Feature / HRG4 continued: chapters N-Q

N Obstetrics

Obstetrics covers the treatment of women before, during and after child birth. The obstetrics chapter has no sub-chapters and so all HRGs begin with NZ – the Z indicating the lack of chapter splits. It includes all obstetric procedures and diagnoses and some aspects of embryology and placental disorders.

In version 3.5, chapter N addressed both neonatal care and obstetrics but in HRG4, the care of just-born babies (which would have included more than 30% of finished consultant episodes (FCEs) in the chapter in version 3.5) has been transferred to chapter P – diseases of childhood.

Even with this change, the number of HRGs in the chapter has increased to 19 from 12 in the version 3.5 chapter.

The obstetric HRGs are categorised into delivery and non-delivery HRGs. There are also HRGs for supervision of pregnancy, addressing brief treatment in purpose-built and managed outpatient areas. A length of stay split of less than one day has also been introduced to differentiate between day case activity and inpatient activity.

There are further sub-divisions by complication and comorbidities, plus a paediatric split. Recognising the difference in obstetrics coding, some secondary diagnoses are implicit in obstetrics cases with complications. So under HRG4 patients may be grouped to a complication HRG based on primary diagnosis or procedure – improving the accuracy of grouping.

Also within version 3.5, HRG N12 (antenatal admissions not related to delivery event) was a high-volume HRG with some 550,000 cases a year across England. ICD and OPCS codes mapping to this HRG included procedures on the foetus and diagnoses affecting pregnancy. Following a code review, some now map to delivery HRGs. The remaining codes are divided into three clinical contact categories: observation only, investigation, and full investigation.

In the six months to September 2006, some 640,000 FCEs were undertaken that would have fallen within this chapter. Three HRGs account for nearly two-thirds of this total. NZ01B (normal delivery 19 years and over without CC) included nearly 172,000 FCEs, NZ04A (clinical contact for observation (ante- or post-natal) 19 years and over) 126,000; and NZ05A (clinical contact with investigation (ante- or post-natal) 19 years and over) 114,000.

The higher costs associated with multiple births are also picked up. For instance, ICD-10 code O820 (delivery by elective Caesarean section) would normally group to NZ03A (Caesarean section 19 years and over). But with a further multiple pregnancy diagnosis (for example, O301- triplet pregnancy), the case groups to NZ03C (Caesarean section with complications).


P Diseases of childhood and neonates

This chapter covers paediatric medicine (for children aged up to and including 18 years) and neonatal medicine. Neonatal medicine covers the care of newborn children, typically up to one month old. The chapter is split into two sub-chapters: PA (paediatric medicine) and PB (neonatal disorders).

The chapter is purely medical. There are no surgical procedures. Paediatric surgery is covered by applying a paediatric age split (equal to or less than 18) to surgical HRGs included in other chapters.

In version 3.5, neonatal care was included in chapter N (obstetrics and neonatal care) but has been transferred into chapter P under HRG4. As the new HRGs were being developed, it was recognised that the majority of neonates in hospital would be in a critical care ward. This led to a separate project to develop HRGs for neonatal critical care. These critical care HRGs, together with paediatric critical care, will be included in chapter X, which covers unbundled elements of care, including critical care, high-cost drugs and devices. This means there are only two HRGs within the neonatal sub-chapter – one for major diagnoses (PB01Z) and one for minor diagnoses (PB02Z).

The number of HRGs in the chapter has almost tripled compared with version 3.5, rising from 31 to 92. It is a high-activity chapter with more than 720,000 FCEs mapping to it in the first six months of 2006/07. A new HRG to recognise the care given to healthy babies (PA61Z) accounts for the single largest block of these episodes, nearly 226,000. (This HRG effectively completes the classification rather than necessarily describing medical care provided.) The other major contributors to the activity include: PB02Z (minor neonatal diagnoses) at just over 90,000; PA12Z (asthma or wheezing) at 21,400; and PA29Z (abdominal pain) at 19,400.

As the chapter relates to all diagnoses relevant or possible for children, the breadth of treatment covered is vast. For instance, there are HRGs for renal disease, skin disorders, allergies, eating disorders, asthma and head injuries. The main splits within the chapter relate to the presence of complications and comorbidities.

Greater granularity has been achieved by the introduction of major, intermediate and minor classifications for some disorders, such as for upper respiratory tract disorders (PA9, PA33 and PA10). Another example of the complexity of conditions is the expansion of cancer groupings. Just one HRG existed in version 3.5 within this chapter. This has been expanded to five, identifying the type of malignancy. And these are split according to length of stay.

Under HRG4, secondary diagnoses can influence the HRG assignment. For instance, an ICD-10 diagnosis code of C831 (diffuse non-Hodgkin’s small cleaved cell (diffuse) lymphoma) for a patient aged 18 years and under would normally group to PA43B (other neoplasms with length of stay one day or more without CC). But the inclusion of a secondary diagnosis of infection (for example, J201 acute bronchitis due to haemophilius influenzae) plus a diagnosis of neutropenia (D70X agranulocytosis) will change the grouping to PA45Z (febrile neutropenia with malignancy).


Q Vascular system

The vascular system includes all the body’s blood vessels, including arteries (which pass oxygen-rich blood to the body’s tissues), veins (which return blood from the tissues to the heart) and capilliaries (which run between the arteries and veins). There are no sub-chapters: all HRGs begin with QZ – the Z indicating the lack of chapter splits. It includes all vascular procedures and disorders undertaken in admitted or non-admitted care settings. This includes procedures carried out on patients who were not admitted for a vascular problem – such as vascular access for renal replacement therapy.

The 19 HRGs in version 3.5 have been expanded to 31 in HRG4. For instance, one HRG in version 3.5 covering all varicose vein procedures has been replaced with five HRGs. These include both primary unilateral and bilateral varicose vein procedures without CC (QZ10B and QZ09B), the redoing of unilateral and bilateral varicose veins without CC (QZ08B and QZ07B) and varicose veins with ulcer or with CC (QZ06Z). The choice of numbering and lettering leaves the door open for further HRGs to be added to differentiate between different procedures with CC. A new requirement has also been introduced demanding that patients assigned to one of these five HRGs have a primary diagnosis for varicose veins.

The one HRG covering vascular access in version 3.5 has been replaced with four: QZ13A (vascular access for renal replacement therapy with CC); QZ13B (vascular access for renal replacement therapy without CC), QZ14A (vascular access except for renal replacement therapy with CC), and QZ14B (vascular access except for renal replacement therapy without CC). The with or without CC split is important. Original design analysis showed that length of stay for the QZ13 vascular access HRG with CC (six days) was more than twice that of those without CC (2.4 days).

In fact, new complication and comorbidity splits have been developed and CC splits added to a number of HRGs. Another example is the revised HRG for non-surgical peripheral vascular disease. This HRG usually comprises those patients admitted with a vascular diagnosis but without a procedure being performed. Under HRG4, the HRG has been split into three, reflecting major CC (QZ17A), intermediate CC (QZ17B) and without CC (QZ17C). The average length of stay in the original design analysis ranges from 19 days for the major CC, through six days for intermediate and down to just three days for without CC.

Just over 113,000 FCEs would have mapped to this chapter from April to September 2006. The highest activity HRGs include QZ14B (vascular access except for renal replacement therapy without CC) at 13,400 of the 113,000; QZ10B (primary unilateral varicose vein procedures without CC) at 12,200, and QZ17B (non-surgical peripheral vascular disease with intermediate CC) at just under 10,000.

There are a number of catch-all HRGs. For instance, root HRG QZ05 (miscellaneous vascular procedures) captures ligations, excisions, canulations and stripping procedures, while QZ18 (procedures on the lymphatic system) includes procedures such as excisions and drainage of the lymph nodes and ducts.

New OPCS codes, released in OPCS-4.3, which the NHS should have been using since April 2006, acknowledge new technology being used. For instance, there is a new OPCS code L86.2 for ultrasound guided foam sclerotherapy for varicose vein of leg.