCS and HRG codes allows reporting at a much greater level of detail. The greater level of detail provided by HRG4 will: • • • •
Give a more accurate record of resource use Support DH targets on 18 week waits Provide clearer guidance for appropriate coding of unusual procedures Provide data that can be used more readily for resource management.
Differences from HRG4 Reference Cost Grouper 2006/2007 •
Remapping of codes to more appropriately reflect resource There has been some remapping of ICD-10 diagnosis and OPCS-4.4 procedure codes to more accurately reflect resource use.
•
Remapping of less specific OPCS codes After a cross-chapter coding review some less specific OPCS-4.4 .8 and .9 codes, were remapped where appropriate to a lower resource HRG than the rest of the codes within the same rubric.
•
New HRGs created to improve design HRGs have been created to cover areas of work that have been better defined in the latest revision of OPCS-4.4 codes. HRGs have also been created from splitting an HRG to more accurately reflect resource use. Redundant HRGs have been deleted The remapping of codes left some redundant HRGs that cannot be generated as all the source codes now map to different HRGs. These redundant HRGs have been removed from the design.
•
Further detail about these changes can be found in the HRG4 Design Changes document (An Excel workbook) that can be downloaded from the Prepare for HRG4 web page. URL: http://www.ic.nhs.uk/our-services/standards-andclassifications/casemix/hrg4/prepare-for-hrg4
RA. Diagnostic Imaging.doc Author: Casemix Service
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Grouping logic The original intention was to have a one-to-one mapping from the OPCS-4.4 codes to the Diagnostic Imaging HRGs. However, this was not possible within the constraints of OPCS-4.4. It has therefore been necessary to use subsidiary codes to improve the fit between the OPCS-4.4 codes and Diagnostic Imaging HRGs. The OPCS-4.4 codes that require a subsidiary code in order to be mapped to the HRGs are shown below. The OPCS-4.4 codes entered here have been selected as the best fit across the range to point to the relevant HRG. OPCS-4.4 U05.1 U05.2 U05.3 U05.4 U05.5 U06.1 U06.3 U07.1 U07.2 U08.1 U08.2 U08.4 U09.1 U09.2 U10.2 U10.3 U11.1 U11.3 U11.4 U11.7 U12.2 U12.3 U12.4 U13.2 U13.3 U13.6 U16.2 U17.3 U17.5 U21.1 U21.2 U21.5 U21.6 U35.2 U37.1 U37.2
Label Computed tomography of head Magnetic resonance imaging of head Functional magnetic resonance imaging of head Computed tomography of spine Magnetic resonance imaging of spine Computed tomography of sinuses Ultrasound of thyroid Computed tomography of chest Magnetic resonance imaging of chest Computed tomography of abdomen Ultrasound of abdomen Upper gastrointestinal series Computed tomography of pelvis Ultrasound of pelvis Cardiac computed tomography angiography Cardiac magnetic resonance imaging Ultrasound of carotid artery Vascular ultrasound nec Computed tomography scan of cerebral vessels Magnetic resonance angiography Ultrasound of scrotum Ultrasound of kidneys Ultrasound of bladder Ultrasound of joint Magnetic resonance imaging of joint Computed tomography of bone Magnetic resonance cholangiopancreatography Barium swallow Computed tomography of colon Magnetic resonance imaging nec Computerised tomography nec Contrast fluoroscopy nec Ultrasound scan nec Laser Doppler ultrasound velocimetry Magnetic resonance imaging of kidneys Computed tomography of kidneys
The subsidiary codes used in HRG grouping are shown in the table below: RA. Diagnostic Imaging.doc Author: Casemix Service
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OPCS-4.4 Y94.1 Y94.2 Y94.3 Y97.1 Y97.2 Y97.3 Y97.8 Y97.9 Y98.2 Y98.3 Y98.4 Y98.5 Y98.6 Y98.7
Label Dopamine transporter scan Octreotide imaging Metaiodobenzylguanidine imaging Radiology with pre and post contrast Radiology with pre contrast Radiology with post contrast Other specified radiology with contrast Unspecified radiology with contrast Radiology of two body areas Radiology of three body areas (or 20 -40 minutes) Radiology of four body areas Radiology of > 4 body areas (or > 40 minutes) Mobile/intraoperative procedures of any/all body areas Extensive patient repositioning to obtain required image series
The OPCS-4.4 code plus the subsidiary OPCS-4.4 codes (Y94.-, Y97.- or Y98.-) can then generate the appropriate Diagnostic Imaging HRG. The OPCS-4.4 codes that group to the Nuclear Medicine HRGs are shown below: OPCS-4.4 Label B16.4 Parathyroid washout T91.2 Scanning of sentinel lymph node U01.8 Other specified diagnostic imaging of whole body U06.2 Dacryoscintigraphy U06.5 Scanning of thyroid gland NEC U10.1 Cardiac computed tomography for calcium scoring U10.4 Myocardial positron emission tomography U10.5 Radionuclide angiocardiography U10.6 Myocardial perfusion scan U10.7 Cardiac multiple gated acquisition scan U11.5 Thallium stress test U12.5 Static renogram U12.6 Mercaptoacetyltriglycine renogram U12.7 Nuclear cystography U14.1 Nuclear bone scan of whole body U14.2 Nuclear bone scan - special views U14.3 Nuclear bone scan - three phase U14.4 Nuclear bone scan - two phase U14.8 Other specified nuclear bone scan U14.9 Unspecified nuclear bone scan U15.1 Lung perfusion scanning NEC U15.2 Lung ventilation scanning NEC U15.3 Ventilation perfusion quotient scan U16.1 Hepatobiliary nuclear scan U17.1 Meckels scan U17.2 Selenium 75 homocholic acid taurine study U18.1 Scintimammography U21.3 Positron emission tomography NEC U21.4 Single photon emission computed tomography NEC U23.1 Red cell mass studies U23.2 White cell scan using indium 111 U23.3 White cell scan using technetium 99 RA. Diagnostic Imaging.doc Page 6 of 8 Author: Casemix Service Date: 15 January 2008 Copyright © 2007, The Information Centre, Casemix Service. All rights reserved.
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U23.4 U25.1 U25.2 U25.3 U25.4 U25.8 U25.9 U26.1 U26.5
Ferrokinetic studies C14 urea helicobacter pylori breath test C14 glycocholic acid breath test Hydrogen breath test Urea helicobacter pylori breath test NEC Other specified breath tests Unspecified breath test Glomerular filtration rate testing Schilling test
Worked example The following example shows the subsidiary code logic and how it affects grouping. For OPCS-4.4 code U05.1 CT of head: •
If subsidiary code Y97.1 Radiology with pre & post contrast is also recorded, then the activity groups to HRG RA10Z CT one area, pre & post contrast
•
If subsidiary code Y97.3 Radiology with post contrast is also recorded, then the activity groups to HRG RA09Z CT one area, post contrast
•
If no subsidiary code is recorded, then the activity will group to HRG RA08Z CT one area, no contrast.
Unbundling All of the HRGs within this sub-chapter are unbundled and will derive HRGs that are additional to a core HRG for the care event.
Potential data collection issues Radiology Departments generally have their own information systems which may not necessarily be linked to Patient Administration Systems (PAS). Providers will need to ensure that there is a mechanism in place to provide relevant information to clinical coders so that unbundled diagnostic imaging procedures and Nuclear Medicine procedures can be entered as OPCS-4.4 codes on PAS. Data collection is a cause of concern for departments who do not have access to good electronic data collection systems. This work has coincided with the RA. Diagnostic Imaging.doc Author: Casemix Service
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implementation programme for PACS (picture archiving and communication systems) across England as part of the work of NHS Connecting for Health. Once these systems are in place, all procedures will be coded and the HRGs will be captured automatically. The National Imaging Lead for the Department of Health is involved in this work and is fully aware of the issues and potential for linking clinical information to that required for the new financial flows. In the interim, it has been recognised that too simplistic a system risks failing to capture the required level of detail for PbR to reimburse departments accurately but too complex a system risks overloading the coding system, resulting in poor quality data. It is felt that these HRGs achieve the best balance currently possible but will be flexible enough to support improved data collection when better systems become available. The unbundled Diagnostic Imaging and Nuclear Medicine HRGs are derived wholly from OPCS-4.4 codes and allocation to an HRG is therefore dependent on adequate specificity of coding. Where coding is at the .8 (other specified) or .9 (unspecified) level, this is likely to result in a failure to group. This is because these codes are not specific and do not identify the type of radiological procedure or the resource used. Clinical coders will need clinical input and comprehensive documentation of procedures to be able to code this activity. It is important that coders use the most up to date OPCS-4.4 code set.
Further developments / refinement pending No immediate changes are planned; however policy and/or service requirements may require refinement to the current design of the chapter in line with relevant HRG4 Grouper release timescales.
Glossary of terms Please refer to the following URL for a full glossary of terms used in this document. http://www.ic.nhs.uk/jargon-buster
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