HRG4 Companion - Health & Social Care Information Centre
Contents
1. 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 be clinically meaningful and contain activity with similar resource intensity 2 2 HRG4 Code Structure HRG4 uses a five character code structure to identify HRGs Chapter Subchapter HRG Number Split AA A e The first character represents the HRG Chapter A e The first two characters together represent the HRG Subchapter AA e The next two numeric characters represent the HRG Number within the chapter NN e The final character signifies the Split applicable to the episode A Chapters Subchapter HRGs are divided into clinically meaningful sections Known as chapters and subchapters The first character of an HRG code indicates the chapter and the second character indicates the subchapter HRG Number The HRG Number is a two digit numeric code which identifies the HRG within the chapter In principle the lower the HRG number with2. Casemix Service HRG4 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 Contents 1 Introduction to HRG4 1 1 Casemix 1 2 Healthcare Resource Groups HRGs 1 3 HRG4 1 4 The HRG4 Grouper 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 Consultations 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 OMOMDMON Noonan Dan BRE BB a h k N 5 Further Information 5 1 Useful Links and Contact Details 5 2 HRG4 Casemix Design Framework 5 3 Clinical Bodies Represented on EWGs _ sl ld PM PP HRG4 Companion v1 4 doc 1 Introduction to HRG4 1 1 Casemix Casemix is a method of classifying patient care based on resources expected to be co
3. RG 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 with the dominant procedure For example lf 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 If 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 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 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
4. cedure OPCS based HRGs only and does not apply to diagnosis ICD based HRGs 2 4 HRGs for Non Admitted Consultations Non Admitted Consultation HRGs require that a procedure Is recorded where relevant but do not use diagnosis data even if recorded HRG derivation cannot be dependent on diagnosis as the data is not mandated as part of the outpatient Commissioning Data Set 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 Copyright 2011 The Health and Social Care Information Centre All Rights Reserved NHS The Information Centre for health and social care HRG4 Companion v1 4 doc NHS The Information Centre for health and social care 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 f only one procedure is recorded within a patie
5. from a specified list an HRG will be derived representing higher resource use than for either procedure on its own For example lf 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 either HB32A Intermediate Foot Procedures for non Trauma Category 2 19 years and over or HB32B Intermediate Foot Procedures for non Trauma Category 2 18 years and under then this is escalated to the Major category HRG in this case HA12C Major Hip Procedures Category 1 for Trauma without CC Copyright O 2011 The Health and Social Care Information Centre All Rights Reserved HRG4 Companion v1 4 doc NHS The Information Centre for health and social care Summation 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 0 1or2 BZ23Z Vitreous Retinal Pr
6. herapy planning and delivery Diagnostic Imaging Rehabilitation Critical Care Specialist Palliative Care 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 Copyright 2011 The Health and Social Care Information Centre All Rights Reserved 10 HRG4 Companion v1 4 doc NHS The Information Centre for health and social care Unbundled Unbundled Unbundled Unbundled Core A Chemotherapy High Cost 7 Diagnostic 7 Rehabilitation HRG HRGs Drug HRGs Imaging HRGs HRGs 4 Stakeholder Engagement lt 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 ha
7. in a chapter the higher the expected resource use of that HRG relative to other HRGs within that chapter Split A split is a single character code in the last position of an HRG 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 that no split is present 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 LA 03 A Nisley Transplant 19 years and over from Live Copyright 2011 The Health and Social Care Information Centre All Rights Reserved for NHS The Information Centre health and social care HRG4 Companion v1 4 doc 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 setting 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 pro
8. itish 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 and has helped us to ensure that it is clinically meaningful and that it accurately reflects current working practice Copyright 2011 The Health and Social Care Information Centre All Rights Reserved Ta Nervous System Procedures HRG4 Companion v1 4 doc NHS The Information Centre for health and social care The HRG4 Documentation Sulte 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
9. mined 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 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 f
10. nsumed in the provision of care The casemix classifications for the NHS in England are Healthcare Resource Groups HRGs The Casemix Service within the NHS Information Centre is responsible for the development and maintenance of the classification and has editorial control over supporting documentation 1 2 Healthcare Resource Groups HRGs Healthcare Resource Groups are the main grouping methodology that the Casemix Service develops and supports These clinically meaningful groupings of patient activity based on procedures and diagnoses are similar in terms of resource to ensure they support national funding policy 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 NHS HRGs also offer organisations the ability to understand their activity in terms of the types of patients they care for and their treatments 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 1 3 HRG4 HRG4 Is a casemix classification which aggregates patient level data into HRGs It has been 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
11. nt record and it has a hierarchy value of 5 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 There are thirteen bands running from 3 to 15 inclusive Bands 3 and 4 represent uniprofessional and multiprofessional consultations only Band 5 is the lowest significant band for procedures excluding outpatient attendances with band 15 representing the most resource intensive procedures e Band 0 represents procedures which 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 t
12. o 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 coded for outpatients that represent only uniprofessional attendance e Band 4 represents procedures coded for outpatients that represent only multiprofessional or multidisciplinary attendances Copyright 2011 The Health and Social Care Information Centre All Rights Reserved HRG4 Companion v1 4 doc 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 the 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 deter
13. ocedures category 1 3 4o0r5 BZ22Z Vitreous Retinal Procedures category 2 6 7 8 9o0r10 BZ21Z Vitreous Retinal Procedures category 3 11 or over 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 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 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 Unbundled HRGs have been developed for following service areas Chemotherapy procurement and delivery Radiot
14. or Non Admitted Consultation treatments and so cannot apply complication and comorbidity splits 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 Any diagnosis 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 ICD 10 codes that end in 9 where the same three digit ICD 10 code has been determined as the primary diagnosis of the spell Copyright O 2011 The Health and Social Care Information Centre All Rights Reserved NHS The Information Centre for health and social care HRG4 Companion v1 4 doc NHS The Information Centre for health and social care 3 5 Multiple trauma A mechanism has been developed to identify high resource complex diagnoses and treatments associated 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 H
15. rules and criteria followed when designing Casemix classification systems HRG4 Grouper Reference Manual provides full instructions on how to prepare and group data using the HRG4 Grouper software application HRG4 Summary of Changes 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 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 Copyright O 2011 The Health and Social Care Information Centre All Rights Reserved 14
16. s 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 Clinical Specialists from 78 NHS Trusts 38 NHS Finance Representatives 29 Specialised Services Representatives 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 on going maintenance and enhancement by reviewing and where necessary revising design parameters and assessing the performance of HRGs Copyright O 2011 The Health and Social Care Information Centre All Rights Reserved HRG4 Companion v1 4 doc 5 Further Information 5 1 Useful Links and Contact Details NHS Information Centre Casemix and Healthcare Resource Groups Telephone Email NHS Connecting for Health OPCS World Health Organisation ICD 10 Department of Health Payment by Results 5 2 HRG4 Casemix Design Framework The Casemix Design Framework is maintained by the Design Authority for Casemix who w
17. 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 4 The HRG4 Grouper 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 algorithm to assign HRGs to the patient records The grouper produces output files which contain the original input data with assigned HRGs and quality files containing details of any errors or conflicts Please refer to the HRG4 Grouper Reference Manual for more information Copyright 2011 The Health and Social Care Information Centre All Rights Reserved NHS The Information Centre for health and social care HRG4 Companion v1 4 doc 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 involved
18. ww ic nhs uk www ic nhs uk casemix 0845 300 6016 enquiries ic nhs uk www cfh nhs uk www cfh nhs uk opcs www who int www who int classifications icd www dh gov uk pbr provide a strategic steer for all stakeholder groups with regard to maintaining consistency of design intent and methodology across current HRG chapters Copyright 2011 The Health and Social Care Information Centre All Rights Reserved NHS The Information Centre for health and social care HRG4 Companion v1 4 doc NHS The Information Centre for health and social care 5 3 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 Br
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