3 SUS PbR Processing For 2012/13 In this part of the session we will look at :Annual UpdateBest PracticeReadmissionsAge DerivationsSpell ConstructionExclusionsICD-10A+E Codes
4 Annual Update Introduction SUS PbR is updated each year to align its processing methods with the annual PbR Policy guidance published by the Department of Health to support each financial year.The primary focus of SUS PbR Release 11 is to implement the DH PbR policy for 2012/13 across SUS PbR’s processing methods, extracts and user interface.In addition to policy updates, further changes have been made to improve the usability aspects of the online system and extracts. These changes have been implemented as a direct response to feedback received from users following previous releases.
5 Annual Update Facts and Figures In 2012/ HRGs are now included in the National Tariff against 1168 in 2011/12In 2012/13 there are 1215 Daycase Tariffs against 1168 in 2011/12In 2012/13 there 296 HRG available for Short Stay Emergency Tariff against 356 in 2011/12In 2012/13 there are 83 Procedural HRG carrying an OP tariff against 60 in 2011/12Specialised Services for Children in 2012/13 at 50% against 60% in 2011/12
6 Annual Update SUS Processing SUS processing logic has been changed to accommodate the relevant business rules and tariff changes outlined in Department of Health PbR Guidance 2012/13 with SUS PbR processing submitted data for the years 2010/11, 2011/12 and 2012/13HRG4 grouping logic has been applied to Admitted Patient Care (APC), Outpatients (OP) and Accident and Emergency (EM) 2011/12 and 2012/13Exception: Accident & Emergency (EM) Spells processed for 2010/11 processed using HRG3.2 grouping logic
7 Best Practice Best Practice Session 1 Background Best Practice Tariff IndicatorsSpecialised Service Codes & Best Practice Flags formatsCountsBest Practice Session 2Invalid CombinationsShort Stay Emergency Spells with BPT flagsNational Tariff AdjustmentApplying BPT Action FlagsBPT Action Flag definitions
8 Best Practice Background The Department of Health introduced Best Practice Tariffadjustments in 2010/11 with the aim of reimbursing providers for improving the quality of care.Best Practice initially addressed four high volume areas;cataracts, fragility hip fracture, gall bladder and acute stroke.These were chosen due to the significant and unexplained variation in practice and to give a clear consensus of what clinical best practice constituted.Best Practice was further extended in 2011/12 to cover additional procedures across breast surgery, gynaecology, orthopaedics, urology, hernia repair, interventional radiology, total primary hip and knee replacements and transient ischaemic attack.
9 Best Practice Best Practice Indicators Best Practice has been extended again in 2012/13 with the following effects:There are now approximately 40 BPT Indicators (flags) for procedures eligible for Best Practice Tariff adjustmentBest Practice flags/adjustments applied to APC Spells only
10 Best Practice Specialised Service Codes and Best Practice Flags This year the Grouping process will output separate Specialised Service Codes (SSC) and Best Practice flags with the format of these flags being the same for the Local Payment grouper and the SUS Grouper.The Grouper formats are:Specialised Service Code (SSC) = SSnn e.g. SS08Best Practice = BPnn e.g. BP36Note: Making this change ensures that the difference between BPT and SSC flags is much clearer for users from a processing and output perspective.
11 Best PracticeFlags from the Grouper for Best Practice are produced at Spell levelFlags from the Grouper for Best Practice are DISTINCT i.e. only one distinct value per Spell. However you can have multiple flags per Spell (but not the same flag multiple times)Example output from Local/SUS GrouperRowNoProvSpNoIterationSpellFlag1181SS08BP362BP39396BP41405SS23
12 Best PracticeCountsSUS will provide an SSC “count” and a BPT “count” in APC Spells showing the number of flags output by the Grouper.The individual BPT and SSC flags (maximum of 5) are shown in the APC Spell extracts in the following attributes called:SSCSpecialised Service Code 1Specialised Service Code 2Specialised Service Code 3Specialised Service Code 4Specialised Service Code 5BPTBPT Indicator 1BPT Indicator 2BPT Indicator 3BPT Indicator 4BPT Indicator 5
13 Readmissions Session 1 Recap of Readmissions in 2011/12 Pairs of Readmissions EventsReadmissions FlagsMultiple YearsTransfersReadmissions ExtractsSession 2Pathway Linkage‘Child’ Spell eligibility‘Parent’ Spell eligibilityDH Tariff Adjustment (Parent)DH Tariff Adjustment (Child)How to interpret the extractExamples of Pathways
14 Readmissions Readmissions in 2011/12 Readmissions policy was introduced in April 2011Commissioners can decide to retain funds for Spells that are deemed a readmission within 30 days to make investments in other areas to reduce the number of readmissionsReadmission activity in SUS for 2011/12 output to a Managed Service “Readmissions” extract available to Commissioners only.
15 Readmissions Readmissions in 2012/13 – Pairs of Readmissions Events Readmissions in 2012/13 are processed in the same way as last year using a readmissions pathway with the following changes:A pathway may contain more than one ‘Pair’ of readmission eventsA Pair being the original admission (Parent) with a readmission (Child) within 30 daysThis means that each individual ‘Pair’ needs to be evaluated for eligibility rather than the whole pathway
16 Readmissions Readmissions Flags A series of flags have been introduced to show eligibility as a‘Readmission’ and which Financial year the events belong to:RAP ELIGIBLE PARENTRAP ELIGIBLE CHILDRAP DH Tariff ADJUSTMENT PARENTRAP DH Tariff ADJUSTMENT CHILDRAP Validation Parent IndicatorRAP Validation Child IndicatorFinancial YearThese flags will appear on the Readmissions extract (which is aYEARS to DATE extract, which starts from the 1st April 2011).
17 Readmissions Multiple Years SUS will reprocess the 2011/12 readmission data using the Release 11 logic to ensure that the data is consistent across both years of the readmission.New pathway identities will not be assigned.If the readmission Spell (Child) has a previous discharge Spell (Parent) in an earlier financial year. To process this type of cross financial year ‘Pair’ the reference used will be that associated with the financial year of the Child.
18 Readmissions Transfers Two new attributes have been added to the Readmissions extract which help users identify where a transfer between providers forms part of a readmission pathway. The new attributes identify the originating and destination spell/provider.Transfers between providers are ‘flagged’ where the transfer is after 1st April 2012 and referred to by the following terms:Transfer Out - The Spell that transfers the patient will be flagged as ‘TP1’.Transfer In - The Spell that receives the patient will be flagged as ‘TC1’.
19 Readmissions Readmission Extracts Extracts to both Commissioners and Providers are provided in Release 11Pathways may contain events that cross multiple Commissioners and multiple ProvidersIf a Commissioner has one event in a pathway then all events of that pathway will be included in their extract for Release 11If a Provider has one event in a pathway then all events of that pathway will be included in their extract for Release 11
20 Age Derivations Age Derivations Release 11 will apply derivations to calculate AGE as follows:A+E = Arrival Date minus Date of Birth in complete YEARS(no Rounding)OP = Appointment Date minus Date of Birth in complete YEARS (no Rounding)APC Episodes = Episode Start Date minus Date of Birth in complete YEARS (no Rounding) or based on Age at CDS Activity Date where Date of Birth has not been submittedThese derivations will populate a NEW attribute EPISODE AGE .
21 Age DerivationsPrior to Release 11, on an APC Episode, AGE was derived as AGE AT START OF Spell (Admission date minus DOB) and then used in PbR processingIn Release 11, the AGE at episode start will be used to input to the Grouper using the new attribute EPISODE AGEFor an APC Spell the age will be taken from the episode that is classed by the Grouper as the pseudo dominant episode (Spell Report Flag =’1’)This will populate a NEW attribute Spell AGE
22 Spell Construction Spell Construction – Same Day Admissions In previous years, the rule for same day admissions was complex.An episode would be joined to a Spell if the same patient on the same day was admitted to the same provider and the Length of stay was zero and episode flags had been set.
23 Spell Construction Spell Construction – Same Day Admissions To cater for same day admissions in Release 11, if an episode has the following conditions then it will create a new Spell without further consideration:EPISODE NUMBER is equal to ‘1’LAST EPISODE IN Spell is equal to ‘1’Length Of Stay is ‘0’This logic will be applied for all years being processed in SUS PbR once Release 11 has been transitioned.The order that Spell logic is applied is as follows:DAYCASECONFIDENTIAL SpellsSAME DAY ADMISSIONSNHS NUMBERHPS + DOB + SEX
24 ExclusionsExclusionsExclusions occur at 3 different stages of the PbR process to ensure that only appropriate data records are processed in line with current DH PbR business rules. The stages are:Pre-processing excludes records with insufficient data to process within PbR Example - an APC Episode with no Admission Date would not be capable of creating or linking to an existing Spell.Pre-grouping excludes elements which DH define as not contributing to the Spell HRGPost –Grouping exclude APC Spells, OP or A+E Episodes from having the tariff appliedNote: In previous releases events excluded in point (1) have not been made available via extracts.
25 Exclusions PbR UnSpellable Activity Release 11 introduces a new single (APC, OP and A+E) Managed Service extract “PbR UnSpellable Activity”.This will contain events excluded in pre-processing that have not been made available via extracts in previous releases.A full extract will be available to NHS CFH and HSCIC to all providers and commissioners.Note: Data that cannot be attributed to a particular provider/commissioner will be available to HSCIC.
26 Exclusions Outpatients Procedural HRG processing Prior to Release 11 Where an OP Attendance has been assigned a procedural HRG (does not begin with WF) and no tariff is assigned to the HRG in OP Mandatory tariff, SUS PbR will derive an ‘Attendance HRG’ (does begin with WF)In previous years the tariff has then been applied using the SUS Attendance HRGIn Release 11 an additional step is performed to apply MSC and TFC OP Exclusions using the SUS Attendance HRG and then apply tariff if the episode is not excluded
27 Outpatient Exclusions Example 1 Derive Attendance SUS HRG OP AttendanceTFC 102 and HRGAA20ZOutpatient Exclusions Example 1OP Attendance has a TFC of 102 and the OP Attendance has a grouper assigned HRG for AA20Z.ApplyTariffNoTariff AvailableOP Mandatory tariff has no entry for AA20Z SUS PbR derives an Attendance HRG of WF01A.Derive Attendance SUS HRGOPCTFC ExclusionsAppliedSUS PbR applies OP TFC Exclusions .If Excluded -NO TariffWF01A + TFC of 102 is excluded, so no tariff applied.
28 Exclusions Outpatient Exclusions Example 2 OP AttendanceTFC 101 and HRG0AA20ZOP Attendance has a TFC of 101 and the OP Attendance has a grouper assigned HRG for AA20Z.Outpatient Exclusions Example 2ApplyTariffNoTariff AvailableDerive Attendance SUS HRGOP Mandatory tariff has no entry for AA20Z SUS PbR derives an Attendance HRG of WF01A.OPCTFC ExclusionsAppliedSUS PbR applies OP TFC Exclusions .WF01A + TFC of 101 is NOT excluded. OP Mandatory Tariff for WF01A + TFC 101 results in a tariff of £96.If NOT Excluded apply tariff -£96
29 Exclusions Exclusions - Global Validations A global validation will be introduced following spell creation in Release 11 where if the Spell does not have all days between the Admission Date and Discharge Date (inclusive) accounted for by episode start and end days (inclusive), the Spell will be deemed to have a data quality issue.The Spell will be classed as not PbR Qualified (excluded from tariff) and have the Spell Core HRG set to NA.The following attributes will be set:‘Spell EXCLUSION REASON’ will be set to ‘MISSING_EPISODES(S)’ in APC Spells extract.‘PbR EXCLUDED IND’ will be set to ‘2’ in APC Episode Extract.‘Spell in PbR/Not in PbR’ will be set to ‘9’.
30 Exclusions Excluded Episodes transformed to Single Episode Spells Excluded Episodes are considered as Single Episode Spells which will be displayed in the APC Spells, A+E and OP extracts, each with its own unique ID and with its original Spell ID also present in the extract to allow traceability back to the Spell the episode was excluded from.The Spell in PbR/Not in PbR will be set with ‘7’ to mark the Spell as ‘A singleton episode Spell created by an excluded episode’
31 ICD-10ICD-10 CodesInternational Classification of Diseases (10th Revision) and OPCS codes (Office of Population Censuses and Surveys) are grouped together in SUS to form HRGs which are used in tariffing Spells.The fourth edition of the ICD-10 diagnosis classification will be implemented from April SUS Auto Grouper and appropriate reference data tables will be updated accordingly.For activity relating to previous financial years for example a discharge date before 31/3/12, grouping will use the valid ICD-10 code set and processing rules for that year and will not UZ01Z when the “deleted” codes are submitted against activity for 2010/11 and 2012/12.Note: SUS will not group until a Spell is complete.
32 A+E Codes SUS PbR will apply the following processing rules to A+E Treatment Codes1. No spaces will be removed from the Original Input Data2. Truncate to three characters (including any spaces)3. Pass the three character code to the SUS Auto-Grouper4. The original Treatment Code will be used to populate the extractsThese will only be applied to EM episodes that have an AE ARRIVAL DATE equal to or greater than 1st April 2012.
33 A+E Codes SUS PbR will apply the following processing rules to A+E Investigation CodesNo spaces will be removed from the Original Input DataTruncate to TWO characters (including any spaces)Pass the two character code to the SUS Auto-GrouperThe original Investigation Code will be used to populate the extracts
34 A+E Codes SUS PbR will apply the following processing rules to A+E Diagnosis Codes1. No spaces will be removed from the Original Input DataThe original Diagnosis Code will be used to populate the extracts.
35 Derivation of PCT Derivation of PCT from GP Practice Prior to Release 11 the PCT was derived for APC using the CDS ACTIVITY DATEFrom Release 11, for APC episodes SUS will derive the PCT from date at the episode start dateThe APC Spell PCT will be the PCT derived on the pseudo dominant episode (Spell Report Flag =’1’)
36 Extracts In this part of the session we will look at: Online Extracts Managed Service ExtractsChanges to Existing Extracts
37 Extracts Online Extracts There are 3 new Online Extracts for 2012/13: Critical Care (CC)Multi-Birth (MB)Ward Stay (WS)
38 Extracts Managed Service Extracts for 2012/13 PbR UnSpellable Activity This new extract will allow the user to see all records submitted to PbR and details all episodes that have not been eligible for PbR processing (and as a consequence have no PbR derived attributes). This new extract will allow the user to see all records submitted to PbR.Provider ReadmissionsTo support Providers, the Readmission extract that was previously only available to Commissioners is now available to Providers.
39 Extracts Changes to Existing Extracts To support users and the new functionality the followingextracts have been amended.The embedded workbook below contains the new attributes that have been added to extracts in Release 11Release 11. They are as follows;APC SpellsAPC EpisodesOutpatient EpisodesA&E(EM) EpisodesUnSpellable (New)ReadmissionsCritical CareWard StayMulti BirthsNote: FULL online extracts reflect the changes mentionedin these standard extracts.
40 Extracts Changes to Existing Extracts The following extracts do not have new attributes inRelease 11:BP - CataractsSupplementary APC SpellsSupplementary APC EpisodesSupplementary OutpatientsSupplementary Emergency Medicine (EM)APC Error ExtractOP Error ExtractEM Error Extract
41 Extracts APC Spells Extract Attributes Removed in R11 Best Practice SSCBest Practice SSC ApplicableBPT Combination IndicatorPbR Readmission IndicatorNumber of Spells Prior to ReadmissionNumber of Spells Following ReadmissionFirst Spell Identifier (Readmission)Organisation Code (Code of Provider of Original Parent Admission)
42 Extracts Outpatient Extract Attributes Removed in R11 BPT Combination IndicatorEM Extract Attributes Removed in R11Core HRG For InformationHRG Code Version - For InformationThe Readmissions extract has had 105 attributes removed to reduce the IG issues with sharing data between Providers where pathways have more than Provider involved.
43 Extracts Ward Stay Extract Attributes Removed in R11 Episode Number Multi Birth Extract Attributes Removed in R11
44 Extracts In this part of the session we will look at: De-duplicating Records due to Reasons for Access
45 Extracts De-Duplicating Records To prevent the duplication of extracts where multiplereasons for access exist and to reduce the need for local users to locally de-duplicate the 2012/13 PbR extracts the “Include Copy Recipient” has been removed as a separate selection option.Consequently SUS PbR will read the organisation code against every reason for access and output only one instance of the record regardless of the number of reasons for access.This “Single Record” approach applies to all extractswith the exception of supplementary extracts wheremultiple rows may be displayed.