1. © RSR Consultants Ltd HRG4 Background RSR Consultants Ltd retain copyright to these slides (produced March 2009) and are free to be used for non-income generating purposes by subscribers to our PbR queries website. We require our logo and name to stay on the slides when they are used. For more information contact Richard Russell, richard@rsrconsultants.com

2. © RSR Consultants Ltd HRG4 (1) Moving from A01 (Chapter, Number) to AA01A (Chapter, Sub Chapter, Number, Split e.g. <19) Supported by OPC4.3 (>2000 new codes >25% more) with 1400 groups under HRG4 vs 650 under HRG vn3.5 Greater setting independance This is more about Inpatients then anything else although A&E has 8 categories rather than current 3

3. © RSR Consultants Ltd HRG4 (2) Technically Outpatients are identified by one single HRG4 group But then Treatment Function Code used by PbR for billing purposes So no real change from a practical point of view

4. © RSR Consultants Ltd HRG4 (3) 3 levels of complications / co morbidities (none, intermediate, major) vs current 2 (with or without) Separate Paediatrics, new age split and splits on LoS So to summarise the average tariff under HRGvn3.5 splits out into the simple and complex tariff under HRG4 in a more refined way

5. © RSR Consultants Ltd HRG4 (4) HRG4 covers more services Chemotherapy Critical Care Diagnostic Imaging Emergency & Urgent Care Rehabilitation Radiotherapy Specialist Palliative Care But this does not mean PbR covers more services

6. © RSR Consultants Ltd HRG4 (5) It accommodates multiple procedures i.e. Not global, chapter specific Takes account of bilaterals Applies escalator logic & considers all coding not just dominant FCE FCE ANGIOGRAPHY EA41Z Cardiac Catheterisation + FCE CORONARY BYPASS EA14Z = SPELL EA15Z- Coronary Artery Bypass Graft with Cardiac Catheterisation If first FCE has >1 trauma diagnosis then multiple trauma HRG

7. © RSR Consultants Ltd HRG4 (6) HRGvn3.5 D39 Chronic Obstructive Pulmonary Disease or Bronchitis with CC D40 Chronic Obstructive Pulmonary Disease or Bronchitis without CC HRG4 DZ21A Chronic Obstructive Pulmonary Disease or Bronchitis with length of stay 1 day or less discharged home DZ21B Chronic Obstructive Pulmonary Disease or Bronchitis with Intubation with Major CC DZ21C Chronic Obstructive Pulmonary Disease or Bronchitis with Intubation with CC DZ21D Chronic Obstructive Pulmonary Disease or Bronchitis with Intubation without CC DZ21E Chronic Obstructive Pulmonary Disease or Bronchitis with NIV without Intubation with Major CC DZ21F Chronic Obstructive Pulmonary Disease or Bronchitis with NIV without Intubation with CC DZ21G Chronic Obstructive Pulmonary Disease or Bronchitis with NIV without Intubation without CC DZ21H Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation with Major CC DZ21J Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation with CC DZ21K Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation without CC Improved granularity in terms of complications

8. © RSR Consultants Ltd HRG4 (7) HRGvn3.5 C35 Major Maxillo-facial/ENT Procedures HRG4 CZ18R Major Maxillo-facial Procedures 19 years and over CZ18U Major Maxillo-facial Procedures 18 years and under Improved granularity re age split

9. © RSR Consultants Ltd HRG4 (8) HRGvn3.5 E15 Percutaneous Coronary Intervention HRG4 EA31Z Percutaneous Coronary Intervention (0-2 Stents) EA32Z Percutaneous Coronary Intervention (0-2 stents) and Catheterisation EA33Z Percutaneous Coronary Interventions with 3 or more Stents EA34Z Percutaneous Coronary Interventions with 3 or more Stents and Catheterisation Improved granularity re defining the type of care given

10. © RSR Consultants Ltd HRG4 (9) HRGvn3.5 S24 Respite Care HRG4 WA15K Respite care length of stay 9 days or more with Major CC WA15L Respite care length of stay 9 days or more with Intermediate CC WA15M Respite care length of stay 9 days or more without CC WA15N Respite care length of stay between 5 and 8 days with Major CC WA15O Respite care length of stay between 5 and 8 days with Intermediate CC WA15P Respite care length of stay between 5 and 8 days without CC WA15S Respite care length of stay 4 days or less with Major CC WA15T Respite care length of stay 4 days or less with Intermediate CC WA15U Respite care length of stay 4 days or less without CC Improved granularity re LoS But this does not mean PbR covers more services just that they are in more detail

11. © RSR Consultants Ltd HRG4 (10) One spell can now have multiple HRGs e.g. Procedure HRG + Critical Care HRGs. HRG4 identifies services that could be unbundled: Renal Dialysis (chapter LC) Diagnostic Imaging (RA) Chemotherapy (SB) Radiotherapy (SC) Specialist Palliative Care (SD) Rehabilitation (VC) Critical Care (XA to XC) High Cost Drugs (XD) HRG4 can unbundle doesn’t mean PbR does

12. © RSR Consultants Ltd HRG4 (11) Chemotherapy split between Drug Procurement (for each drug cycle or regimen: SB01Z to SB10Z) and Delivery (attendance for treatment: SB11Z to SB15Z) Only get Delivery Chemo HRGs for Outpatients or Day Case i.e. Not Inpatients > 1 day length of stay Chemotherapy excluded so drugs used as part of the service also excluded. However the drug might also be excluded in its own right (e.g. Rituximab) regardless of the service

13. © RSR Consultants Ltd HRG4 (12) High Cost Drugs: XD01Z through to XD38Z To see full list of XD descriptions go to down load the code to group zip file at www.ic.nhs.uk/services/casemix/hrg4/prepare-for-hrg4 towards the bottom under the heading “Code to Group Table (Updated Jan 08)”. Sheet 6 row 1352 downwards has the full list e.g. XD01Z Primary Pulmonary Hypertension drugs band 1www.ic.nhs.uk/services/casemix/hrg4/prepare-for-hrg4 To see how it is coded in the same file go to sheet 10, in cell BA1 select XD01 from the drop down and you see that OPCS code X821 Primary pulmonary hypertension drugs Band 1 is how this HRG4 group is identified NB XD35 Other specified HCD and XD36 Unspecified HCD

14. © RSR Consultants Ltd HRG4 (13) Chemotherapy split between Drug Procurement (for each drug cycle or regimen) and Delivery (attendance for treatment) Only get Delivery Chemo HRGs for Outpatients or Day Case i.e. Not Inpatients > 1 day length of stay Chemotherapy excluded so drugs used as part of the service also excluded. However the drug might also be excluded in its own right (e.g. Rituximab) regardless of the service

15. © RSR Consultants Ltd HRG4 (14) Uncoded activity now has a more detailed error report UZ01Invalid Primary Diagnosis UZ02Poorly Coded Primary Diagnosis UZ03Age Conflicting with Diagnosis UZ04Diagnosis Conflicting with Anatomical Sites UZ05Invalid Primary Procedures UZ06Poorly Coded Primary Procedures UZ11NCC Failed to Group (Neonatal Critical Care) UZ12PCC Failed to Group (Paediatric Critical Care) So should be able to reduce the level of uncoded activity