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Code confusion: managing the mental health register

1 September 2006

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Jill Burke
Primary Care Training
Solutions Director

Jill specialises in training and consultancy specific to primary care. Her expertise lies not only in clinical IT systems but also in the GMS contract and the Quality and Outcomes Framework (QOF). Jill’s company provides consultancy services to PCOs, practices and many other NHS-related organisations

Many practices have discovered that their mental health (MH) register has increased way beyond their expectations. It was expected that this register would be larger than in previous years, as there have been several changes to criteria for inclusion:

  • You no longer have to acquire permission from patients to be included on this register.
  • Appropriate diagnosis codes will put patients on this register.
  • Patients on the MH or NSFMH (National Service Framework for Mental Health) register are included.
  • Patients who have had a script for lithium issued in the six months before the reference date (1 April 2006) are included (NB: these patients are excluded from MH9 and MH6, unless they have another qualifying code).

Even so, why have the numbers increased so drastically? Well, data quality is one answer. The diagnosis codes included in the dataset for MH are aimed at patients with psychosis, bipolar affective disorder and schizophrenia – these are actually the same criteria as in previous years. However, many codes that you may have used previously for patients suffering with depression fall into this Read code structure.

By fully understanding the hierarchy of the Read code structure, we can see why this is the case. A code commencing with E1 indicates a nonorganic psychosis; this can be further broken down into:

  • E10: schizophrenic disorders.
  • E11: bipolar psychoses.
  • E12: paranoid states.
  • E13: reactive psychoses.
  • E14: psychoses with childhood origin.

In the past, you may have selected codes within this hierarchy for patients with a depression that has no relation to any of the above indications; by doing so, you have unintentionally selected incorrect codes.

The business rule sets for the MH register has excluded some codes that begin with E1. These are:

  • E118: Seasonal Affective Disorder.
  • E11z1: rebound mood swings.
  • E11z2: masked depression.
  • E135: agitated depression.
  • E140%: autism.

However, the problem does not only lie with codes beginning with E1; many Eu codes are also included: Eu2% and Eu3% in particular.

It is essential that the practice looks at all patients newly included on the MH register to confirm that their diagnosis falls into the correct category. If they should not be included, the code will need to be changed to one of the more “general” codes not specified in the rule sets.

The code E112 appears to be one of the main culprits. If you have used E112 with the term “agitated depression” or “endogenous depression”, these patients will be included on the register. It is likely that many of these patients clinically do not meet the necessary criteria and should not be included. If this is the case, edit their entry. “E135: agitated depression” may be an alternative code to use, as this is not included in the MH rule set. E113 and E1137 also appear to have been misused on numerous occasions and require detailed checking.

Adding “9H7: removed from severe mental illness register” will not remove patients from the register if they have a diagnosis code. This code only applies to patients included on the register with the codes 9H6 on the NSFMH register and 9H8 on the severe mental illness register.

Using exception codes
Exception coding as an alternative to removing or editing Read codes is not acceptable. The exception codes 9h91 and 9h92 (“patient unsuitable” and “informed dissent”, respectively) should only be used where patients meet the criteria and also have a terminal illness, are extremely frail (“patient unsuitable”) or do not respond to invites (“informed dissent”). Practices not following this path may find their prevalence figures are inappropriately inflated and open for assessor investigation.

Other data-quality issues
In 2004–2006, only patients who agreed to follow up would have been included on the MH register. If your practice has received any refusals from patients in the past, it would be advisable to reassess patients’ inclusion, as this refusal acts as a permanent exception code.

When editing or deleting entries from a patient’s record, it is always advisable to follow a clearly defined deletion/editing policy (in addition to the inbuilt audit trail), which allows changes to be clearly identified and traced.

All practices are signed up to the Data Protection Act; this means that you have agreed to ensure that all patient data are accurate. Data quality can bring along a whole host of legal issues. Yes, the patient may have agitated depression, but if coded incorrectly, meaning they appear on the MH register when they shouldn’t, you could find yourself in breach of the Data Protection Act.

The code 212S (“depression resolved”) will not remove patients from the MH register. It is not an exception code included in the business rule sets for MH. It will, however, remove a patient from the depression indicators.

The indicators
There are five indicators for MH. Indicators MH4 and MH5 apply to all patients taking lithium. If a patient’s prescription for lithium has been on the system during the financial year, but the patient no longer takes the medication, add the code 665B (“lithium stopped”). This is an expiring exception code; as long as another script is not issued after the code is added, it will remove the patient from the monitoring criteria.

MH6 is the requirement for each patient to have a comprehensive care plan agreed by themselves, their family and/or carers, which is documented in their records. This care plan can be generated by another agency or secondary care, but practices must be confident that the plan is comprehensive and has been agreed with all concerned. For patients who do not have a care plan, the practice must produce one – there are guidelines in the revised General Medical Services (GMS) contract. Alternatively, if appropriate, the patient should be referred to another agency or secondary care for follow-up. Patients who are on the register due to having had a script for lithium but no other reason are excluded from this indicator.

Patients who fail to attend a previously arranged appointment for their annual review should be followed up by the practice within 14 days of their nonattendance. This requirement, the MH7 indicator, will set certain challenges for practices, as it is only mental health annual reviews that require follow-up. Practices will need to have a mechanism in place to identify the purpose of an appointment when booked; it cannot be presumed that just because a patient is on the MH register any appointment they make is for their MH review.

Once it has been ascertained that a MH review appointment has been missed, the code 9N4t should be added to the patient’s record, dated the day of the missed appointment. Within 14 days, a proactive follow-up should be made with the patient, their family or carer. If this is unsuccessful, or in cases where it is  appropriate, a patient’s Community Psychiatric Nurse (CPN) may also be contacted. Details of the follow-up should be recorded in the patient notes (free text), alongside the code 8HB8.

Last but not least, MH9 – the mental health review. It has always been the case that this review should cover the physical health of the patient, an area often overlooked due to the complex nature of mental health. This indicator now clearly states what is required during a review, and also states that there should be evidence to support the advice or monitoring given: blood pressure, alcohol, smoking status, body mass index (BMI), smears where appropriate, etc. The code to indicate that the review has taken place should be added to the record, and the supporting information added to the patient record in the normal way. Patients who are on the register due to having had a script for lithium but no other reason are excluded from this indicator.

There are fewer points for maintaining the MH register, yet there is a considerable amount of work to be done to ensure that the correct patients are being targeted, and that practice prevalence is accurately maintained. Practices should also ensure summarisers are adequately trained in this area to ensure all the data tidy-up work is not undone. This is only one area that requires careful planning and management, and it is not even one of the new disease areas.

You may well have training issues to address. This is not just an admin or clinical task. It needs to involve both teams working together to be successful. Remember: results always depend on your preparation.