HRG4 Companion. - Health & Social Care Information
Contents
1. Information Centre for health and social care Clinical Bodies Represented on EWGs The following organisations were formally represented on the Expert Working Groups involved in development Association of British Neurologists Society of British Neurological Surgeons Royal College of Anaesthetists British Pain Society Royal College of Ophthalmologists British Association of Otorhinolaryngologists Head and Neck Surgeons Faculty of Dental Surgery British Thoracic Society Society of Cardiothoracic Surgeons British Cardiac Society Royal College of Surgeons British Society of Gastroenterology British Association of Rheumatology British Geriatrics Society British Orthopaedic Association British Association of Surgical Oncologists British Burns Association British Association of Plastic Surgeons British Association of Dermatologists Association of Genito urinary Medicine British Diabetic Association British Association of Urological Surgeons Renal Association Royal College of Obstetricians and Gynaecologists Royal College of Paediatrics and Child Health British Association of Perinatal Medicine Vascular Society Royal College of Radiologists British Nuclear Medicine Society British Society of Haematologists Faculty of Clinical Oncology Joint Collegiate Committee of Oncology We gratefully acknowledge the support given to us by these organisations Their input was central to the design and development of HRG4 an2. 2011 The Information Centre Casemix Service All rights reserved 11 NHS The Information Centre for health and social care 4 Stakeholder Engagement It is widely recognised that one of the major strengths of HRG4 is the level of clinical involvement in its development and the importance of Casemix Stakeholder Engagement groups has been acknowledged by the Department of Health the NHS Royal Colleges and numerous professional and other bodies The HRG4 Development Programme remains committed to an iterative process of stakeholder consultation Each subchapter has at least one Expert Working Group EWG assisting and advising on the definitions of the HRGs within it Expert Reference Panels and Steering Groups provide cross chapter interface in areas such as Rehabilitation and High Cost Drugs These groups provide invaluable medical financial and allied health professional guidance for the design and development of HRGs They are made up of e Clinical Specialists from 78 NHS Trusts e 38 NHS Finance Representatives e 29 Specialised Services Representatives e Clinical Representatives from 51 Royal Colleges and Professional Bodies HRGs could not have been developed without the commitment of members of these stakeholder groups HRG4 is updated on an annual basis to ensure clinical relevance and design accuracy The key role played by EWGs and other advisory bodies continues through ongoing maintenance and enhancement by revie
3. Casemix Service HRG4 The as Information Centre HRG4 Companion The NHS Information Centre is England s central authoritative source of health and social care information The Casemix Service designs and refines classifications that are used by the NHS in England to describe healthcare activity The NHS Information Centre www ic nhs uk 0845 300 6016 enquiries ic nhs uk The Casemix Service www ic nhs uk casemix Glossary of Terms www ic nhs uk jargon buster Department of Health Payment by Results www dh gov uk pbr NHS Connecting for Health www cfh nhs uk 1 Introduction to HRG4 1 1 HRG4 1 2 Healthcare Resource Groups 1 3 HRG4 Groupers 2 HRG4 Design Concepts 2 1 The Casemix Design Framework 2 2 HRG4 Code Structure 2 3 Setting Independence 2 4 HRGs for Non Admitted Care 3 HRG4 Grouping Logic 3 1 Procedure Hierarchies 3 2 Diagnosis Hierarchies 3 3 Complication and Comorbidity Splits 3 4 Multi episode Spells 3 5 Multiple trauma 3 6 Accommodating Multiple Procedures 3 7 Unbundling 4 Stakeholder Engagement 5 Further Information Useful Links and Contact Details HRG4 Casemix Design Framework Clinical Bodies Represented on EWGs The HRG4 Documentation Suite Copyright 2011 The Information Centre Casemix Service All rights reserved HRG4 Companion v1 0 doc OOM ON Noonan O1saA pgp ZR DD h O O NO h Go a er Sr A O O mak O1 1 Introduction to HRG4 1 1 H
4. Chapter Summaries provide an overview of the scope composition and grouping logic of individual subchapters along with illustrative worked examples They also include updates on the changes within subchapters HRG4 Code to Group workbook provides details on all mappings between primary classification codes and HRGs Also detailed within the workbook are the logic conditions required to generate the HRGs HRG4 Code to Group User Manual serves as an introduction to using the Code to Group workbook to perform manual grouping It also details some basic design concepts and provides worked examples of a variety of different grouping scenarios HRG4 Chapter Listings provide details listed by HRG of the codes that can map to those groups along with details of flags lists and complications and comorbidities HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 15
5. HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 10 NHS The Information Centre for health and social care When all significant procedures in an admitted patient care episode or spell are unbundled diagnosis is used to derive a core HRG for the episode For non admitited care if all procedures are unbundled the episode is allocated one of the eight relevant non admitted care attendance HRGs as a core HRG Unbundled HRGs have been developed for following service areas e Chemotherapy procurement and delivery e Radiotherapy planning and delivery e Diagnostic Imaging e Rehabilitation e Critical Care e Specialist Palliative Care e High Cost Drugs Unbundled HRGs provide the following benefits e Better representation of activity and cost e Support for service redesign e Support for Patient Choice Some significant elements of cost and activity can be unbundled from core HRGs The impact of unbundling is that a case will be assigned more than one HRG if it includes any unbundled elements The Unbundled components become an HRG in their own right as additions to a core HRG For example a case could be assigned the following HRGs depending on the elements of care recorded within it Unbundled Unbundled Unbundled Unbundled Core 7 Pistol High Cost Diagnostic Rehabilitation HRG HRGs Drug HRGs Imaging HRGs HRGs HRG4 Companion v1 0 doc Copyright
6. involved in the design process with regard to HRG scope and concepts format data and performance requirements These stakeholders are predominantly comprised of representatives from the relevant Royal Colleges and clinical professions colleagues from the Department of Health Policy and Operations team and other interested bodies such as NHS Connecting for Health the independent sector and NHS Chief Executives In summary the design rules stipulate e The data used to define the HRGs should ideally be routinely available e There should be a manageable number of HRG groupings to cover all patients e Each HRG should contain activity with a similar pattern of resource intensity and be clinically meaningful e The HRG should be designed to encourage patient choice and the provision of care in different settings 2 2 HRG4 Code Structure HRG4 uses a 5 character code structure to identify HRGs AANNA Chapter Subchapter HRG Number Split e The first character represents the HRG Chapter e The first two characters together represent the HRG Subchapter e The next two numeric characters represent the HRG Number within the chapter e The final character signifies the Split applicable to the episode Chapters Subchapter Healthcare Resource Groups are divided into clinically meaningful sections known as chapters and subchapters Subchapters are identified by a two character code The first character indicates the chapter and the second cha
7. to result in additional resources being used and split HRGs accordingly A particular diagnosis may be a major complication for some procedures whilst not being a relevant complication for others The relevance and ranking of complications and comorbidities are regularly assessed at subchapter level by individual Expert Working Groups to ensure they remain appropriately allocated and ranked CC splits and Non Admitted Consultation treatments Diagnosis is not a mandatory item in the Outpatient Commissioning Data Set The grouping process does not therefore use diagnosis for Non Admitted Consultation treatments and so cannot apply complication and comorbidity splits HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 3 4 Multi episode Spells In a multi episode spell all diagnoses are evaluated as potential complications and comorbidities with the exception of the primary diagnosis for the episode containing the dominant procedure All diagnoses within a spell other than the spell primary diagnosis is regarded as a secondary diagnosis for the purposes of CC checking with the exception of duplicate diagnoses within a spell and four digit CD 10 codes that end in 9 where the same three digit CD 10 code has been determined as the primary diagnosis of the spell 3 5 Multiple trauma A mechanism has been developed to identify high resource complex diagnoses and treatments associ
8. Genital Tract Complex Major Procedures Both procedures have an associated flag attached which requires the grouper to reference a list containing the other procedure Where both procedures are identified within the record an HRG is assigned which considers both significant procedures HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved NHS The Information Centre for health and social care NHS The Information Centre for health and social care Escalator Logic Escalator logic can drive grouping to a higher HRG to reflect additional complexity If a procedure is performed in conjunction with another procedure from a specified list an HRG will be derived representing higher resource use than would have been the case for either procedure on its own For example if W471 Primary prosthetic replacement of head of femur not using cement is recorded as the dominant procedure with no other procedures present then HRG HA13C Intermediate Hip Procedures for Trauma without CC will be assigned However if a procedure from any other HA or HB Intermediate Category HRG is also recorded such as W042 Triple fusion of joints of hindfoot which as a dominant procedure would map to HB32Z Intermediate Foot Procedures for non Trauma Category 2 then this is escalated to the Major category HRG in this case HA12C Major Hip Procedures Category 1 for Trauma without CC Summa
9. RG4 HRG4 is a casemix classification which aggregates patient level data into Healthcare Resource Groups HRGs Casemix is a system whereby the complexity of care provided to a patient is reflected in an aggregate secondary healthcare classification HRG4 was developed to support the Department of Health Payment by Results PbR national policy by providing a classification framework that represents current clinical practice In addition HRG4 supports service planning costing and commissioning between PCTs and trusts by providing reliable and consistent activity data to e Support the focus on patient centred care to enable patient choice e Support the analysis of healthcare needs and monitoring of service provision to inform service planning HRG4 was developed as the successor to HRG v3 5 In addition to the introduction of several new design concepts the main benefits of HRG4 are increased scope settings granularity and specificity These benefits are optimised through accurate good quality coding 1 2 Healthcare Resource Groups Healthcare Resource Groups HRGs are clinically meaningful groupings of patient activity based on both procedures and diagnoses These groups are similar from a resource perspective to ensure that they also support national funding policy HRGs are the main grouping methodology that the Casemix Service develops and supports HRGs offer organisations the ability to understand their activity in terms of the t
10. alone are not valid in the primary position and are therefore invalid for grouping such as approach or site of operation codes e Band 1 represents procedures whose resource use is minimal and where diagnosis is used as the driver in grouping These are generally non operative procedures such as fitting a sling or administering an injection e Band 2 represents procedures that will generate unbundled HRGs Procedure hierarchies are not used to determine unbundled HRGs as every instance of such a procedure being recorded will generate an unbundled HRG A hierarchy value is assigned for methodological completeness e Band 3 represents procedures only coded for outpatients that represent only uniprofessional disciplinary attendance e Band 4 represents procedures only coded for outpatients that represent only multiprofessional disciplinary attendances HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved NHS The Information Centre for health and social care NHS The Information Centre for health and social care 3 2 Diagnosis Hierarchies Using clinical knowledge and length of stay analysis each diagnosis code has been assigned a hierarchy level associated with its resource consequences Like the procedure hierarchies this provides a comparator mechanism to rank diagnoses according to their relative complexities across all HRG chapters e For single episode spells t
11. ated with multiple trauma cases For example significant simultaneous traumatic injuries involving more than one body area Traumatic single injuries are addressed elsewhere within the relevant chapters For further information please refer to the HRG4 Chapter Summary for VA Multiple Trauma 3 6 Accommodating Multiple Procedures In the majority of cases the dominant procedure as determined by the procedure hierarchy is used to derive the HRG However certain subchapters contain specific multiple procedure logic designed to determine the derived HRG using more than one procedure Multiple Procedure Logic Where there are a relatively small number of procedures that can be performed in combination with one another flags may be used to derive the HRG dependant on what other procedures are recorded along with the dominant procedure For example if P231 Anterior and posterior colporrhaphy NEC is recorded as the dominant procedure with no other procedures present then HRG MAO3B Lower Genital Tract Major Procedures without CC will be assigned lf Q088 Other specified vaginal excision of uterus is recorded as the dominant procedure with no other procedures present then HRG MAO7B Upper Genital Tract Major Procedures without malignancy without CC will be assigned However if either if these procedures are the dominant procedure and the other procedure is also recorded within the record then the HRG derived will be MA02Z Lower and Upper
12. d has helped us to ensure that it is clinically meaningful and that it accurately reflects current working practice HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 14 NHS The l Information Centre for health and social care The HRG4 Documentation Suite The HRG4 Documentation Suite is a comprehensive resource of supporting materials designed to assist users in understanding the design concepts logic and practical use of the HRG4 Grouper Below is a list of the various HRG4 documents which are available to download from The Casemix Service website www ic nhs uk casemix HRG4 Companion is a starting point and general reference for new and existing users providing an introduction to HRGs groupers HRG4 design concepts and grouping logic and useful links to further information Casemix Design Framework defines the rules and criteria followed when designing Casemix classification systems HRG4 Guide to File Preparation assists users in preparing data for use with the grouper application HRG4 Grouper User Manual provides full instructions on how to group data with the HRG4 Grouper software application HRG4 Summary of Changes document provides an overview of the main changes between the current HRG4 grouper design and its predecessor HRG4 Roots workbook identifies new HRGs deleted HRGs and changes to existing HRG Labels between designs using colour coding HRG4
13. g For example an endoscopy would generate the same HRG regardless of whether it was performed as an outpatient a daycase or an inpatient procedure This rule applies to procedure OPCS based HRGs only and does not apply to diagnosis ICD 10 based HRGs 2 4 HRGs for Non Admitted Care Outpatient HRGs require that a procedure is recorded where relevant but do not use diagnosis data even if recorded Outpatient HRG derivation cannot be dependent on diagnosis as the data is not mandated as part of the outpatient Commissioning Data Set CDS The underlying procedure required for HRG derivation may not always be recorded for outpatients or ward attenders and it is also possible that a procedure is not carried out In these situations HRG4 allows allocation of an HRG where minimum mandatory information is recorded These are assigned to one of the global Non Admitted HRGs within Subchapter WF For further information please refer to the HRG4 Chapter Summary for WF Non Admitted Consultations HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 3 HRG4 Grouping Logic 3 1 Procedure Hierarchies Using clinical knowledge and cost data each procedure code has been assigned a hierarchy level associated with its resource consequences These hierarchies provide a comparator mechanism that ranks all procedures and considers their relative complexities across all HRG chapters e lf only one pr
14. he primary diagnosis will be that recorded in the appropriate primary diagnosis field of the patient record e For multiple episode spells where a procedure deemed significant for grouping has occurred the primary diagnosis for the spell will be that of the episode containing the most significant procedure as determined by the procedure hierarchy e For multiple episode spells where no procedure significant for grouping is recorded or where procedures have been unbundled and where primary diagnoses differ between episodes in the spell the spell primary diagnosis will be determined by referencing the hierarchical ranking of each of the primary diagnoses The primary diagnosis with the highest hierarchy value will be used to drive the grouping process for the spell e Inthe case of there being two or more diagnoses of equal hierarchical ranking within the record the first will be used to determine the HRG There are five diagnosis hierarchy bands running from 3 to 7 inclusive Band 3 represents the lowest expected resource use and band 7 represents the most resource intensive diagnoses 3 3 Complication and Comorbidity Splits Complication and comorbidity splits are a way of incorporating varying severity and complexity levels within the design of the HRGs Where clinically relevant to do so an HRG is split by complication and comorbidity CC by use of a subchapter specific CC list whose purpose is to reflect diagnoses that are expected
15. ocedure is recorded within a patient record and it has a hierarchy value of 3 or more then this procedure will be used for grouping If more than one procedure is recorded then all procedures within the record will be examined e f more than one procedure has been recorded the grouper will select the dominant procedure by referencing the hierarchical ranking of each procedure The dominant procedure will be used to drive the grouping process e Inthe case of there being two or more procedures of equal hierarchical ranking within the record the first will be used to determine the HRG e Inthe absence of any procedure or where a procedure is deemed insignificant for grouping primary diagnosis will drive the HRG In Payment Grouper products for the 2011 12 financial year there are eleven bands running from 3 to 13 inclusive with band 3 representing the lowest expected resource use and band 13 representing the most resource intensive procedures From the 2012 13 financial year for Payment and the HRG4 2009 10 Reference Costs Grouper the number of bands has been extended to thirteen running from 3 to 15 inclusive This is to accommodate coding of outpatient consultations Bands 3 and 4 represent uniprofessional and multiprofessional consultations only Band 5 becomes the lowest significant band for procedures excluding outpatient attendances with band 15 representing the most resource intensive procedures e Band 0 represents procedures which
16. racter indicates the subchapter HRG Number A two digit numeric code which identifies the HRG within the chapter In principle the lower the HRG number within a chapter the higher the expected resource use of that HRG relative to other HRGs within that chapter HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved NHS The Information Centre for health and social care NHS The Information Centre for health and social care Split A split is a single character code which details the presence of splits which further describe the activity such as age length of stay or complications A value of Z indicates no split The example below shows the code structure for an HRG with split In this case the split value of A represents an age split The details of the split are defined in the HRG label Chapter Subchapter HRG Number Split HRG Label Kidney Transplant 19 years and over LA 03 from Live donor The information represented by the split value can vary across subchapters A value of A represents an age split in Subchapter LA but that does not mean that A necessarily represents age split across all subchapters 2 3 Setting Independence HRG4 supports setting independent service delivery This means that if a procedure or intervention can be performed across different care settings then the same HRG can be derived regardless of settin
17. tion Logic In Subchapter BZ secondary procedures have a modifying effect on HRG assignment All Vitreous Retina VR procedures have been assigned to a VR band from 1 to 5 depending on their relative complexity The higher the VR band the higher the complexity The Vitreous Retina HRGs are assigned based on the sum of the bands of all VR procedures present within a record Sum of VR Bands HRG BZ23Z Vitreous Retinal Procedures category 1 BZ22Z Vitreous Retinal Procedures category 2 6 7 8 9 or 10 BZ21Z Vitreous Retinal Procedures category 3 BZ20Z Vitreous Retinal Procedures category 4 For example C791 Vitrectomy using anterior approach C831 Pigment epithelium translocation of retina These procedures have VR bands of 3 and 4 making a total of 7 so the HRG derived would be BZ21Z Vitreous Retinal Procedures category 3 Please note that the multiple procedure logic examples provided in section 3 7 are valid for the HRG4 2011 12 Local Payment Grouper design and may not apply within the HRG4 2010 11 Reference Costs Grouper design For further details and worked examples of specific multiple procedure logic please refer to the HRG4 Chapter Summaries 3 Unbundling Unbundling is the first step in the grouping process following data validation Unbundled procedures are processed separately to derive unbundled HRGs The grouper then ignores these unbundled components when deriving the core HRG for an episode or spell
18. wing and where necessary revising design parameters and assessing the performance of HRGs HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved NHS The l Information Centre for health and social care 5 Further Information Useful Links and Contact Details NHS Information Centre www ic nhs uk Casemix and Healthcare Resource Groups www ic nhs uk casemix Telephone 0845 300 6016 Email enquiries ic nhs uk NHS Connecting for Health www cfh nhs uk OPCS www cfh nhs uk opcs World Health Organisation www who int ICD 10 www who int classifications icd Department of Health Payment by Results www dh gov uk pbr Reference Costs Collection Guidance 2009 10 financial year www dh gov uk en publicationsandstatistics publications DH_ 112590 Reference Costs Publications 2008 09 financial year www dh gov uk en publicationsandstatistics publications DH_111591 National Tariff and Supporting Information 2010 11 financial year www dh gov uk en publicationsandstatistics publications DH_ 112284 HRG4 Casemix Design Framework The Casemix Design Framework is maintained by the Design Authority for Casemix who provide a strategic steer for all stakeholder groups with regard to maintaining consistency of design intent and methodology across current HRG chapters HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved 13 NHS The
19. ypes of patients they care for and the treatments they undertake They enable the comparison of activity within and between different organisations and provide an opportunity to benchmark treatments and services to support trend analysis over time HRGs are currently used as a means of determining fair and equitable reimbursement for care services delivered by providers These consistent units of currency support standardised healthcare commissioning across the service 1 3 HRG4 Groupers The HRG4 grouper is a software application that implements the HRG4 design in order to process patient records The grouper software application performs validation checks on the required fields and then uses a complex mapping algorithm to assign HRGs to the patient records The grouper produces output data files which contain the original inout data with assigned HRGs and quality files containing details of any errors or conflicts Full instructions on how to prepare data for use with the HRG4 grouper and use the Grouper can be found in the HRG4 Guide to File Preparation and HRG4 Grouper User Manual HRG4 Companion v1 0 doc Copyright 2011 The Information Centre Casemix Service All rights reserved NHS The Information Centre for health and social care 2 HRG4 Design Concepts 2 1 The Casemix Design Framework HRG4 design is governed by the Casemix Design Framework which provides comprehensive guidance for the various stakeholders
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