Payment by Results Business Rules

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1 Payment by Results Business Rules

2 DH INFORMATION READER BOX Policy HR / Workforce Management Planning / Clinical Document Purpose Gateway Reference Title Author Publication Date Target Audience For Information Estates Commissioning IM & T Finance Social Care / Partnership Working Payment by Results in Business Rules DH PbR Team 05 Feb 2009 PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, Medical Directors, Special HA CEs, Directors of Finance, Communications Leads Circulation List #VALUE! Description These Business Rules will support the implementation of PbR in Cross Ref Superseded Docs Action Required Timing Contact Details N/A N/A N/A N/A Payment by Results Team Room 3W52, Quarry House Quarry Hill Leeds LS2 7UE For Recipient's Use PbR Business Rules Page 2 of 19

3 Contents Background... 4 Grouper software... 4 Data stages... 5 PbR pre-processing stage... 5 Grouping stage... 6 PbR post-grouping stage... 6 PbR rules stage... 6 Accident & Emergency (A&E) tariff... 7 Figure 1 A&E flow diagram... 8 Outpatients... 9 Figure 2 Outpatients flow diagram Admitted Patients Short stay elective Short stay emergency Excess bed day payments Specialised services top-ups Alteplase Figure 3 Admitted patients flow diagram Figure 3a Short stay elective flow diagram Figure 3b Short stay emergency flow diagram Figure 3c Excess bed day flow diagram Figure 3d Specialised services top-ups flow diagram Figure 3e Alteplase flow diagram PbR Business Rules Page 3 of 19

4 Background 1. Payment by Results (PbR) is a rules based system for paying NHS provider organisations. PbR sets tariffs on the basis of Healthcare Resource Groups (HRGs). In PbR will be using the HRG4 currency for admitted patients and outpatients and HRGv3.2 (as per the tariff) for Accident and Emergency. 2. This note is intended to set out the business rules for PbR in and to accompany, but not replace, the Payment by Results Guidance for These business rules are consistent with those that will be applied in the national Secondary Uses Service (SUS) PbR algorithm for Grouper software 4. This document refers to the HRG4 grouper software provided by the NHS Information Centre (IC). 5. A grouper takes individual patient data and groups it to a HRG. Under HRG4 this HRG is called a core HRG; the grouper may also produce extra HRGs called unbundled HRGs (however, unbundled HRGs do not have mandated tariffs under PbR in ). 6. In general, providers use the grouper to plan, benchmark and to send the results to commissioners as part of their request for payment. Commissioners can also use this grouper if they have access to the raw data. 7. It should be noted that the NHS IC local groupers group data to HRGs, they do not apply tariff s or structural elements to the grouped data, this needs to be done by users or by a third party. SUS PbR however groups the data and applies these tariff s and structural elements. 8. This note assumes that where users are locally grouping data (for example for local tariffs not in the mandatory scope of PbR) and that they are making use of the NHS IC grouper software. Where users are using different grouping methods/software then this guidance may need to be adapted locally to fit. 9. Further details regarding HRGs and the NHS IC Grouper software are available on the NHS IC s website PbR Business Rules Page 4 of 19

5 Data stages 10. There are several stages in the application of PbR rules to data, and the details of these are contained later in this document. The broad stages that are applicable are: Stage PbR Pre-Processing Stage Grouping PbR Post-Grouping Stage PbR Rules Stage Description Removing episodes and adjusting lengths of stay prior to grouping Running the data through the grouper software Removing spells after they have been grouped Applying PbR rules and tariff s/ structural elements to data PbR pre-processing stage 11. PbR pre-processing is the term used to define the preliminary processing of data, from a PbR perspective, prior to it being fed through the NHS IC grouper software. 12. Certain episodes are excluded from PbR. These episodes are excluded because they are outside of the scope of PbR, be that for services (e.g. mental health services) or certain types of patients (e.g. private patients in NHS hospitals). The majority of pre-processing episode level exclusions are usually identified at TFC level. It is important to note, under HRG4, HRG exclusions are applied at the post-processing spell level and not at the episode level. 13. A full list of exclusions can be found under the Tariff Information section of the Payment by Results in website. However, please note that only those marked as pre-processing or pre-processing at episode level should be excluded at this stage. 14. Some pre-processing exclusions do not have specific codes listed (for example, the community services exclusion). It is recommended that where there are no specific codes, providers and commissioners discuss these exclusions and use previous definitions as a starting point for negotiation. 15. When the relevant (excluded) episodes have been identified then providers and commissioners should agree payment locally for any elements excluded in the pre-processing (episode level) stage. 16. At the pre-processing (episode level) stage it is important that episode lengths of stay are adjusted to take into account those services outside of PbR, for example critical care lengths of stay. The minimum length of stay for an episode is 0. Once the data has been grouped, these adjusted episode lengths of stay will feed into the spell level length of stay. PbR Business Rules Page 5 of 19

6 17. Therefore, for the purposes of PbR, a spell s length of stay is the sum of the episode length of stays within it, less any episode level (pre-processing) exclusions and any length of stay s (for example for critical care lengths of stay). 18. Once the relevant excluded episodes have been removed and any relevant s have been made for length of stays, the data is ready to be grouped. Grouping stage 19. Users should refer to the manuals and documents available on the NHS IC website including the guide to file preparation as to how to group data, what fields are required, what grouping pre-processing maybe required etc. PbR post-grouping stage 20. After the grouping process has been run successfully, post-grouping exclusions should be applied to the data. These include outpatient TFC exclusions and HRG exclusions. Please note that HRG exclusions are only applied post-processing and at the spell level under HRG A full list of exclusions can be found under the Tariff Information section of the Payment by Results in website. PbR rules stage 22. After the data has been pre-processed, grouped and then had post-processing exclusions applied to it, it is ready to have PbR rules applied to it. PbR has three types of mandatory tariff (these are covered below) and non-mandatory tariffs (which are not covered in this document). 23. The three types of mandatory tariff are: Accident & Emergency Outpatient Consultations Admitted Patient Care 24. All of the three types of mandatory tariff need to have the Market Forces Factor (MFF) applied to them. The MFF should be applied after any other tariff /structural element. 25. It is expected that where prices for activity have been negotiated locally, as a result of local flexibilities, including unbundling, the MFF element of the agreed local price should continue to be paid locally by the PCT. 26. Further details regarding the MFF can be found in the Payment by Results Guidance for The MFF payment index is available found under the Guidance and Supporting Information section of the Payment by Results in website. PbR Business Rules Page 6 of 19

7 Accident & Emergency (A&E) tariff 27. In PbR will be using HRGv3.2 (as per the tariff) for A&E activity. 28. Broadly speaking, A&E in PbR has a one-to-one relationship between the outputted HRGs and the A&E tariff. As although the A&E tariff has only three different tariffs, they are published at the HRG level. 29. The two exceptions to this are Minor Injury Units (MIUs) and patients who are Dead On Arrival (DOA). 30. MIUs should only ever attract the minor A&E tariff regardless of which HRG is actually triggered from the data. MIUs can be identified by the A&E department type field. 31. Likewise, DOAs should always attract the standard tariff; however, DOAs do not have a HRG under HRGv3.2 and as such, users will need to ensure that DOAs receive the appropriate tariff. The SUS PbR algorithm for will include a SUS-specific HRG for DOA. It should also be noted that DOAs are triggered by the A&E patient group code 70 Brought in dead. 32. Below is a flow diagram (figure 1) showing the individual steps taken in the PbR rules stage for A&E data. PbR Business Rules Page 7 of 19

8 Figure 1 A&E flow diagram A&E Grouped Data Figure 1 Was the patient DOA? (I.e. A&E Patient Group code 70) Apply standard A&E tariff Is the data for a Minor Injuries Unit (MIU)? Apply MFF Apply minor A&E tariff Apply the tariff for the output A&E HRG Apply MFF Apply MFF PbR Business Rules Page 8 of 19

9 Outpatients 33. For PbR in under outpatients there is a mixture of mandated, nonmandated and no national tariffs. 34. n-admitted consultations (i.e. outpatient consultations), for some treatment function codes, have mandated tariffs, some have non-mandated tariffs and some have no tariff (and so are for local negotiation). The outpatient planned same day (or procedure) tariff is non-mandatory in Commissioners and providers will be able to negotiate whether or not they agree to use the non-mandatory price or some other formulation to support payment for the activity. 36. Where a non-admitted consultation HRG (HRG4 sub-chapter WF) has been assigned to data, users need to determine whether the TFC for the data has a mandatory tariff. If it does then the mandated tariff applies, if not then either a non-mandatory tariff is supplied or no tariff is supplied, either of which would be for local negotiation between providers and commissioners. 37. Below is a flow diagram (figure 2) showing the individual steps taken in the PbR rules stage for outpatient data. PbR Business Rules Page 9 of 19

10 Figure 2 Outpatients flow diagram Outpatient Grouped Data Figure 2 Is it for a non-admitted consultation (sub-chapter WF) Is it for consultant led activity? Local negotiation (n-mandatory planned same day tariff) Cross-compare HRG with TFC. Does it have a mandatory tariff? Local negotiation Apply Mandatory Tariff Local negotiation (possibly with a nonmandatory tariff) Apply MFF PbR Business Rules Page 10 of 19

11 Admitted Patients 38. The admitted patient tariff is priced at HRG level, however there are different tariffs depending upon the patient s admission type and classification. A HRG may not necessarily have a tariff for each of the different admission types. 39. The different admission types and their tariffs are: Admission Type Daycase elective admission Ordinary elective admission Ordinary non-elective admission Tariff Planned Same Day Tariff Elective Inpatient Tariff n-elective Inpatient Tariff 40. There are also further tariff structural elements for admitted patients that may or may not apply to data. 41. These tariff structural elements are: Short stay elective Short stay emergency Excess bed day payments Specialised services top-ups Alteplase 42. Further details for these s/structural elements are shown below. In addition there are a series of flow diagrams (figures 3 to 3e, pages 14-19) showing each of the individual steps taken in the PbR rules stage for admitted patient data. Short stay elective 43. If the short stay elective is applicable to a HRG then it is shown as such on the published tariff. The short stay elective is only applicable to ordinary elective inpatient admissions. Furthermore, the short stay elective only applies to adults (defined as 19 years old or over). 44. Where an ordinary elective admission s spell level HRG is subject to a short stay elective, and the (adjusted) spell length of stay is less than 2 days (i.e. equals 0 or 1 day), then the tariff applicable is the planned same day tariff and not the elective inpatient tariff. If either of these criteria are not met then the full elective tariff is applicable. 45. Short stay elective tariffs can still have specialised service s and/or the alteplase made to them, if they fulfil the relevant criteria. 46. The flow diagram at figure 3a (page 15) shows the individual steps taken in the PbR rules stage for the short stay elective. PbR Business Rules Page 11 of 19

12 Short stay emergency 47. If the short stay emergency is applicable to a HRG then it is shown as such in the published tariff. The short stay emergency is only applicable to ordinary non-elective inpatient admissions with an admission method of emergency admission (codes or 28). Furthermore, the short stay emergency only applies to adults (defined as 19 years old or over). 48. Where an ordinary non-elective admission s spell level HRG is subject to a short stay emergency and the (adjusted) spell length of stay is less than 2 days (i.e. equal to 0 or 1 day) then the tariff applicable is the reduced short stay emergency tariff and not the non-elective tariff. If either of these criteria are not met then the full non-elective tariff is applicable. 49. Short stay emergency tariffs can still have specialised service s made to them if they fulfil the specialised service criteria. 50. The flow diagram at figure 3b (page 16) shows the individual steps taken in the PbR rules stage for the short stay emergency. Excess bed day payments 51. It is important to note that spell lengths of stay should have already been adjusted at the episode level at the pre-processing stage. This is because it may affect the length of stay for the spell level HRG and as such may affect which HRG is at the spell level (as some HRGs have length of stay logic). 52. Where an adjusted spell length of stay (for either elective or non-elective inpatient tariffs) for a HRG exceeds the spell trimpoint published as part of the tariff package, an excess bed day payment is payable for each day beyond the trimpoint. However, it should be noted that if a patient is deemed fit for discharge and fines have been imposed on local authorities under the delayed discharge arrangements then PCTs should not be liable for any further outlier payment (for SUS, this will need to be manually applied using data available in SUS). 53. The flow diagram at figure 3c (page 17) shows the individual steps taken in the PbR rules stage for excess bed day payments. Specialised services top-ups 54. For PbR in specialised service top-ups are paid for specialised services for children and orthopaedic services (please note, the orthopaedic top-up is only applicable to adults). All organisations remain eligible for orthopaedic top-ups with the specialised services for children top-up being applicable only for eligible organisations. A list of those organisations eligible for the specialised services for children top-up is available under the Eligible Providers tab of the Mandatory Tariffs spreadsheet. This can be found under the Tariff Information section of the Payment by Results in website. PbR Business Rules Page 12 of 19

13 55. If an organisation is eligible for both top-ups and a spell is eligible for both, then only the highest percentage top-up is applied. 56. It should be noted that as the local grouper does not apply tariff s or tariff structural elements, it does not incorporate organisation eligibility and as such, intervention is required to ensure that only those top-ups that an organisation is eligible for are applied to any data. In addition, the grouper may output both specialised service top-ups for the same spell. 57. To determine which spells are applicable for specialised service top-ups, the grouper software uses the specialised service code trigger list, published found under the Guidance and Supporting Information section of the Payment by Results in website. 58. This trigger list includes a mixture of OPCS procedure and intervention codes and ICD diagnosis codes. To trigger a top-up, the OPCS codes can be in any position in the patient record, however for the diagnosis codes to trigger a top-up they must be in the primary position. 59. The specialised services top-up is applied after any short stay s or excess bed day s are made, but prior to any alteplase. 60. It should also be noted that a list of spell HRGs that cannot have a specialised top-up applied to them is included in PbR tariff package. 61. The flow diagram at figure 3d (page 18) shows the steps taken in the PbR rules stage for specialised service top-ups. Alteplase 62. The use of the drug Alteplase for stroke receives a targeted (in this is 828). All organisations are eligible for this. 63. To trigger the additional payment for Alteplase the core HRG for the spell needs to be AA22Z and the spell also needs to have the unbundled HRG XD07Z. Where these two criteria are met, all organisations should receive the targeted. 64. As this is a tariff /structural element, it will not be output by the local groupers. 65. The flow diagram at figure 3e (page 19) shows the individual steps taken in the PbR rules stage for the Alteplase Adjustment. PbR Business Rules Page 13 of 19

14 Figure 3 Admitted patients flow diagram Inpatient Grouped Data Figure 3 Does the HRG/ admission type combination have a mandatory tariff? Is the short stay elective applicable? (Go to figure 3a) Local negotiation for price Is the short stay emergency applicable? (Go to figure 3b) Are any excess bed day payments applicable? (Go to figure 3c) Is the spell eligible for specialised service top -ups? (Go to figure 3d) Is the spell eligible for the Alteplase? (Go to figure 3e) Apply any relevant s to the base tariff price (in the above order) and apply MFF to calculate final price PbR Business Rules Page 14 of 19

15 Figure 3a Short stay elective flow diagram Inpatient Grouped Data Figure 3a Is the admission type ordinary elective? Is the HRG applicable for the short stay elective? Is the patient a child? (< 19) Is the length of stay less than 2? Apply short stay elective PbR Business Rules Page 15 of 19

16 Figure 3b Short stay emergency flow diagram Inpatient Grouped Data Figure 3b Is the admission type ordinary non-elective with an admission method of emergency (21-24 or 28)? Is the HRG applicable for the short stay emergency? Is the patient a child? (< 19) Is the length of stay less than 2? Apply short stay emergency PbR Business Rules Page 16 of 19

17 Figure 3c Excess bed day flow diagram Inpatient Grouped Data Figure 3c Is the admission type either ordinary elective or ordinary non-elective? Does the (adjusted) spell length of stay (LoS) exceed the trimpoint? * Apply no excess bed day payment Multiply the difference (LoS trimpoint) by the excess bed day tariff Apply no excess bed day payment It should be noted that any excess bed day payment may need to be adjusted to take into account any fines to local authorities under delayed discharge arrangements. *Elective & n-elective admissions may have different trimpoints PbR Business Rules Page 17 of 19

18 Figure 3d Specialised services top-ups flow diagram Inpatient Grouped Data Figure 3d Is the spell applicable for a specialised top -up? Is the spell HRG applicable for a specialised top-up? topup Is the spell eligible for the specialised top-up for specialised children? (SSC 23) topup Is the organisation eligible for the top-up? Is the spell eligible for the specialised top-up for orthopaedics? (SSC 34) Apply specialised children s Top-up Apply orthopaedic specialised top -up topup PbR Business Rules Page 18 of 19

19 Figure 3e Alteplase flow diagram Inpatient Grouped Data Figure 3e Is the spell core HRG AA22Z? Does the spell also have an unbundled HRG of XD07Z Apply to Alteplase Adjustment ( 828 in 2009/10) PbR Business Rules Page 19 of 19

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