Guide to Unbundling Page 1 of 33 Author: The National Casemix Classifications Service Date: February 2009

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1 Version No: 4.0 Issue Date: 13 February 2009 Page 1 of 33

2 GUIDE TO UNBUNDLING - CONTENTS 1 INTRODUCTION OUTLINE OF UNBUNDLING WHY UNBUNDLE? WORKED EXAMPLE WHAT COMPONENTS ARE UNBUNDLED? WHEN DOES UNBUNDLING HAPPEN IN THE GROUPING PROCESS? WHICH DATASETS PRODUCE UNBUNDLED HRGS? WHAT HAPPENS WHEN ALL PROCEDURES ARE UNBUNDLED? HOW ARE UNBUNDLED HRGS SHOWN IN THE GROUPER OUTPUT? ON WHAT BASIS ARE UNBUNDLED HRGS ALLOCATED? CHAPTER SPECIFIC GUIDANCE CHEMOTHERAPY RADIOTHERAPY INTERVENTIONAL RADIOLOGY DIAGNOSTIC IMAGING REHABILITATION SPECIALIST PALLIATIVE CARE ADULT CRITICAL CARE PAEDIATRIC AND NEONATAL CRITICAL CARE RENAL DIALYSIS HIGH COST DRUGS APPENDIX 1 HIGH COST DRUG MAPPING TO OPCS 4.4 CODE AND ASSOCIATED HRG...30 Copyright 2009, The Information Centre, Standards and Classifications. All rights reserved. This work remains the sole and exclusive property of The Information Centre and may only be reproduced where there is explicit reference to the ownership of The Information Centre. This work may be re-used by NHS and government organisations without permission. Commercial re-use of this work must be granted by The Information Centre.

3 1 Introduction HRG4 introduces the concept of unbundling. This guide explains unbundling and describes how the concept has been applied to specific chapter areas within HRG4. It includes a number of worked examples and notes that will help users to understand how relevant data are collected, coded and grouped to produce unbundled HRGs. 2 Outline of Unbundling In HRG v3.5 each episode of care would derive a single HRG. In HRG4, some significant elements of cost and activity have been unbundled from core HRGs. The impact of unbundling is that under HRG4 a case will be assigned more than one HRG if it includes any unbundled elements. The unbundled component becomes an HRG in its own right as an addition to a core HRG. For example, a case could be assigned the following HRGs depending on the components within it: Core HRG + Unbundled Unbundled Unbundled Unbundled Renal High Cost Diagnostic Rehabilitation Dialysis + Drug + Imaging + HRGs HRGs HRGs HRGs Unbundled HRGs have been developed to comply with the design rules which apply to all HRGs. Principally, there must be at least 600 cases expected per annum nationally, or the total national cost must be at least 1.5 million per annum. 3 Why Unbundle? The benefits of unbundling are to: Improve the performance of HRGs so that they can better represent activity and costs Support service redesign Support Patient Choice (e.g. choice of scan provider). It is increasingly likely that patients will attend different providers for different parts of the care pathway.

4 4 Worked example Assume a patient is admitted with a head injury and abdominal pain after falling and has a CT scan (head) immediately on admission. A day later they have a further CT scan of the abdomen. In HRG v3.5, this case would be grouped to HRG H64 (Head Injury <70 w/o cc) In HRG4, it is grouped to Core HRG HD37C Head Injury without CC Unbundled HRG RA08Z Computerised Tomography Scan, one area, no contrast Case A Primary Diagnosis (ICD-10) S09.9 Unspecified injury of head Procedure 1 (OPCS-4.4) U05.1 Computed tomography of head Y98.1 Radiology of one body area (or <20 minutes) Procedure 2 (OPCS-4.4) U08.1 Computed tomography of abdomen NEC Y98.1 Radiology of one body area (or <20 minutes) HRG v3.5 H64 Core HRG HD37C HRG4 Unbundled HRG RA08Z RA08Z 5 What components are unbundled? Unbundled HRGs have been developed for: Chemotherapy procurement and delivery Radiotherapy planning and delivery Diagnostic Imaging Rehabilitation Renal Dialysis Critical Care Specialist Palliative Care High cost drugs The unbundled activity will be identified by data items or codes typically a new or existing OPCS code. The unbundling of a component or process of care will be applied consistently throughout HRG4, except in the following cases:

5 Only one Emergency and Urgent Care HRG will be assigned per attendance and no element of treatment will be unbundled from the accident and emergency CDS. 6 When does unbundling happen in the grouping process? Unbundling is the first step in the grouping process, following data validation. Unbundled procedures are removed from the data input file and processed separately to derive unbundled HRGs. The grouper then ignores these unbundled components when deriving the core HRG for an episode or spell. 7 Which datasets produce unbundled HRGs? Unbundled HRGs can be derived from the Admitted Patient Care and Outpatient datasets. The Accident and Emergency dataset does not generate unbundled HRGs; investigation and treatment activity is incorporated in the core HRGs for emergency and urgent care. 8 What happens when all procedures are unbundled? In some cases, all procedures in an episode may be unbundled, e.g. in an attendance for renal dialysis where no other procedures are performed. Even where there are no procedures remaining after unbundling, the grouper will always allocate a core HRG for the episode or spell in addition to the HRGs for the unbundled components. When all significant procedures in an inpatient Finished Consultant Episode (FCE) or spell are unbundled, diagnosis is used to derive a core HRG for the episode. For non-admitted care, if all procedures are unbundled the episode is allocated one of the eight relevant non-admitted care attendance HRGs as a core HRG. 9 How are unbundled HRGs shown in the grouper output? Any unbundled components will be shown against the relevant FCE / spell. Unbundled HRGs are shown as the last (right-most) entries in the grouper output for the FCE/spell to which they relate. There is no significance to the order in which unbundled HRGs are listed. For the second iteration of the HRG4 Reference Costs Grouper, released to the NHS in January 2008, unbundled HRGs were also provided in relational

6 output format, as a separate file, in addition to being included on the output file as the last (most right) entries. This output is also produced from the HRG4 2008/09 Reference Costs grouper. The FCE HRGs in a spell can be linked through the use of a common spell identifier to enable local analysis. 10 On what basis are unbundled HRGs allocated? All unbundled HRGs are event based, as recorded using appropriate underlying classifications, e.g. OPCS-4.4 codes. The unit of activity for these unbundled HRGs varies according to case type: Unbundled Component Chemotherapy regimen Chemotherapy - delivery Radiotherapy planning Radiotherapy - treatment Diagnostic Imaging Rehabilitation Renal Dialysis Adult Critical Care Paediatric and Neonatal Critical Care Specialist Palliative Care High cost drugs Currency 1 HRG per regimen procured 1 HRG per cycle of delivery 1 HRG per planning instance 1 HRG per fraction delivered 1 HRG per imaging activity 1 HRG per rehabilitation assessment 1 HRG per diem for each individual recorded delivery of rehabilitation 1 HRG per session of dialysis treatment 1 HRG per critical care period, based on number of organs supported 1 HRG for each day of Critical Care 1 HRG per diem for each episode of care 1 HRG per drug prescribed per spell, excluding drugs delivered within Chemotherapy regimens Users should refer to the Reference Costs guidance issued by the Payment by Results team at the Department of Health for details of the currency used to collect 2008/09 Reference Costs data. These currencies may be reviewed by PbR prior to application for reimbursement. 11 Chapter Specific Guidance 11.1 Chemotherapy The chemotherapy HRGs for cancer treatment have been unbundled from the medical and the surgical inpatient and non-admitted care HRGs. All patients

7 will therefore receive a core HRG based on surgical procedures or primary diagnoses and one or more additional chemotherapy HRGs. Trusts will receive multiple delivery HRGs per cycle if the cycle is delivered on multiple attendances. Each time a new chemotherapy cycle starts, a new regimen will be recorded. Under HRG4, chemotherapy groupings are based on cycles and are split between chemotherapy drug procurement (regimen) and delivery. Each patient will be allocated one HRG for the regimen procured per cycle and one HRG for each attendance for treatment, to reflect the complexity of treatment and hence resource usage. Pharmacy costs will be included in the procurement codes as detailed in the 2008/09 Reference Costs guidance. The chemotherapy regimen HRGs are banded into 10 bands, with an additional HRG to accommodate procurement of drugs for regimens not on the national list. The list of regimens has been compiled from lists supplied by members of the Network Pharmacy Group. The chemotherapy delivery HRGs for the first attendance take account of the resources required for the delivery of one cycle of the chemotherapy regimen. The subsequent delivery is a single generic code and this will be further reviewed in the future HRG design. In respect of chemotherapy, Inpatient Ordinary Admissions, Regular day attenders, Day cases, Same day inpatients and Outpatients are all treated the same from an HRG perspective and all can generate the same HRGs. In most cases there is a straightforward 1 to 1 mapping of OPCS-4.4 codes to HRGs as shown below: Chemotherapy regimen grouping logic OPCS-4.4 HRG HRG Label X70.1 SB01Z Procure Chemotherapy drugs for regimens in Band 1 X70.2 SB02Z Procure Chemotherapy drugs for regimens in Band 2 X70.3 SB03Z Procure Chemotherapy drugs for regimens in Band 3 X70.4 SB04Z Procure Chemotherapy drugs for regimens in Band 4 X70.5 SB05Z Procure Chemotherapy drugs for regimens in Band 5 X70.8 SB16Z Procure Chemotherapy drugs for regimens not on the national list X71.1 SB06Z Procure Chemotherapy drugs for regimens in Band 6 X71.2 SB07Z Procure Chemotherapy drugs for regimens in Band 7 X71.3 SB08Z Procure Chemotherapy drugs for regimens in Band 8 X71.4 SB09Z Procure Chemotherapy drugs for regimens in Band 9 X71.5 SB10Z Procure Chemotherapy drugs for regimens in Band 10

8 Chemotherapy delivery grouping logic OPCS-4.4 HRG HRG Label X73.1 SB11Z Deliver exclusively Oral Chemotherapy X73.8 SB11Z Deliver exclusively Oral Chemotherapy X73.9 SB11Z Deliver exclusively Oral Chemotherapy X72.3 SB12Z Deliver simple Parenteral Chemotherapy at first attendance X72.2 SB13Z Deliver more complex Parenteral Chemotherapy at first X72.1 SB14Z attendance Deliver complex Chemotherapy, including prolonged infusional treatment at first attendance X72.4 SB15Z Deliver subsequent elements of a Chemotherapy cycle X72.9 SB17Z Deliver chemotherapy for regimens not on the national list NHS organisations must ensure that they collect appropriate and accurate OPCS-4.4 codes for chemotherapy activity to ensure that they receive the necessary unbundled chemotherapy HRG. If chemotherapy data are collected on a secondary system, organisations must be able to transfer it to their PAS system in order for the necessary grouping to HRG to take place. It is important that coders use the most up to date OPCS code set to record chemotherapy. These codes were not covered by OPCS-4.2. A mapping of the regimens to OPCS 4.4 codes for procurement of chemotherapy drugs can be found at the following website. /codingstandards/opcs4/downloads/chemo This file should be used to determine which band a regimen maps to Radiotherapy The radiotherapy HRGs have been unbundled from the medical and the surgical inpatient and non-admitted care HRGs. All patients will therefore receive a core HRG based on surgical procedures or primary diagnoses and one or more additional radiotherapy HRGs. Providers will receive multiple delivery HRGs (one per fraction) if a course of radiotherapy is delivered over multiple attendances. HRG4 groups for radiotherapy include one set for pre-treatment (planning) processes and one set for treatment delivered, with a separate code being allocated for each fraction delivered. These groups are: Radiotherapy planning

9 Radiotherapy treatment (delivery per fraction) The planning HRGs are banded into 9 bands based on increased complexity, with a tenth band intended to capture Other Radiotherapy Planning. The planning HRG is intended to cover all attendances required for completion of the planning process. It is not intended that individual attendances for parts of this process will be recorded separately. The planning HRG does not include the consultation at which the patient consents to radiotherapy, nor would it cover any outpatient attendance for medical review required by any change in status of the patient. The treatment HRGs are banded into 8 bands of treatment based on increased complexity, with a ninth band for Other Radiotherapy Treatment. For each fraction of treatment delivered, one HRG will be assigned. Radiotherapy HRGs are driven by OPCS-4.4 codes and the majority have a direct mapping. The logic used relies on the coding of a secondary procedure to indicate a general anaesthetic or delivery of a fraction using a megavoltage or orthovoltage machine. The radiotherapy HRGs are listed in the table below. HRG Label Define volume for SXR, DXR, electron or Megavoltage Radiotherapy SC01Z without imaging and with simple calculation Define volume for simple Radiation Therapy with imaging (Simulator, CT SC02Z scanner etc) but with simple calculation and without Dosimetry SC03Z Define volume for simple Radiation Therapy with imaging and Dosimetry Define volume for multiple phases of complex Radiation Therapy with SC04Z imaging and Dosimetry Define volume for Radiation Therapy with imaging, Dosimetry and technical SC05Z support e.g. mould room Define volume for Radiation Therapy with imaging and Intensity-modulated SC06Z Radiation Therapy Dosimetry or equivalent SC07Z Prepare for Total Body Irradiation SC08Z Prepare for Intracavitary Radiotherapy SC09Z Prepare for Interstitial Radiotherapy SC10Z Other Radiotherapy Planning SC21Z Deliver a fraction of treatment on a superficial or orthovoltage machine SC22Z Deliver a fraction of treatment on a megavoltage machine SC23Z Deliver a fraction of complex treatment on a megavoltage machine Deliver a fraction of Radiotherapy on a megavoltage machine using SC24Z General Anaesthetic SC25Z Deliver a fraction of Total Body Irradiation SC26Z Deliver a fraction of Intracavitary Radiotherapy without General Anaesthetic

10 SC27Z Deliver a fraction of Intracavitary Radiotherapy with General Anaesthetic SC28Z Deliver a fraction of Interstitial Radiotherapy SC29Z Other Radiotherapy Treatment The OPCS-4.4 codes relating to the radiotherapy HRGs are listed in the table below: OPCS-4.4 Label X63.1 Volume definition for radiotherapy with imaging and intensity-modulated radiation therapy dosimetry X63.2 Volume definition for radiotherapy with imaging, dosimetry and technical support X63.3 Volume definition for multiple phases of complex radiotherapy with dosimetry X63.4 Volume definition for simple radiotherapy with imaging and dosimetry X63.5 Volume definition for simple radiotherapy with imaging and simple calculation X63.6 Volume definition for superficial or deep X-ray, electron or megavoltage radiotherapy with simple calculation X63.8 Other specified radiotherapy volume definition X63.9 Unspecified radiotherapy volume definition X64.1 Preparation for total body irradiation X64.2 Preparation for intracavitary radiotherapy X64.3 Preparation for interstitial radiotherapy X64.8 Other specified radiotherapy preparation X64.9 Unspecified radiotherapy preparation X65.1 Delivery of a fraction of total body irradiation X65.2 Delivery of a fraction of intracavitary radiotherapy X65.3 Delivery of a fraction of interstitial radiotherapy X65.4 Delivery of a fraction of external beam radiotherapy NEC X65.5 Oral delivery of radiotherapy for thyroid ablation X65.8 Other specified radiotherapy delivery X65.9 Unspecified radiotherapy delivery The mapping of the OPCS-4.4 codes to their respective radiotherapy HRGs can be found in the Code to Group spreadsheet available from the Casemix Service website at Notes: It is important that coders use the most up to date OPCS code sets to record radiotherapy. This activity was not covered by OPCS-4.2.

11 A separate OPCS-4.4 code needs to be recorded for each fraction delivered for outpatients and regular day attenders. Local constraints on the number of fields available on PAS may limit the number that can be recorded to a maximum per record. This is unlikely to be an issue for outpatient and regular day attenders treatment as it is improbable that more than 3 fractions are given at a single attendance. However, for inpatients, there may be insufficient procedure fields available to enter all the fractions. This is likely to apply to most inpatients who receive radiotherapy treatment. Providers are therefore only required to record one fraction of Radiotherapy delivery in an inpatient setting, regardless the number of total fractions given Interventional Radiology At present the design of the original unbundled interventional radiology HRGs is under review. Unbundled HRGs are therefore no longer generated for interventional radiology activity Diagnostic Imaging For the purpose of the 2008/09 reference costs, all diagnostic imaging with the exception of plain film x-ray and obstetric ultrasound scans can be unbundled and will derive HRGs that are additional to a core HRG for the care event. Each imaging procedure other than those for plain-film x-ray should be separately recorded using a valid OPCS-4.4 code and will generate a separate HRG in the reference cost grouper. These HRGs are dependent on imaging activity being coded using OPCS-4.4 and included in the APC or outpatient dataset for input to the grouper. Providers need to ensure that imaging data is collected and coded or they will fail to generate the appropriate diagnostic imaging unbundled HRGs. It is imperative that for the correct HRG for Diagnostic Imaging being generated the OPCS-4 codes recorded follow national clinical coding guidance both in terms of the codes used and the sequencing of these codes. Further information on OPCS-4 codes can be obtained by contact NHS Connecting For Health datastandards@nhs.net 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 the OPCS coding scheme. It has therefore been necessary to use subsidiary codes to improve the fit between the OPCS-4.4 and Diagnostic Imaging HRG codes.

12 The OPCS-4.4 code plus the subsidiary codes can then generate the appropriate Diagnostic Imaging HRG code in the grouper. 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 codes Y97.1 Radiology with pre and post contrast and Y98.1 Radiology of one body area (or <20 minutes) are recorded, then the activity groups to RA10Z CT one area, pre and post contrast If subsidiary code Y97.3 Radiology with post contrast and Y98.1 Radiology of one body area (or <20 minutes) are recorded, then the activity groups to RA09Z CT one area, post contrast) Notes: Radiology Departments generally have their own information systems which may not necessarily be linked to PAS. Providers will need to ensure that there is a mechanism in place to provide relevant information to clinical coders so that imaging procedures can be entered as OPCS-4.4 codes on PAS. Clinical coders will need clinical input and comprehensive documentation of procedures to be able to code this activity. Diagnostic Imaging 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. It is important that coders use the most up to date OPCS code set. 81 new codes (95% of the total for this chapter) have been added through the 4.3 and 4.4 revisions of OPCS. 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 implementation programme for PACS (picture archiving and communication systems) across England as part of the work of Connecting for Health. 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

13 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 Rehabilitation Rehabilitation HRGs are only generated where care is identified as taking place under a specialist rehabilitation consultant or within a discrete rehabilitation ward or unit. They require the recording of OPCS-4.4 U50.- U54.- codes to generate an unbundled rehabilitation HRG in addition to the core HRG for the care episode. Where a patient is not admitted specifically to a rehabilitation unit or where rehabilitation treatment is undertaken without transfer to a specialist consultant, or without transfer to a rehabilitation unit, such activity will not be coded, according to NHS Connecting for Health coding rules. Thus this will not be identified as discrete rehabilitation and will not generate an unbundled rehabilitation HRG. Rehabilitation assessment is identified by OPCS-4.4 codes X60.- and does not require a rehabilitation diagnosis to generate any of the three rehabilitation assessment HRGs. Derivation of rehabilitation HRGs is dependent on the recording of rehabilitation activity using one of the following OPCS-4.4 codes: OPCS-4.4 Label Code U50.1 Delivery of rehabilitation for amputation of limb U50.2 Delivery of rehabilitation for hip fracture U50.3 Delivery of rehabilitation for joint replacement U50.4 Delivery of rehabilitation for rheumatoid arthritis U50.5 Delivery of rehabilitation for osteoarthritis U50.8 Other specified rehabilitation for musculoskeletal disorders U50.9 Unspecified rehabilitation for musculoskeletal disorders U51.1 Delivery of rehabilitation for brain injuries U51.2 Delivery of rehabilitation for spinal cord injury U51.3 Delivery of rehabilitation for pain syndromes U51.8 Other specified U51.9 Unspecified U52.1 Delivery of rehabilitation for drug addiction U52.2 Delivery of rehabilitation for alcohol addiction U52.8 Other specified U52.9 Unspecified U53.1 Delivery of rehabilitation following plastic maxillofacial reconstruction U53.2 Delivery of rehabilitation following other plastic reconstruction U53.3 Delivery of rehabilitation for burns

14 U53.4 Delivery of rehabilitation for trauma nec U53.8 Other specified U53.9 Unspecified U54.1 Delivery of rehabilitation for acute cardiac disorders U54.2 Delivery of rehabilitation for respiratory disorders U54.3 Delivery of rehabilitation for stroke U54.8 Other specified U54.9 Unspecified X60.1 Rehab. Assessment by multidisciplinary, non-specialised team X60.2 Rehab. Assessment by multidisciplinary, specialised team X60.3 Rehab. Assessment by unidisciplinary team X60.8 Other specified X60.9 Unspecified Example 1 A patient is admitted for a hip replacement. After an initial period of 10 days under the care of the Orthopaedic consultant, they are transferred within the same provider for discrete rehabilitation care under the care of a rehabilitation consultant. A rehabilitation delivery OPCS-4.4 code is recorded on the patient record. They are subsequently discharged after 20 days of rehabilitation. The activity is therefore described as follows: 2 finished consultant episodes with an overall length of stay of 30 days 1 single provider spell The expected output from the HRG4 Reference Cost grouper would be: HRG HA12C VC18Z*20 Label Major Hip Procedures Category 1 without CC (Core HRG for the treatment episode) Rehabilitation for joint replacement (Unbundled HRG for discrete rehabilitation). Note: The grouper output will produce an unbundled rehabilitation HRG for each day of an episode that contains an appropriate rehabilitation OPCS-4.4 code. Depending on the output format, this may be detailed in a relational list, or indicated by the use of the multiplier (*) symbol against the number of unbundled rehabilitation HRGs generated (so example one is shown as VC18Z*20). Example 2 A patient is admitted for a hip replacement and subsequently receives rehabilitation care within the same provider, without transfer to a specialist rehabilitation consultant or a discrete rehabilitation unit. No rehabilitation delivery OPCS-4.4 code is recorded on the patient record. The patient is discharged after 30 days.

15 In this case, the activity is therefore described as follows: 1 finished consultant episode with an overall length of stay of 30 days 1 single provider spell. The rehabilitation care is regarded as part and parcel of the hip replacement procedure. The HRG4 Reference Costs grouper would therefore generate a single HRG for the spell, for Hip replacement, with a length of stay of 30 days. Notes: It is important that coders use the most up to date OPCS code set. 30 new codes specifically for rehabilitation are in OPCS-4.4; these were not covered by OPCS-4.2. Data quality may be variable for these codes because of the difficulties in differentiating between routine and discrete rehabilitation, which may be dependent on historical local practice and individual organisation structure. Allied health professionals should clearly document the rehabilitation activity in the patient casenotes and also specify whether it is assessment or delivery activity. Clear documentation is the key factor in recording rehabilitation activity to ensure generation of an appropriate rehabilitation HRG Specialist Palliative Care All Specialist Palliative Care [SPC] is unbundled and will generate SPC HRGs that are additional to the core episode HRG. The Hospital Specialist Support HRG will always be in addition to a diagnosis/surgical HRG which covers the FCE and Spell. HRGs SD01A and SD01B for Inpatient Specialist Palliative Care (not Same Day) will be generated on a per diem basis. The grouper output will detail an SPC HRG for each day in an episode of care. Two additional HRGs have been created for Inpatient Specialist Palliative Care Same Day (SD02A and SD02B). This is to facilitate the Expert Working Group requirement that differentiates between same day and multi-day patients where the expected resource use differs. The HRGs are split based on age, with a distinction being made between 19 years and over, and 18 years and under. There are therefore 10 HRGs within the current SPC HRG design:

16 HRG Label SD01A Inpatient Specialist Palliative Care 19 years and over SD01B Inpatient Specialist Palliative Care 18 years and under SD02A Inpatient Specialist Palliative Care Same Day 19 years and over SD02B Inpatient Specialist Palliative Care Same Day 18 years and under SD03A Hospital Specialist Palliative Care Support 19 years and over SD03B Hospital Specialist Palliative Care Support 18 years and under SD04A Medical Specialist Palliative Care Attendance 19 years and over SD04B Medical Specialist Palliative Care Attendance 18 years and under SD05A Non-Medical Specialist Palliative Care Attendance 19 years and over SD05B Non-Medical Specialist Palliative Care Attendance 18 years and under Inpatients (including Day Cases) Six HRGs Inpatient SPC Hospital - Specialist Support Adults (over 19 years) Children (18 or under) Adults Children Adult Inpatients admitted under the care of a Specialist Palliative Medicine consultant excluding patients discharged on the day of admission unless they die on the day of admission and excluding patients who have been admitted for holiday relief/ respite care. Paediatric Inpatients admitted under the care of a Specialist Palliative Medicine consultant excluding patients discharged on the day of admission unless they die on the day of admission and excluding patients who have been admitted for holiday relief/ respite care. Adult Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving support from a member of a Specialist Palliative Care Team as described by NICE Guidance - Improving Supportive and Palliative Care for Adults with Cancer (2004). The specialist support can be given for a patient with a nonmalignant or a malignant condition in an inpatient setting. Paediatric Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving support from a member of a Specialist Palliative Care Team as described by NICE Improving Outcomes Guidance for Children and Young Adults with Cancer (2005). The specialist support can be given for a patient with a nonmalignant or a malignant condition in an inpatient setting. The inpatient SPC HRGs are shown overleaf.

17 HRG SD01A Label Inpatient Specialist Palliative Care 19 years and over Definition Age on Admission 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine) AND Length of Stay > 0 OR Discharge Method = 4 (Patient died) AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative care AND NOT Primary Diagnosis (ICD- 10) = Z75.5 Holiday relief care Adult Notes Inpatients under the care of a Specialist Palliative Medicine consultant Excluding patients discharged on the day of admission unless they die on the day of admission Excluding patients admitted for respite care. Paediatric SD01B Inpatient Specialist Palliative Care 18 years and under As above with: Age < 19 Inpatients under the care of a Specialist Palliative Medicine consultant Excluding patients discharged on the day of admission unless they die on the day of admission Excluding patients admitted for respite care.

18 HRG SD02A SD02B SD03A Label Inpatient Specialist Palliative Care Same Day 19 years and over Inpatient Specialist Palliative Care Same Day 18 years and under Hospital Specialist Palliative Care Support 19 years and over Definition Age on Admission 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine) AND Length of Stay = 0 AND Discharge Method 4 (Patient did not die) AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative care AND NOT Primary Diagnosis (ICD- 10) = Z75.5 Holiday relief care As above with: Age < 19 Age on Admission 19 AND Secondary Diagnosis (ICD-10)= Z51.5 Palliative Care AND NOT Main Specialty Code = 315 (Palliative Medicine) Adult Notes Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving input from a Specialist Palliative Care specialist support service Paediatric SD03B Hospital Specialist Palliative Care Support 18 years and under As above with: Age < 19 Inpatients not under the care of a Specialist Palliative Medicine consultant but receiving input from a Specialist Palliative Care specialist support service.

19 Outpatients, Day therapy assessments and Interventions Four HRGs The HRG designs are: HRG SD04A SD04B SD05A SD05B Label Medical Specialist Palliative Care Attendance 19 years and over Medical Specialist Palliative Care Attendance 18 years and under Non-Medical Specialist Palliative Care Attendance 19 years and over Non-Medical Specialist Palliative Care Attendance 18 years and under Definition Age 19 AND Main Specialty Code = 315 (Palliative Medicine) AND Treatment Function Code = 315 (Palliative Medicine) As above with: Age < 19 Age 19 AND Main Specialty Code = 950 (Nursing Episode) OR 960 (Allied Health Profession Episode) AND Treatment Function Code = 315 (Palliative Medicine) As above with: Age < 19 The Outpatient Attendance CDS can record contacts by Medical, Nursing and Allied Health Professionals (AHPs). Chaplains and Social Workers may record contacts as AHPs as well as Physiotherapists, Speech and Language Therapists, Occupational Therapists, Podiatrists, Dieticians, Clinical Psychologists etc. Patients receiving Chemotherapy and other unbundled interventions such as MRIs, high cost drugs etc will receive additional HRGs for each unbundled component Adult Critical Care There are seven HRGs defined for Level 2 and Level 3 Adult Critical Care. A single unbundled HRG will be produced per adult critical care period. These ACC HRGs are effectively unbundled from the rest of the patient episode. For reference cost grouping, days in critical care must be deducted from the overall patient length of stay to avoid double counting.

20 The HRGs are based on the level of support required by the patient as evidenced by the number of organs supported: Total Organ Groups HRG Supported 6 XC01Z Adult Critical Care - 6 Organs Supported 5 XC02Z Adult Critical Care - 5 Organs Supported 4 XC03Z Adult Critical Care - 4 Organs Supported 3 XC04Z Adult Critical Care - 3 Organs Supported 2 XC05Z Adult Critical Care - 2 Organs Supported 1 XC06Z Adult Critical Care - 1 Organs Supported 0 XC07Z Adult Critical Care - 0 Organs Supported Fields within the ACCMDS used by this standard are: CCMDS Field Description Critical Care Unit Function Advanced Respiratory Support Days Basic Respiratory Support Days Advanced Cardiovascular Support Days Basic Cardiovascular Support Days Renal Support Days Neurological Support Days Dermatological Support Days Critical Care Level 2 Days Critical Care Level 3 Days Note: Liver support is included in ACCMDS but is currently excluded from the Adult Critical Care Levels 2 and 3 HRGs due to lack of available data. Patients Covered By Adult Critical Care HRGs The HRGs XC01Z to XC07Z will be assigned to all patients with an ACCMDS record with the exception of non Level 2 and 3 patients with zero organs supported. Description Critical care level 2 days Critical care level 3 days Value Total calendar days during which level two care was provided during the period Total calendar days during which level three care was provided during the period