Download Notes 4. In the final column we have added some comments to help

V26 Contract Codes
Index - click on hyperlink
Asthma
Atrial Fibrillation
Cancer
Contraception (Additional Services Domain of Contract)
Coronary Heart Disease
Chronic Kidney Disease
COPD
CVD Primary Prevention
Dementia
Depression
Diabetes
Epilepsy
Heart Failure
Hypertension
Hypothyroid
Learning Disabilities
Mental Health
Obesity
Osteoporosis
Palliative Care
Peripheral Arterial disease (PAD)
Public Health Domain - Blood Pressure
Rheumatoid Arthritis
Smoking
Stroke/TIA
Notes
1. Codes are taken from Version 26 of the Dept of Health Dataset and Business Rules (published July 2013) with adjustments for Scottish specific areas.
2. In some cases common nomenclature has been used. Codes that end with '%' indicated that this code plus any below it in the heirachy are suitable. Codes connected by a hyphen indicate that any codes
between and including the 2 connected codes are suitable.
3. Letters in brackets in item column refer to Field Names in the IT specifications
4. In the final column we have added some comments to help with coding and to indicate changes for v25/ V26 (2013-14) compared with previous versions.
5. For all enties that that were previously in last 15 months, this is now required in the last 12 months.
1
Item
Asthma Diagnosis (AST)
Asthma-related Drug Prescription
Indicator
Code
ASTHMA
Code
Breakdown
To Index
Term
H33%
Asthma
H3120
Chronic asthmatic bronchitis
21262
212G.
Asthma resolved
Asthma resolved
Population requires an Asthma code and an asthma related prescription in the last 12 months.
AST001
Prescribed in the last year.
AST001
Asthma Resolved
AST001
Exception Codes (ASTEXC)
all except AST001
9hA..
9hA1.
9hA2.
9OJ2.
Exception reporting: asthma quality indicators
Excepted from asthma quality indicators: Patient unsuitable
Excepted from asthma quality indicators: Informed dissent
Refuses asthma monitoring
Spirometry reversibility positive
Positive reversibility test to salbutamol
Positive reversibility test to ipratropium bromide
Positive reversibility test to a combination of salbutamol and ipratropium bromide
Positive reversibility test to corticosteroids
Airways obstruction reversible
Post bronchodilator spirometry
Referral for spirometry
9hA%
Spirometry Codes (ASTSPIR)
AST002
33G1.
33H1.
33I1.
33J1.
33K1.
663J.
745D4
8HRC.
Spirometry Exception codes (SPEX)
AST003
8I3b.
8I6L.
8I2j.
33720
Spirometry test declined
Spirometry not indicated
Spirometry contraindicated
Unable to perform spirometry
AST003
33950
339c.
339d.
339g.
339n.
339A.
339B.
66Yc.
66YX.
66YY.
Diurnal variation of peak expiratory flow rate
Peak expiratory flow rate pre steroids
Peak expiratory flow rate post steroids
Serial peak expiratory flow rate
Serial peak expiratory flow rate abnormal
Peak flow rate before bronchodilation
Peak flow rate after bronchodilation
Number of consecutive days at less than 80% peak expiratory flow rate
Peak expiratory flow rate monitoring
Peak expiratory flow rate monitoring using diary
PEFR Codes (PEFR)
Comments v26
Patients can be coded with both Asthma and COPD if appropriate. Note that there are differences between
the the Asthma and COPD Spirometry Codes, the Asthma spirometry code choice only includes those
showing positive reversibility.
2
Code
ASTHMA cont.
Code
Breakdown
137..
1371.
1372.
1373.
1374.
1375.
1376.
1377.
1378.
1379.
137A.
137B.
137C.
137D.
137F.
137G.
137H.
137j.
137l.
137m.
137n.
137o.
66YJ.
66YK.
66YQ.
66YR.
8B3j.
9OJA.
Asthma annual review
Asthma follow-up
Asthma monitoring by nurse
Asthma monitoring by doctor
Asthma medication review
Asthma monitoring check done
137..-137D.
137F.-137H.
137J.
137K.
Smoking Habit Codes (SMOK)
AST004
137M.-137T.
137M.
137N.
137O.
137P.
137Q.
137R.
137S.
137T.
137V.
137X.-137h.
Review Codes (REV)
AST003
To Index
Term
Tobacco consumption
Never smoked tobacco
Trivial smoker - < 1 cig/day
Light smoker - 1-9 cigs/day
Moderate smoker - 10-19 cigs/d
Heavy smoker - 20-39 cigs/day
Very heavy smoker - 40+cigs/d
Ex-trivial smoker (<1/day)
Ex-light smoker (1-9/day)
Ex-moderate smoker (10-19/day)
Ex-heavy smoker (20-39/day)
Ex-very heavy smoker (40+/day)
Keeps trying to stop smoking
Admitted tobacco cons untrue ?
Ex-smoker - amount unknown
Trying to give up smoking
Pipe smoker
Cigar smoker
Stopped smoking
Rolls own cigarettes
Ex pipe smoker
Ex cigar smoker
Cigarette smoker
Smoking started
Current smoker
Ex smoker
Date ceased smoking
Smoking reduced
Cigarette consumption
Cigar consumption
Tobacco consumption NOS
Pipe tobacco consumption
Ready to stop smoking
Thinking about stopping smoking
Not interested in stopping smoking
Smoking restarted
Reason for restarting smoking
Cigarette pack-years
Minutes from waking to first tobacco consumption
Ex-cigarette smoker
Ex roll-up cigarette smoker
Failed attempt to stop smoking
Total time smoked
Waterpipe tobacco consumption
137X.
137Y.
137Z.
137a.
137b.
137c.
137d.
137e.
137f.
137g.
137h.
Comments v26
Required recording for 14 to 19 year olds in the last 12 months. Note - these patients will also require
Smoking Cessation support (QOF Indicators SMOK004 and SMOK005).
3
Code
ASTHMA cont.
Code
Breakdown
To Index
Term
AST003
6635.
663P.
663P0
663P1
663P2
663Q.
663e.
663e0
663e1
663f.
663w.
663x.
Increasing exercise wheeze
Asthma limiting activities
Asthma limits activities 1 to 2 times per month
Asthma limits activities 1 to 2 times per week
Asthma limits activities most days
Asthma not limiting activities
Asthma restricts exercise
Asthma sometimes restricts exercise
Asthma severely restricts exercise
Asthma never restricts exercise
Asthma limits walking up hills or stairs
Asthma limits walking on the flat
Asthma Sleep codes (RCPSLP)
AST003
663N.
663N0
663N1
663N2
663O.
663O0
663r.
66YP.
66Yq.
66Yr.
66Ys.
Asthma disturbing sleep
Asthma causing night waking
Asthma disturbs sleep weekly
Asthma disturbs sleep frequently
Asthma not disturbing sleep
Asthma never disturbs sleep
Asthma causes night symptoms 1 to 2 times per month
Asthma night-time symptoms
Asthma causes night time symptoms 1 to 2 times per week
Asthma causes symptoms most nights
Asthma never causes night symptoms
Asthma Day Symptoms (RCPDSYMP)
AST003
663q.
663s.
663t.
663u.
663v.
Asthma daytime symptoms
Asthma never causes daytime symptoms
Asthma causes daytime symptoms 1 to 2 times per month
Asthma causes daytime symptoms 1 to 2 times per week
Asthma causes daytime symptoms most days
Asthma Smoking exception code
(SMOKASTEXC)
AST004
137k.
Refusal to give smoking status
Asthma Exercise codes (RCPEXCER)
Comments v26
4
Code
Atrial Fibrillation (AFIB)
AF001
Atrial Fibrillation
Code
Breakdown
G573% (excluding
G5731)
G573.
G5730
G5732
G5733
G5734
G5735
G573z
To Index
Term
212R.
Atrial fibrillation resolved
Exceptions (AFIBEXC)
all except AF001
9hF0.
9hF1.
Excep atr fib qual ind: Pt uns
Exc atr fib qual ind: Inf diss
Salicylate contra-indications:persistent
(XSAL)
AF003
14LK.
ZV148
U6051
TJ53.
H/O: aspirin allergy
[V]Personal history of aspirin allergy
[X]Salicylates causing adverse effects in therapeutic use
Adverse reaction to salicylates
Salicylate contra-indications:expiring
(TXSAL)
AF003
8I24.
8I38.
8I66.
8I70.
Aspirin prophylaxis contra-indicated
Aspirin prophylaxis refused
Aspirin not indicated
Aspirin not tolerated
Excluded
14LP.
Warfarin contraindications: persistent
(XWAR)
Warfarin contraindications: expiring
TXWAR)
AF003, AF004
AF003, AF004
U6042
ZV14A
H/O: warfarin allergy
Adverse reaction to anticoagulants
Adverse reaction to warfarin sodium
Adverse reaction to nicoumalone
Adverse reaction to phenindione
Adverse reaction to anticoagulants NOS
[X]Anticoagulants causing adverse effects in therapeutic use
[V]Personal history of warfarin allergy
8I25.
8I3E.
8I65.
8I71.
8I2R.
8I3d.
8I6N.
8I7A.
8I2o.
8IES.
8I611
8I7R.
Warfarin contraindicated
Warfarin declined
Warfarin not indicated
Warfarin not tolerated
Anticoagulation contraindicated
Anticoagulation declined
Anticoagulation not indicated
Anticoagulation not tolerated
Dabigatran contraindicated
Dabigatran declined
Dabigatran not indicated
Dabigatran not tolerated
TJ42% (except
TJ420)
TJ42.
TJ421
TJ422
TJ423
TJ42z
Comments v26
Atrial fibrillation and flutter
Atrial fibrillation
Paroxysmal atrial fibrillation
Non-rheumatic atrial fibrillation
Permanent atrial fibrillation
Persistent atrial fibrillation
Atrial fibrillation and flutter NOS
Removes from population if dated after most recent AFIB code
5
Code
Atrial Fibrillation cont.
Code
Breakdown
To Index
Term
Clopidrogel contraindications:persistent
(XCLO)
AF003
14LQ.
U6048
ZV14B
Clopidrogel contraindications:expiring
(TXCLO)
AF003
8I2K.
8I3R.
8I6B.
8I72.
Clopidogrel contraindicated
Clopidogrel declined
Clopidogrel not indicated
Clopidogrel not tolerated
Dipyridamole CI persisting (XDIPY)
AF003
14LX.
TJC44
H/O: dipyridamole allergy
Adverse reaction to dipyridamole
[X]Coronary vasodilators causing adverse effects in therapeutic use, not elsewhere
classified
U60C3
H/O: clopidogrel allergy
[X]Clopidogrel causing adverse effects in therapeutic use
[V]Personal history of clopidogrel allergy
Dipyridamole CI expiring (TXDIPY)
AF003
8I2b.
8I3n.
8I6a.
8I7J.
Dipyridamole contraindicated
Dipyridamole declined
Dipyridamole not indicated
Dipyridamole not tolerated
OTC salicylate codes (OSAL)
AF003
67I8.
8B63.
8B3T.
Advice about taking aspirin
Salicylate prophylaxis
Over the counter aspirin therapy
Salicylate prescriptions (SAL)
AF003
8B6P.
Clopidogrel prophylaxis
Clopidogrel prescriptions and code (CLO)
AF003
Dipyridamole prescriptions (DIPY)
AF003
Warfarin Prescriptions and code (WAR)
AF003, AF004
8B2K.
Anticoagulant prescribed by third party
Stroke Risk Assessment using CHAD (CHAD)
AF002, AF003,
AF004
38DE.
Congestive heart failure, hypertension, age, diabetes, stroke 2 risk score
Comments v26
Needs to be recorded within the last 6 months
Prescription for antiplatelets or anticoagulants needs to be within last 6 months.
Requires a value for result added. Requires entry every 12 months unless they have had a previous CHADS2
score of >1.
6
Code
B0…-B32z.
B34..-B6z0
(excluding B677.)
CANCER
Code
Breakdown
B0%
B1%
B2%
B3...
B30%
B31%
B32%
B34%
B35%
B36..
B3y..
B3z..
B4%
B5%
To Index
Term
Malignant neoplasm of lip, oral cavity and pharynx
Malignant neoplasm of digestive organs and peritoneum
Malignant neoplasm of respiratory tract and intrathoracic organs
Malignant neoplasm of bone, connective tissue, skin and breast
Malignant neoplasm of bone and articular cartilage
Malignant neoplasm of connective and other soft tissue
Malignant melanoma of skin
Malignant neoplasm of female breast
Malignant neoplasm of male breast
Local recurrence of malignant tumour of breast
Malignant neoplasm of bone, connective tissue, skin and breast otherwise specified
Malignant neoplasm of bone, connective tissue, skin and breast NOS
Malignant neoplasm of genitourinary organ
Malignant neoplasm of other and unspecified sites
Comments v26
Non-melanotic skin cancers excluded. Morphology codes (starting' BB%') also not included.
B6% (excluding
Malignant neoplasm of lymphatic and haemopoietic tissue
B677.)
Cancer Diagnosis (CAN)
CAN001
Byu..-Byu41
Byu5.-ByuE0
Byu..
Byu0.
Byu1%
Byu2%
Byu3%
Byu4.
Byu40
Byu41
Byu5%
Byu6.
Byu7%
Byu8%
Byu9%
ByuA%
ByuB%
ByuC%
ByuD%
ByuE.
ByuE0
[X]Additional neoplasm classification terms
[X]Malignant neoplasm of lip, oral cavity and pharynx
[X]Malignant neoplasm of digestive organs
[X]Malignant neoplasm of respiratory and intrathoracic organs
[X]Malignant neoplasm of bone and articular cartilage
[X]Melanoma and other malignant neoplasms of skin
[X]Malignant melanoma of other and unspecified parts of face
[X]Malignant melanoma of skin, unspecified
[X]Malignant neoplasm of mesothelial and soft tissue
[X]Malignant neoplasm of breast
[X]Malignant neoplasm of female genital organs
[X]Malignant neoplasm of male genital organs
[X]Malignant neoplasm of urinary tract
[X]Malignant neoplasm of eye, brain and other parts of central nervous system
[X]Malignant neoplasm of thyroid and other endocrine glands
[X]Malignant neoplasm of ill-defined, secondary and unspecified sites
[X]Malignant neoplasms of lymphoid, haematopoietic and related tissue
[X]Malignant neoplasms of independent (primary) multiple sites
[X]Malignant neoplasms of independent (primary) multiple sites
Acquired renal cyst with neoplastic change
Drash syndrome
9h8..
9h81.
9h82.
Exception reporting: cancer quality indicators
Excepted from cancer quality indicators: Patient unsuitable
Excepted from cancer quality indicators: Informed dissent
K1323
K01w1
Cancer exception codes (CANEXC)
all except CAN001 9h8%
Cancer Care Review (MDRV)
CAN002
For Cancers newly diagnosed in the last 15 months (previously was 18 months). Review is required within 3
months after diagnosis (previously was 6 months).
Cancer care review
8BAV.
Code
Contraception
Code
Breakdown
Multiple other codes automatically included within existing code searches.
To Index
Term
Comments v26
Women age <=54
Emergency Contraception prescriptions and
codes (EHC)
CON001, CON003
Combined Oral Contraception prescription
and code (COC)
61F1.
61A1.
Prescribed post-coital OCP
Morning after pills given
In last 13 months and after 1.4.09
CON001, CON002 6147.
Combined oral contraceptive
In last 12 months and after 1.4.09
Progestogen only pill prescription and code
(POC)
CON001
6148.
Progestagen only oral contrac.
In last 12 months and after 1.4.09.
Contraceptive patch prescription (CP)
CON001, CON002
Contraceptive Diaphram prescription and code CON001
6161.
CAP fitted
IUD Insertion prescription and codes
6151.
7E090
ZV251
IUD fitted
Introduction of intrauterine contraceptive device
In last 10 yrs and after 1.4.09.
[V]Intrauterine contraceptive device insertion
Insertion of T shaped 375 millimetres squared copper coated intrauterine contraceptive
device
CON001
In last 12 months and after 1.4.09
61511
In last 12 months and after 1.4.09
6152.
615B.
615Q.
7E092
7E093
7E095
IUD removed
IUD expelled
Intrauterine contraceptive device removed by other healthcare provider
Removal of intrauterine contraceptive device NEC
Removal of displaced intrauterine contraceptive device
Removal of Mirena coil
7E094
Introduction of Mirena coil
7E096
Replacement of intrauterine system
61R..
Intrauterine system contraception
Contraceptive Implant - prescription and codes CON001
7G2AG
61KC.
7G2AH
7G2AJ
9kr..
Insertion of Implanon
Insertion of subcutaneous contraceptive implant by other healthcare provider
Reinsertion of subcutaneous contraceptive
Insertion of etonogestrel radiopaque contraceptive implant
Subdermal etonogestrel implant insertion enhanced services administration
In last 3 yrs and after 1.4.09.
Contraceptive implant removal
CON001
7G2H7
7G2HA
7G2HB
7G2HC
61KF.
Removal of subcutaneous contraceptive
Removal of Implanon
Removal of etonogestrel radiopaque contraceptive implant
Removal of subcutaneous contraceptive implant using ultrasound guidance
Removal of subcutaneous contraceptive implant by other healthcare provider
Dated after latest Implant insertion code or prescription.
Contraceptive injectable - prescriptions only
CON001
Sexual Health Exception codes (SHEXC)
9hK0.
all except CON001
9hK1.
IUD / IUS Removal
CON001
IUS Insertion prescription and code
CON001
Dated after latest IUS or IUD code or prescription
In last 5 yrs and after 1.4.09.
Injection prescriptions are detected if prescribed in the last 12 months
Except.sexual health indic.: pt. unsuitable
Except. sexual health indic.: informed dissent
7
CONTRACEPTION cont.
Code
LARC advice (LARCADV +LARCADV2))
LARC Verbal advice (LARCVERB +
LARCVERB2)
Term
8CAw.
Advice about long acting reversible contraception
679K2
Education for intrauterine system
CON002, CON003
CON002, CON003 8CAw1
8CAw2
LARC written advice (LARCWRIT
+LARCWRIT2)
To Index
Code
Breakdown
CON002, CON003 8CEF.
8CEG.
Comments v26
Dated in last 12 months for pts on oral or patch contraceptives. Dated within 1 month of most recent
Emergency contraception code or prescription. Advice requires both written AND verbal advice. If one of
these codes used then assume both given
Verbal advice about long acting reversible contraception
Written advice about long acting reversible contraception
If these codes used then required to enter one code from each section to meet indicator, showing that both
written and verbal advice given.
Intrauterine device contraception leaflet given
Long acting reversible contraception leaflet given
8
Code
G3…-G309.
G30B.-G330z
(excluding G310.)
Coronary Heart Disease Codes (IHD)
CHD001
G33z-G3401
G342-G35X.
G38..-G3z..
CHD
Code
Breakdown
G3…
G30..
G300.
G301%
G302.
G303.
G304.
G305.
G306.
G307%
G308.
G309.
G30B.
G30X%
G30y%
G30z.
G31..
G311%
G312.
G31y%
G32..
G33..
G330%
G33z%
G34..
G340%
G342.
G343.
G344.
G34y%
G34z%
G35%
G38%
G39..
G3y..
G3z..
Ischaemic heart disease
Acute myocardial infarction
Acute anterolateral infarction
Other specified anterior myocardial infarction
Acute inferolateral infarction
Acute inferoposterior infarction
Posterior myocardial infarction NOS
Lateral myocardial infarction NOS
True posterior myocardial infarction
Acute subendocardial infarction
Inferior myocardial infarction NOS
Acute Q-wave infarct
Acute posterolateral myocardial infarction
Acute transmural myocardial infarction of unspecified site
Other acute myocardial infarction
Acute myocardial infarction NOS
Other acute and subacute ischaemic heart disease
Preinfarction syndrome
Coronary thrombosis not resulting in myocardial infarction
Other acute and subacute ischaemic heart disease
Old myocardial infarction
Angina pectoris
Angina decubitus
Angina pectoris NOS
Other chronic ischaemic heart disease
Coronary atherosclerosis
Atherosclerotic cardiovascular disease
Ischaemic cardiomyopathy
Silent myocardial ischaemia
Other specified chronic ischaemic heart disease
Other chronic ischaemic heart disease NOS
Subsequent myocardial infarction
Postoperative myocardial infarction
Coronary microvascular disease
Other specified ischaemic heart disease
Ischaemic heart disease NOS
9h0..
9h01.
9h02.
Exception reporting: CHD quality indicators
Excepted from CHD quality indicators: Patient unsuitable
Excepted from CHD quality indicators: Informed dissent
Gyu3.% (excluding
Gyu31)
Exception Codes (CHDEXC)
all except CHD001 9h0%
To Index
Term
Comments v26
[X]Ischaemic heart diseases
9
Code
CHD cont.
Code
Breakdown
G30..
G300.
G301%
G302.
G303.
G304.
G305.
G306.
G307%
G308.
G309.
G30B.
G30X%
G30y%
G30z.
G35..
G350.
G351.
G353.
G35X.
G38..
G380.
G381.
G382.
G383.
G384.
G38z.
To Index
Term
Gyu34
Gyu36
Acute myocardial infarction
Acute anterolateral infarction
Other specified anterior myocardial infarction
Acute inferolateral infarction
Acute inferoposterior infarction
Posterior myocardial infarction NOS
Lateral myocardial infarction NOS
True posterior myocardial infarction
Acute subendocardial infarction
Inferior myocardial infarction NOS
Acute Q-wave infarct
Acute posterolateral myocardial infarction
Acute transmural myocardial infarction of unspecified site
Other acute myocardial infarction
Acute myocardial infarction NOS
Subsequent myocardial infarction
Subsequent myocardial infarction of anterior wall
Subsequent myocardial infarction of inferior wall
Subsequent myocardial infarction of other sites
Subsequent myocardial infarction of unspecified site
Postoperative myocardial infarction
Postoperative transmural myocardial infarction of anterior wall
Postoperative transmural myocardial infarction of inferior wall
Postoperative transmural myocardial infarction of other sites
Postoperative transmural myocardial infarction of unspecified site
Postoperative subendocardial myocardial infarction
Postoperative myocardial infarction, unspecified
[X]Acute transmural myocardial infarction of unspecified site
[X]Subsequent myocardial infarction of unspecified site
CHD006(S)
9hM..
9hM0.
9hM1.
Exception reporting: myocardial infarction quality indicators
Excepted from myocardial infarction quality indicators: informed dissent
Excepted from myocardial infarction quality indicators: patient unsuitable
CHD002(S)
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
BP Recording Exception Codes (BPEX)
CHD002(S)
8I3Y.
Blood pressure procedure refused
Maximal BP therapy (HTMAX)
CHD002(S)
8BL0.
Patient on maximal tolerated antihypertensive therapy
G30% (excluding
G30A.)
Myocardial infarction codes (MI)
CHD006(S)
G35%
G38%
Myocardial Infarction exception codes
(MIEXC)
BP Recording Codes (BP)
Comments v26
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values.
10
CHD cont.
Code
To Index
Code
Breakdown
Term
Total Cholesterol Codes (CHOL2)
CHD003(S)
44OE.
44P..
44PH.
44PJ.
44PK.
662a.
Exception from serum cholesterol target persisting (CHEXC)
CHD003(S)
U60CA
TJC24
TJC25
[X]Statin causing adverse effect in therapeutic use
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Exception from serum cholesterol target expiring (TCHEXC)
CHD003(S)
8BL1.
8I3C.
8I27.
8I63.
8I76.
Patient on maximal tolerated lipid lowering therapy
Statin declined
Statins contraindicated
Statin not indicated
Statin not tolerated
Salicylate contra-indications:persistent
(XSAL)
CHD005(S),
CHD006(S)
14LK.
ZV148
U6051
TJ53.
H/O: aspirin allergy
[V]Personal history of aspirin allergy
[X]Salicylates causing adverse effects in therapeutic use
Adverse reaction to salicylates
Salicylate contra-indications:expiring
(TXSAL)
CHD005(S),
CHD006(S)
8I24.
8I38.
8I66.
8I70.
Aspirin prophylaxis contra-indicated
Aspirin prophylaxis refused
Aspirin not indicated
Aspirin not tolerated
Warfarin contraindications: persistent
(XWAR)
CHD005(S),
CHD006(S)
14LP.
Plasma total cholesterol level
Serum cholesterol
Total cholesterol measurement
Serum total cholesterol level
Serum fasting total cholesterol
Pre-treatment serum cholesterol level
U6042
ZV14A
H/O: warfarin allergy
Adverse reaction to anticoagulants
Adverse reaction to warfarin sodium
Adverse reaction to nicoumalone
Adverse reaction to phenindione
Adverse reaction to anticoagulants NOS
[X]Anticoagulants causing adverse effects in therapeutic use
[V]Personal history of warfarin allergy
Warfarin contraindicated
Warfarin declined
Warfarin not indicated
Warfarin not tolerated
Anticoagulation contraindicated
Anticoagulation declined
Anticoagulation not indicated
Anticoagulation not tolerated
Dabigatran contraindicated
Dabigatran declined
Dabigatran not indicated
Dabigatran not tolerated
TJ42% (except
TJ420)
TJ42.
TJ421
TJ422
TJ423
TJ42z
Comments v26
Cholesterol values should also be recorded for the Contract and your software system will have a system to
deal with Read coding of Values.
Warfarin contraindications: expiring
TXWAR)
CHD005(S),
CHD006(S)
8I25.
8I3E.
8I65.
8I71.
8I2R.
8I3d.
8I6N.
8I7A.
8I2o.
8IES.
8I611
8I7R.
Clopidrogel contraindications:persistent
(XCLO)
CHD005(S),
CHD006(S)
14LQ.
U6048
ZV14B
H/O: clopidogrel allergy
[X]Clopidogrel causing adverse effects in therapeutic use
[V]Personal history of clopidogrel allergy
Clopidrogel contraindications:expiring
(TXCLO)
CHD005(S),
CHD006(S)
8I2K.
8I3R.
8I6B.
8I72.
Clopidogrel contraindicated
Clopidogrel declined
Clopidogrel not indicated
Clopidogrel not tolerated
OTC salicylate codes (OSAL)
CHD005(S)
67I8.
8B63.
8B3T.
Advice about taking aspirin
Salicylate prophylaxis
Over the counter aspirin therapy
Salicylate prescriptions (SAL)
CHD005(S),
CHD006(S)
CHD005(S),
CHD006(S)
CHD005(S),
CHD006(S)
8B6P.
Clopidogrel prophylaxis
Prescribed in In last 12 months
8B2K.
Anticoagulant prescribed by third party
Prescribed in In last 12 months
Clopidogrel prescriptions and code (CLO)
Warfarin Prescriptions and Code (WAR)
Prescribed in In last 12 months
11
CHD cont.
Code
14LL.
U60B9
U60BA
U60BB
ZV14C
ZVu6i
ZVu6o
ZVu6q
8I26.
8I2g.
8I2h.
8I2i.
8I36.
8IAS.
8IAT.
8IAV.
8I62.
8I6i.
8I6j.
8I6k.
8I73.
8I7K.
8I7L.
8I7M.
Beta blocker contraindicated
Bisoprolol contraindicated
Carvedilol contraindicated
Nebivolol contraindicated
Beta blocker therapy refused
Bisoprolol therapy refused
Carvedilol therapy refused
Nebivolol therapy refused
Beta blocker not indicated
Bisoprolol not indicated
Carvedilol not indicated
Nebivolol not indicated
Beta blocker not tolerated
Bisoprolol not tolerated
Carvedilol not tolerated
Nebivolol not tolerated
14LM.
K0430
ZV14D
TJC77
TJC78
TJC79
H/O: angiotensin converting enzyme inhibitor allergy
Acute renal failure due to ACE inhibitor
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic
use
[V]Personal history of angiotensin-converting-enzyme inhibitor allergy
Adverse reaction to captopril
Adverse reaction to enalapril
Adverse reaction to ramipril
8I28.
8I3D.
8I64.
8I74.
Angiotensin converting enzyme inhibitors contraindicated
Angiotensin converting enzyme inhibitor declined
Angiotensin converting enzyme inhibitor not indicated
Angiotensin converting enzyme inhibitor not tolerated
CHD006(S)
U60B7
Beta Blocker contraindications:expiring
(TXBB)
CHD006(S)
Beta Blocker prescriptions (BB)
CHD006(S)
CHD006(S)
Ace inhibitor contraindications: expiring
(TXACE)
CHD006(S)
TJC6.
TJC61
TJC62
TJC63
TJC64
TJC65
TJC66
TJC67
TJC68
TJC6z
Comments v26
Prescribed in last 6 months
U60C4
Ace inhibitor contraindications: persistent
(XACE)
Term
H/O: betablocker allergy
Adverse reaction to betablockers
Adverse reaction to acebutolol
Adverse reaction to atenolol
Adverse reaction to labetalol
Adverse reaction to metoprolol
Adverse reaction to nadolol
Adverse reaction to oxprenolol
Adverse reaction to sotalol
Adverse reaction to timolol
Adverse reaction to betablockers NOS
[X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not
elsewhere classified
[X]Adverse reaction to bisoprolol
[X]Adverse reaction to carvedilol
[X]Adverse reaction to nebivolol
[V]Personal history of betablocker allergy
[X]Personal history of allergy to bisoprolol
[X]Personal history of allergy to carvedilol
[X]Personal history of allergy to nebivolol
TJC6%
Beta Blocker contraindications:persistent
(XBB)
To Index
Code
Breakdown
12
CHD cont.
Code
Code
Breakdown
To Index
Term
AII antagonist contraindications: persisting
(XAII)
CHD006(S)
14LN.
U60CB
ZV14E
H/O: angiotensin II receptor antagonist allergy
[X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
[V]Personal history of angiotensin II receptor antagonist allergy
AII antagonist contraindications: expiring
(TXAII)
CHD006(S)
8I2H.
8I3P.
8I6C.
8I75.
Angiotensin II receptor antagonists contraindicated
Angiotensin II receptor antagonist declined
Angiotensin II receptor antagonist not indicated
Angiotensin II receptor antagonist not tolerated
ACE inhibitor prescriptions (ACE)
CHD006(S)
A II antagonist prescription codes (AII)
CHD006(S)
Statin contraindications persisting (XSTAT)
CHD006(S)
CHD006(S)
CHD006(S)
U60CA
TJC24
TJC25
[X]Statin causing adverse effect in therapeutic use
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Flu vaccine contraindications: persisting
(XFLU)
CHD004(S)
14LJ.
U60K4
ZV14F
H/O: influenza vaccine allergy
[X]Influenza vaccine causing adverse effects in therapeutic use
[V]Personal history of influenza vaccine allergy
Flu vaccine contraindications: expiring
(TXFLU)
CHD004(S)
8I2F0
8I6D0
68NE.
68NE0
9OX51
Seasonal influenza vaccination contraindicated
Seasonal influenza vaccination not indicated
No consent - influenza imm.
No consent for seasonal influenza vaccination
Seasonal influenza vaccination declined
Flu vaccine prescriptions and codes
CHD004(S)
65ED.
65E20
65ED0
Seasonal influenza vaccination
Seasonal influenza vaccination given by other healthcare provider
Seasonal influenza vaccination given by pharmacist
Comments v26
Prescribed in last 6 months
Prescribed in last 6 months.
Statin prescriptions (STAT)
Prescribed in the previous 1st September to 31st March.
13
Code
CKD
Code
Breakdown
To Index
Term
Comments v26
Age>=18
CKD Codes Stage 3 - 5 (CKD)
CKD001
1Z12.
1Z1B.
1Z1C.
1Z15.
1Z1D.
1Z1E.
1Z16.
1Z1F.
1Z1G.
1Z13.
1Z1H.
1Z1J.
1Z14.
1Z1K.
1Z1L.
K053.
K054.
K055.
Excluded CKD codes
CKD001
1Z10.
1Z17.
1Z18.
1Z11.
1Z19.
1Z1A.
K051.
K052.
Chronic kidney disease stage 1
CKD stage 1 with proteinuria
CKD stage 1 wthout proteinuria
Chronic kidney disease stage 2
CKD stage 2 with proteinuria
CKD stage 2 wthout proteinuria
Chronic kidney disease stage 1
Chronic kidney disease stage 2
Exception codes (CKDEXC)
all except CKD001
9hE0.
9hE1.
Ex ch kid dis qu ind: Pat uns
Ex ch kid dis qua ind: Inf dis
BP Recording Codes (BP)
CKD002(S)
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
BP Recording Exception Codes (BPEX)
CKD002(S)
8I3Y.
Blood pressure procedure refused
Maximal BP therapy (HTMAX)
CKD002(S)
8BL0.
Patient on maximal tolerated antihypertensive therapy
G2...
G20%
Hypertension (HYP)
CKD003
G24..-G2z..
(excluding G24z1,
G2400, G2410,
G27..)
G240.
G240z
G241.
G241z
G244.
G24z.
G24z0
G24zz
G25..
G26..
G28..
G2y..
G2z..
Gyu2.
Gyu20
Chronic kidney disease stage 3
CKD stage 3 with proteinuria
CKD stage 3 wthout proteinuria
Chronic kidney diseas stage 3A
CKD stage 3A with proteinuria
CKD stge 3A wthout proteinuria
Chronic kidney diseas stage 3B
CKD stage 3B with proteinuria
CKD stge 3B wthout proteinuria
Chronic kidney disease stage 4
CKD stage 4 with proteinuria
CKD stage 4 wthout proteinuria
Chronic kidney disease stage 5
CKD stage 5 with proteinuria
CKD stage 5 wthout proteinuria
Chronic kidney disease stage 3
Chronic kidney disease stage 4
Chronic kidney disease stage 5
See bottom of sheet for classification of CKD.
These codes exclude the patient if dated later than the most recent CKD Codes 3-5.
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values. Requires recording in the previous 12 months
Hypertensive disease
Essential hypertension
Secondary malignant hypertension
Secondary malignant hypertension NOS
Secondary benign hypertension
Secondary benign hypertension NOS
Hypertension secondary to endocrine disorders
Secondary hypertension NOS
Secondary renovascular hypertension NOS
Secondary hypertension NOS
Stage 1 hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Severe hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Stage 2 hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Other specified hypertensive disease
Hypertensive disease NOS
[X]Hypertensive diseases
[X]Other secondary hypertension
14
Code
Hypertension resolved (HYPRES)
Proteinuria (CKDPRT)
CKD cont.
Code
Breakdown
To Index
Term
CKD003
21261
212K.
Hypertension resolved
Hypertension resolved
CKD003
1Z1B.
1Z1D.
1Z1F.
1Z1H.
1Z1K.
R110.
R1100
R1103
R110z
Chronic kidney disease stage 3 with proteinuria
Chronic kidney disease stage 3A with proteinuria
Chronic kidney disease stage 3B with proteinuria
Chronic kidney disease stage 4 with proteinuria
Chronic kidney disease stage 5 with proteinuria
[D]Proteinuria
[D]Albuminuria
[D]Microalbuminuria
[D]Proteinuria NOS
14LM.
K0430
ZV14D
TJC77
TJC78
TJC79
H/O: angiotensin converting enzyme inhibitor allergy
Acute renal failure due to ACE inhibitor
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic
use
[V]Personal history of angiotensin-converting-enzyme inhibitor allergy
Adverse reaction to captopril
Adverse reaction to enalapril
Adverse reaction to ramipril
U60C4
Ace inhibitor contraindications: persistent
(XACE)
CKD003
Ace inhibitor contraindications: expiring
(TXACE)
CKD003
8I28.
8I3D.
8I64.
8I74.
Angiotensin converting enzyme inhibitors contraindicated
Angiotensin converting enzyme inhibitor declined
Angiotensin converting enzyme inhibitor not indicated
Angiotensin converting enzyme inhibitor not tolerated
Albumin/Creatinine or Protein/Creatinine
Ratio (APCR)
CKD004
44lD.
46TC.
46TD.
Urine protein/creatinine ratio
Urine albumin:creatinine ratio
Urine microalbumin:creatinine ratio
Urine specimen exceptions (URINEEXC)
Comments v26
CKD004
9RX..
Declines to give urine specimen
AII antagonist contraindications: persisting
(XAII)
CKD003
14LN.
U60CB
ZV14E
H/O: angiotensin II receptor antagonist allergy
[X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
[V]Personal history of angiotensin II receptor antagonist allergy
If coded in the previous 12 months
AII antagonist contraindications: expiring
(TXAII)
CKD003
8I2H.
8I3P.
8I6C.
8I75.
Angiotensin II receptor antagonists contraindicated
Angiotensin II receptor antagonist declined
Angiotensin II receptor antagonist not indicated
Angiotensin II receptor antagonist not tolerated
ACE inhibitor prescriptions (ACE)
CKD003
Prescribed in last 6 months
A II antagonist prescription codes (AII)
CKD003
Prescribed in last 6 months.
15
To Index
Classification of CRD - From US National Kidney Foundation
Stage 1 - Kidney Damage with normal or raised GFR
Stage 2 - Kidney Damage with mild decrease GFR
Stage 3 - Moderate decrease in GFR
Stage 4 - Severe decrease in GFR
Stage 5 - Kidney Failure
Chronic Kidney Disease is defined as either kidney damage or GFR<60mL/min/1.73m2 over a 3 month period
GFR
>=90
60 - 89
30 - 59
15 - 29
< 15 (or dialysis)
16
Code
COPD
Code
Breakdown
H3…
H31% (except
H3101, H31y0,
H3122)
H32%
COPD Diagnosis COPD)
COPD001
H36..-H3z..
(excluding H3y0.
and H3y1.)
To Index
Term
Comments v26
Chronic obstructive pulmonary disease
Chronic bronchitis
H36..
H37..
H38..
H39..
H3y..
H3A..
H3z..
Emphysema
Mild chronic obstructive pulmonary disease
Moderate chronic obstructive pulmonary disease
Severe chronic obstructive pulmonary disease
Very severe chronic obstructive pulmonary disease
Other specified chronic obstructive airways disease
End stage chronic obstructive airways disease
Chronic obstructive airways disease NOS
Eosinophilic bronchitis
9h5..
9h51.
9h52.
Exception reporting: COPD quality indicators
Excepted from COPD quality indicators: Patient unsuitable
Excepted from COPD quality indicators: Informed dissent
H5832
Diagnosis - Exclusion Codes (COPDEXC)
all except
COPD001
9h5%
Spirometry exception codes (SPEX)
COPD002,
COPD004(S)
8I2j.
8I3b.
8I6L.
33720
Spirometry contraindicated
Spirometry test declined
Spirometry not indicated
Unable to perform spirometry
745D4
Post bronchodilator spirometry
COPD Spirometry Codes (COPDSPIR)
COPD002
8HRC.
Referral for spirometry
Requires re-entry every 12 months
For patients diagnosed after 1.4.11. Requires entry within 3 months before to 12 months after diagnosis
17
COPD cont.
Code
33971
33972
3398.
3399.
339M.
339O.
339O0
Term
339O1
Forced expired volume in 1 second percentage change
FEV1 after change of bronchodilator
FEV1/FVC ratio normal
FEV1/FVC ratio abnormal
FEV1/FVC ratio
Forced expired volume in 1 second
Forced expired volume in 1 second reversibility
FEV1/FVC percent
Percent predicted FEV1
Percentage predicted forced expiratory volume in 1 second after bronchodilation
FEV1/FVC > 70% of predicted
FEV1/FVC < 70% of predicted
FEV1 before bronchodilation
FEV1 after bronchodilation
FEV1 pre steroids
FEV1 post steroids
FEV1/FVC ratio pre steroids
FEV1/FVC ratio post steroids
FEV1/FVC ratio before bronchodilator
FEV1/FVC ratio after bronchodilator
Forced expired volume in one second/vital capacity ratio
339R.-339U.
Codes for FEV1 (FEV1)
To Index
Code
Breakdown
COPD004(S)
339R.
339S.
339S0
339T.
339U.
339a.
339b.
339e.
339f.
339j.-339m.
339j.
339k.
339l.
339m.
MRC Rating (MRC)
COPD003
173H.
173I.
173J.
173K.
173L.
MRC Breathlessness Scale: grade 1
MRC Breathlessness Scale: grade 2
MRC Breathlessness Scale: grade 3
MRC Breathlessness Scale: grade 4
MRC Breathlessness Scale: grade 5
MRC Score >=3 (MRC1)
COPD005
173J.
173K.
173L.
MRC Breathlessness Scale: grade 3
MRC Breathlessness Scale: grade 4
MRC Breathlessness Scale: grade 5
COPD Review (COPDRVW)
COPD003
66YM.
66YB0
66YB1
Chronic obstructive pulmonary disease annual review
Chronic obstructive pulmonary disease 3 monthly review
Chronic obstructive pulmonary disease 6 monthly review
Oxygen Saturation (OXYSAT)
COPD005
44YA0
44YA1
44YA3
Oxygen saturation at periphery
Peripheral blood oxygen saturation on room air at rest
Peripheral blood oxygen saturation on supplemental oxygen at rest
Flu vaccine contraindications: persisting
(XFLU)
COPD006(S)
14LJ.
U60K4
ZV14F
H/O: influenza vaccine allergy
[X]Influenza vaccine causing adverse effects in therapeutic use
[V]Personal history of influenza vaccine allergy
8I2F0
Seasonal influenza vaccination contraindicated
Flu vaccine contraindications: expiring
(TXFLU)
COPD006(S)
8I6D0
68NE.
68NE0
9OX51
Seasonal influenza vaccination not indicated
No consent - influenza imm.
No consent for seasonal influenza vaccination
Seasonal influenza vaccination declined
Flu vaccine prescriptions and codes
COPD006(S)
65ED.
65E20
65ED0
Seasonal influenza vaccination
Seasonal influenza vaccination given by other healthcare provider
Seasonal influenza vaccination given by pharmacist
Comments v26
Requires value added to code
Prescribed in the previous 1st September to 31st March.
18
CVD - Primary Prevention
Code
To Index
Code
Breakdown
Term
Comments v26
Applies to Patients newly diagnosed with Hypertension since 1.4.09. Patients with co-existing CHD, Stroke, TIA, Diabetes, PVD, Familial Hypercholesterolaemia or CKD are excluded from
population
Codes for Hypertension, CHD, Stroke, TIA, Diabetes and CKD as detailed in relevant sections within this spreadsheet.
Patients age under 30 or 75 or over, newly diagnosed with hypertension are excluded from requiring risk assessment (PP1) but do still require lifestyle advice (PP2).
Familial Hypercholesterolaemia
C3200
C3201
C3203
C3204
C3205
C3220
Familial hypercholesterolaemia
Hyperbetalipoproteinaemia
Low-density-lipoprotein-type (LDL) hyperlipoproteinaemia
Fredrickson's hyperlipoproteinaemia, type IIa
Familial defective apolipoprotein B-100
Familial combined hyperlipidaemia
CVD Risk Assessment Exception codes
(CVDEXC)
all
9hJ0.
9hJ1.
Excepted from cardiovascular disease quality indicators: patient unsuitable
Excepted from cardiovascular disease quality indicators: informed dissent
CVD Risk Assessment Exception codes
(CVDEXC1)
CVD-PP001
9hJ0.
9hJ1.
9Oh9.
8IAK.
8IEL.
8IEV.
9NSB.
Excepted from cardiovascular disease quality indicators: patient unsuitable
Excepted from cardiovascular disease quality indicators: informed dissent
Cardiovascular disease risk assessment declined
Cardiovascular disease high risk review declined
QRISK cardiovascular disease risk assessment declined
QRISK2 cardiovascular disease risk assessment declined
Unsuitable for QRISK2 cardiovascular disease risk assessment
CVD Risk Assessment >20% codes (CVDASS1) CVD-PP001
662m.
662n.
JBS cardiovascular disease risk 20 - 30 percent over next ten years
JBS cardiovascular disease risk >30 percent over next ten years
38B10
CVD (cardiovascular disease) risk assessment by third party
38DF.
QRISK cardiovascular disease 10 year risk score
38DR.
Framingham 1991 cardiovascular disease 10 year risk score
38DP.
QRISK2 cardiovascular disease 10 year risk score
38G6.
Joint British Societies cardiovascular disease risk score
38G8.
Dundee CVS risk score
CVD Risk Assessment codes (CVDASS2)
Codes 8IAK., 90h9. , 8IEK., 8IEV,and 9NSB. will only exclude patient from the risk assessment indicator.
They will still require lifestyle advice.
CVD-PP001
38D6.
Lifestyle Counselling (LSAVD)
Excludes from the population if diagnosed before the hypertension diagnosis date.
CVD-PP002
67H..
Assessing cardiovascular risk using Scottish Intercollegiate Guidelines Network
Arrangements being made in Scotland to include this code in specifications
score
67H8.
Lifestyle counselling
Lifestyle advice regarding hypertension
[X]Statin causing adverse effect in therapeutic use
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Statin contraindications persisting (XSTAT)
CVD-PP001
U60CA
TJC24
TJC25
Exception from serum cholesterol target expiring (TCHEXC)
CVD-PP001
8BL1.
8I3C.
8I27.
8I63.
8I76.
Patient on maximal tolerated lipid lowering therapy
Statin declined
Statins contraindicated
Statin not indicated
Statin not tolerated
Statin prescriptions (STAT)
CVD-PP001
For Scot-PASQ
CVD-PP003
68L..
Exercise status screening
Requires entry in the last 12 months for new hypertension since 1.4.09
prescribed in the last 6 months
There is no data extraction for CVD-PP003. A new codes has been requested for Scot-PASQ. This is the
recommended code to use until this becomes available.
19
Code
DEMENTIA
Code
Breakdown
Eu02.
Eu020
Eu021
Eu022
Eu023
Eu024
Eu02y
Eu02z
E00..
E000.
E001%
E002%
E003.
E004%
E00y.
E00z.
Eu01.
Eu010
Eu011
Eu012
Eu013
Eu01y
Eu01z
To Index
Term
Comments v26
F116.
[X]Dementia in other diseases classified elsewhere
[X]Dementia in Pick's disease
[X]Dementia in Creutzfeldt-Jakob disease
[X]Dementia in Huntington's disease
[X]Dementia in Parkinson's disease
[X]Dementia in human immunodef virus [HIV] disease
[X]Dementia in other specified diseases classif elsewhere
[X] Unspecified dementia
Senile and presenile organic psychotic conditions
Uncomplicated senile dementia
Presenile dementia
Senile dementia with depressive or paranoid features
Senile dementia with delirium
Arteriosclerotic dementia
Other senile and presenile organic psychoses
Senile or presenile psychoses NOS
[X]Vascular dementia
[X]Vascular dementia of acute onset
[X]Multi-infarct dementia
[X]Subcortical vascular dementia
[X]Mixed cortical and subcortical vascular dementia
[X]Other vascular dementia
[X]Vascular dementia, unspecified
Drug-induced dementia
Other alcoholic dementia
Chronic alcoholic brain syndrome
[X]Dementia in Alzheimer's disease
[X]Dementia in Alzheimer's disease with early onset
[X]Dementia in Alzheimer's disease with late onset
[X]Dementia in Alzheimer's dis, atypical or mixed type
[X]Dementia in Alzheimer's disease, unspecified
Dementia in conditions EC
[X]Delirium superimposed on dementia
Alzheimer's disease
Alzheimer's disease with early onset
Alzheimer's disease with late onset
Pick's disease
Senile degeneration of brain
Lewy body disease
Dementia Exclusions (DEMEXC)
all except DEM001
9hD0.
9hD1.
Exc demen qual ind: Pat unsuit
Exc demen qual ind: Inform dis
FBC (FBC)
DEM003
423..
426..
42A..
42H..
Haemoglobin estimation
Red blood cell (RBC) count
Mean corpuscular volume (MCV)
Total white cell count
Requires entry within time period 6 months before to 6 months after the first diagnosis date
DEM003
44h4.
44I8.
44h7.
44IE.
44ID.
44IC.
44h9.
44hD.
4Q721
Blood calcium level
Serum calcium
Plasma calcium level
Serum ionized calcium (pH 7.4) level
Serum ionised calcium level
Corrected serum calcium level
Plasma corrected calcium level
Blood ionised calcium level
Calcium adjusted level
Requires entry within time period 6 months before to 6 months after the first diagnosis date
Eu02%
E00%
Dementia
DEM001 (DEM)
Eu01%
E02y1
E012%
Eu00%
E012.
E0120
Eu00.
Eu000
Eu001
Eu002
Eu00z
E041.
Eu041
F110.-F112.
Calcium (CALC)
F110.
F1100
F1101
F111.
F112.
20
Code
Glucose GLUC)
DEM003
DEMENTIA cont.
Code
Breakdown
To Index
Term
44TM.
44f%
44g%
44T1%
44T2%
44T3.
44TA.
44TE.
44TF.
44TG.
44TH.
44TI.
44TJ.
44TK.
Blood glucose series
Serum glucose level
Plasma glucose level
Random blood sugar
Fasting blood sugar
2 hours post food blood sugar
Plasma glucose
30 minute blood glucose level
60 minute blood glucose level
90 minute blood glucose level
120 minute blood glucose level
150 minute blood glucose level
Blood glucose level
Fasting blood glucose level
44U% (excluding
44Uz.)
Blood glucose result
44V..
44V1.
44V2.
44V3.
44V6.
7P172
R102.
R10D.
R1057
Glucose tolerance test
Glucose tolerance test normal
Glucose tol. test impaired
Glucose tol. test diabetic
Extended glucose tolerance test
Glucose tolerance test
[D]Glucose tolerance test abnormal
[D]Elevated blood glucose level
[D]Glucose, blood level abnormal
Comments v26
Requires entry within time period 6 months before to 6 months after the first diagnosis date
IFCC HbA1c (IFCCHBA)
DEM003
42W5.
Haemoglobin A1c level - IFCC standard
Requires entry within time period 6 months before to 6 months after the first diagnosis date
Glucose test exception (GLUCEXC)
DEM003
8IEG.
Blood glucose test declined
requires entry in last 12 months
DEM003
44J3.
44J9.
44JA.
44JC.
44JD.
44JF.
Serum creatinine
Serum urea level
Plasma urea level
Corrected plasma creatinine level
Corrected serum creatinine level
Plasma creatinine level
Requires entry within time period 6 months before to 6 months after the first diagnosis date
Liver function (LIVER)
DEM003
44E..
44E9.
44EC.
44G7.
44G9.
44GA.
44GB.
Serum bilirubin level
Plasma total bilirubin level
Serum total bilirubin level
Plasma gamma-glutamyl transferase level
Serum gamma-glutamyl transferase level
Plasma alanine aminotransferase level
Serum alanine aminotransferase level
Requires entry within time period 6 months before to 6 months after the first diagnosis date.
Thyroid function (DEMTFT)
DEM003
442W.
442X.
442A.
Serum TSH level
Plasma TSH level
TSH - thyroid stim. hormone
Requires entry within time period 6 months before to 6 months after the first diagnosis date
DEM003
42T..
44Le.
Serum vitamin B12
Plasma vitamin B12 level
Requires entry within time period 6 months before to 6 months after the first diagnosis date
Folic acid (FOL)
DEM003
42U4.
42U5.
42UE.
Red blood cell folate
Serum folate
Plasma folate level
Requires entry within time period 6 months before to 6 months after the first diagnosis date.
Dementia review (DEMR)
DEM002
6AB..
Dementia Annual Review
Requires entry within the previous 12 months and after the Dementia diagnosis date.
Renal function (RENAL)
Vit B12 (VITB12)
21
Code
Depression
Code
Breakdown
To Index
Term
Comments v26
Population for prevalence is Depression diagnosed since 1.4.2009 with no subsequent 'depression resolved' code. For DEP001 and DEP002 it is for diagnosis in the previous 1st April to 31st
March.
Age>=18
E0013
E0021
E112%
E113%
E118.
E11y2
E11z2
E130.
E135.
E2003
E291.
E2B..
E2B1.
Eu204
Eu251
Eu32.
Eu320
Eu321
Eu322
Eu323
Eu324
Eu325
Eu326
Eu327
Eu328
Eu32y
Eu32z
Eu33.
Eu330
Eu331
Presenile dementia with depression
Senile dementia with depression
Single major depressive episode
Recurrent major depressive episode
Seasonal affective disorder
Atypical depressive disorder
Masked depression
Reactive depressive psychosis
Agitated depression
Anxiety with depression
Prolonged depressive reaction
Depressive disorder NEC
Chronic depression
[X]Post-schizophrenic depression
[X]Schizoaffective disorder, depressive type
[X]Depressive episode
[X]Mild depressive episode
[X]Moderate depressive episode
[X]Severe depressive episode without psychotic symptoms
[X]Severe depressive episode with psychotic symptoms
[X]Mild depression
[X]Major depression, mild
[X]Major depression, moderately severe
[X]Major depression, severe without psychotic symptoms
[X]Major depression, severe with psychotic symptoms
[X]Other depressive episodes
[X]Depressive episode, unspecified
[X]Recurrent depressive disorder
[X]Recurrent depressive disorder, current episode mild
[X]Recurrent depressive disorder, current episode moderate
Eu332
[X]Recurrent depressive disorder, current episode severe without psychotic symptoms
Eu333
Eu334
Eu33y
Eu33z
Eu341
Eu412
[X]Recurrent depressive disorder, current episode severe with psychotic symptoms
[X]Recurrent depressive disorder, currently in remission
[X]Other recurrent depressive disorders
[X]Recurrent depressive disorder, unspecified
[X]Dysthymia
[X]Mixed anxiety and depressive disorder
212S.
Depression resolved
9hC0.
9hC1.
Exc depr qual: ind: Pat unsuit
Exc depressi qual ind: Inf dis
Bio-psychosocial assessment codes (BIOPSYC) DEP001
38G5.
Biopsychosocial assessment
Exception codes for Bio-psychosocial
assessment (BIOPSYCEXC)
8IET.
Biopsychosocial assessment declined
DEP001
9NSA.
Unsuitable for biopsychosocial assessment
Depression review codes (DEPRVW)
DEP002
9H91.
9H92.
Depression medication review
Depression interim review
Depression (For Dep2) (DEPR)
Eu32% (excluding
Eu32A, Eu32B,
Eu329)
Eu33%
Depression resolved
Depression exceptions (DEPEXC)
all except DEP001
Requires entry on the same date as the depression diagnosis date
Requires entry between 10 and 35 days after diagnosis date
22
Code
DIABETES
Code
Breakdown
To Index
Term
Comments v26
Age >=17
C10..
C109J
C109K
C10C.
C10D.
C10E%
Diabetes mellitus
Insulin treated Type 2 diabetes mellitus
Hyperosmolar non-ketotic state in type 2 diabetes mellitus
Diabetes mellitus autosomal dominant
Diabetes mellitus autosomal dominant type 2
Type 1 diabetes mellitus
C10F% (except
C10F8)
Type 2 diabetes mellitus
C10G%
C10H%
C10M%
C10N%
PKyP.
Secondary pancreatic diabetes mellitus
Diabetes mellitus induced by non-steroid drugs
Lipoatrophic diabetes mellitus
Secondary diabetes mellitus
Diabetes insipidus, diabetes mellitus, optic atrophy and deafness
Diagnosis Resolved
21263
212H.
Diabetes resolved
Diabetes resolved
Diabetes Exception reporting codes (DMEXC) all except DM001
9h4%
Diabetes diagnosis DM)
DM001
9h4..
9h41.
9h42.
Exception reporting: diabetes quality indicators
Excepted from diabetes quality indicators: Patient unsuitable
Excepted from diabetes quality indicators: Informed dissent
Codes for maximum tolerated diabetes
treatment (DMMAX)
DM007(S),
DM008(S),
DM009(S)
8BL2.
Patient on maximal tolerated therapy for diabetes
IFCC HbA1c levels IFCCHBA)
DM007(S),
DM008(S),
DM009(S)
42W5.
Haemoglobin A1c level - IFCC standardised
2BB%
3128%
3128.
31280
31281
31282
31283
31284
3128Z
3129.
312E.-312G.
Retinal screening codes (RET)
DM011
58C1.
68A7.
68A8.
66AD.
8HBD.
8HBG.
8HBH.
9N1v.
9N2U.
9N2V.
9N2e.
9N2f.
9NNC.
312E.
312F.
312G.
.
O/E - retinal inspection
Fundoscopy
Fundoscopy normal
Fundoscopy abnormal
Dilated fundoscopy normal
Camera fundoscopy
Indirect fundoscopy following mydriatic
Fundoscopy NOS
Eye fundus photography
Direct fundoscopy following mydriatic
Camera fundoscopy
Indirect fundoscopy following mydriatic
Retinal photography
Diabetic retinopathy screening
Digital retinal screening
Fundoscopy - diabetic check
Retinopathy follow up
Diabetic retinopathy 12 month review
Diabetic retinopathy 6 month review
Seen in diabetic eye clinic
Seen by optician
Seen by optometrist
Seen by ophthalmologist
Seen by retinal screener
Under care of retinal screener
23
Code
DIABETES cont.
Code
Breakdown
To Index
Term
8I6F.
8I3X.
Diabetic retinopathy screening not indicated
Diabetic retinopathy screening refused
9OLD.
Diabetic patient unsuitable for digital retinal photography
9m0A.
Declined diabetic retinopathy screening
DM012
8I6G.
8I3W.
8IAo.
8IB6.
Diabetic foot examination not indicated
Diabetic foot examination declined
Foot pulse check declined
Patient unsuitable for foot pulse check
Neuropathy testing exception codes (NPTEXC) DM012
8I6G.
8I3W.
8IAn.
8IB5.
Diabetic foot examination not indicated
Diabetic foot examination declined
Neuropathy assessment declined
Patient unsuitable for neuropathy assessment
Foot risk classification (FRC)
DM012
2G5E.
2G5F.
2G5G.
2G5H.
2G5d.
2G5e.
2G5I.
2G5J.
2G5K.
2G5L.
O/E - Right diabetic foot at low risk
O/E - Right diabetic foot at moderate risk
O/E - Right diabetic foot at high risk
O/E - Right diabetic foot - ulcerated
O/E - Left diabetic foot at increased risk
O/E - Right diabetic foot at increased risk
O/E - Left diabetic foot at low risk
O/E - Left diabetic foot at moderate risk
O/E - Left diabetic foot at high risk
O/E - Left diabetic foot - ulcerated
Right foot amputation (AMPR)
DM012
2G42.
2G44.
2G46.
O/E - Amputated right leg
O/E - Amputated right above knee
O/E - Amputated right below knee
Left foot amputation (AMPL)
DM012
2G43.
2G45.
2G47.
O/E - Amputated left leg
O/E - Amputated left above knee
O/E - Amputated left below knee
BP Recording Codes (BP)
DM002(S),
DM003(S)
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
BP Recording Exception Codes (BPEX)
DM002(S),
DM003(S)
8I3Y.
Blood pressure procedure refused
Maximal BP therapy (HTMAX)
DM002(S),
DM003(S)
8BL0.
Patient on maximal tolerated antihypertensive therapy
Retinal exclusion codes (RETEXC)
Foot examination exception codes (FEEXC)
DM011
Comments v26
.
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values.
24
DIABETES cont.
Code
Proteinuria Diagnosis (PRT)
To Index
Code
Breakdown
Term
R110.
R1100
R110z
[D]Proteinuria
[D]Albuminuria
[D]Proteinuria NOS
C10EK
Type 1 diabetes mellitus with persistent proteinuria
C10FL
Type 2 diabetes mellitus with persistent proteinuria
K08yA
K190X
Kyu5G
Proteinuric diabetic nephropathy
Persistent proteinuria, unspecified
[X]Persistent proteinuria, unspecified
DM006(S)
Comments v26
Care should be taken only to use these codes for persistant proteinuria and not for dipstick test results.
Microalbuminural Testing (MALT)
DM005
46TC.
46TD.
Urine albumin:creatinine ratio
Urine microalbumin:creatinine ratio
V25 reduced codeset to 2 codes.
Urine specimen exceptions (URINEEXC)
CKD004
9RX..
Declines to give urine specimen
If coded in the previous 12 months
R1103
[D]Microalbuminuria
Microralbuminuria (MAL)
DM006(S)
C10EL
Type 1 diabetes mellitus with persistent microalbuminuria
C10FM
Type 2 diabetes mellitus with persistent microalbuminuria
14LM.
K0430
ZV14D
TJC77
TJC78
TJC79
H/O: angiotensin converting enzyme inhibitor allergy
Acute renal failure due to ACE inhibitor
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic
use
[V]Personal history of angiotensin-converting-enzyme inhibitor allergy
Adverse reaction to captopril
Adverse reaction to enalapril
Adverse reaction to ramipril
U60C4
Ace inhibitor contraindications: persistent
(XACE)
DM006(S)
Ace inhibitor contraindications: expiring
(TXACE)
DM006(S)
8I28.
8I3D.
8I64.
8I74.
Angiotensin converting enzyme inhibitors contraindicated
Angiotensin converting enzyme inhibitor declined
Angiotensin converting enzyme inhibitor not indicated
Angiotensin converting enzyme inhibitor not tolerated
AII antagonist contraindications: persisting
(XAII)
DM006(S)
14LN.
U60CB
ZV14E
H/O: angiotensin II receptor antagonist allergy
[X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
[V]Personal history of angiotensin II receptor antagonist allergy
AII antagonist contraindications: expiring
(TXAII)
DM006(S)
8I2H.
8I3P.
8I6C.
8I75.
Angiotensin II receptor antagonists contraindicated
Angiotensin II receptor antagonist declined
Angiotensin II receptor antagonist not indicated
Angiotensin II receptor antagonist not tolerated
25
Code
DIABETES cont.
Code
Breakdown
To Index
Term
Comments v26
ACE inhibitor prescriptions (ACE)
DM006(S)
Prescribed in last 6 months
A II antagonist prescription codes (AII)
DM006(S)
Prescribed in last 6 months.
Total Cholesterol Codes (CHOL2)
DM004
44OE.
44P..
44PH.
44PJ.
662a.
Plasma total cholesterol level
Serum cholesterol
Total cholesterol measurement
Serum total cholesterol level
Pre-treatment serum cholesterol level
Exception from serum cholesterol target persisting (CHEXC)
DM004
U60CA
TJC24
TJC25
[X]Statin causing adverse effect in therapeutic use
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Exception from serum cholesterol target expiring (TCHEXC)
DM004
8BL1.
8I3C.
8I27.
8I63.
8I76.
Patient on maximal tolerated lipid lowering therapy
Statin declined
Statins contraindicated
Statin not indicated
Statin not tolerated
Flu vaccine contraindications: persisting
(XFLU)
DM010(S)
14LJ.
U60K4
ZV14F
H/O: influenza vaccine allergy
[X]Influenza vaccine causing adverse effects in therapeutic use
[V]Personal history of influenza vaccine allergy
Flu vaccine contraindications: expiring
(TXFLU)
DM010(S)
8I2F0
8I6D0
68NE.
68NE0
9OX51
Seasonal influenza vaccination contraindicated
Seasonal influenza vaccination not indicated
No consent - influenza imm.
No consent for seasonal influenza vaccination
Seasonal influenza vaccination declined
Flu vaccine prescriptions and codes FLU)
DM010(S)
65ED.
65E20
65ED0
Seasonal influenza vaccination
Seasonal influenza vaccination given by other healthcare provider
Seasonal influenza vaccination given by pharmacist
C/O erectile dysfrunction (EDC)
DM015, DM016
1D1B.
C/O erectile dysfunction
Not C/O erectile dysfunction (EDNC)
DM015
1ABJ.
Does not complain of erectile dysfunction
Diabetic assessment of erectile dysfunction
(DMAED)
DM016
66Av.
Diabetic assessment of erectile dysfunction
66Au.
Diabetic erectile dysfunction review
8Hj0.
Referral to diabetes structured education programme
8Hj3.
Referral to DAFNE diabetes structured education programme
8Hj4.
Referral to DESMOND diabetes structured education programme
8Hj5.
Referral to XPERT diabetes structured education programme
8IE9.
Referral to diabetes education and self management for ongoing and newly diagnosed
structured programme declined
8IEa.
Referral to DAFNE diabetes structured education programme declined
9OLM.
Diabetes structured education programme declined
Referred for diabetes structured education
programme (DSEP)
Diabetes structured education programme
exception codes (DSEPEXC)
DM014
DM014
Diabetic dietary review (DRV)
DM013
66At.
66At0
66At1
Diabetic dietary review
Type I diabetic dietary review
Type II diabetic dietary review
Diabetic dietary review exception codes
(DRVEXC
DM013
8IAs.
Diabetic dietary review declined
Cholesterol values should also be recorded for the Contract and your software system will have a system to
deal with Read coding of Values.
Prescribed in the previous 1st September to 31st March.
Requires entry for new diabetes patients (in last year) within 9 months after their diagnosis date
26
Code
EPILEPSY
Code
Breakdown
To Index
Term
Comments v26
Age >=18
Epilepsy Diagnosis (EPIL)
EP001
F25% (excluding
F2501, F2504,
F2511, F2516,
F25G., F25y4,
F256%, F258.F25A.,F25H.)
F25..
F250.
F2500
F2502
F2503
F2505
F250y
F250z
F251.
F2510
F2512
F2513
F2514
F2515
F251y
F251z
F252.
F253.
F254%
F255%
F257.
F25B.
F25C.
F25D.
F25E.
F25F.
F25X.
F25y.
F25y0
F25y1
F25y2
F25y3
F25y5
F25yz
F25z.
Epilepsy medication Prescription
Epilepsy
Generalised nonconvulsive epilepsy
Petit mal (minor) epilepsy
Epileptic seizures - atonic
Epileptic seizures - akinetic
Lennox-Gastaut syndrome
Other specified generalised nonconvulsive epilepsy
Generalised nonconvulsive epilepsy NOS
Generalised convulsive epilepsy
Grand mal (major) epilepsy
Epileptic seizures - clonic
Epileptic seizures - myoclonic
Epileptic seizures - tonic
Tonic-clonic epilepsy
Other specified generalised convulsive epilepsy
Generalised convulsive epilepsy NOS
Petit mal status
Grand mal status
Partial epilepsy with impairment of consciousness
Partial epilepsy without mention of impairment of consciousness
Kojevnikov's epilepsy
Alcohol-induced epilepsy
Drug-induced epilepsy
Menstrual epilepsy
Stress-induced epilepsy
Photosensitive epilepsy
Status epilepticus, unspecified
Other forms of epilepsy
Cursive (running) epilepsy
Gelastic epilepsy
Localization-related(focal)(partial)idiopathic epilepsy and epileptic syndromes with
seizures of localised onset
Complex partial status epilepticus
Panayiotopoulos syndrome
Other forms of epilepsy NOS
F1321
SC200
Epilepsy NOS
Progressive myoclonic epilepsy
Traumatic epilepsy
21260
212J.
Epilepsy resolved
Epilepsy resolved
EP001
Epilepsy resolved
Prescribed in the previous 6 months.
9h6..
9h61.
9h62.
Exception reporting: epilepsy quality indicators
Excepted from epilepsy quality indicators: Patient unsuitable
Excepted from epilepsy quality indicators: Informed dissent
Epilepsy Exception codes (EPILEXC)
all except EP001
9h6%
Maximum anticonvulsant therapy (MAXEP)
EP002
8BL3.
Patient on maximal tolerated anticonvulsant therapy
Seizure Free > 12 months (LSZ)
EP002
667F.
Seizure free >12 months
27
Code
EPILEPSY cont.
Code
Breakdown
To Index
Term
Comments v26
Females aged under 55
Contraceptive counselling (EPILCC)
EP003
6110.
Contraceptive advice for patients with epilepsy
Preconception advice (EPILCA)
EP003
67IJ0
Pre-conception advice for patients with epilepsy
Pregnancy advice (EPILPA)
EP003
67AF.
Pregnancy advice for patients with epilepsy
Contraceptive advice exceptions
(EPILCCEXC)
EP003
8IAg.
8IB2.
Contraceptive advice for patients with epilepsy declined
Contraceptive advice for patients with epilepsy not indicated
Pre-conception advice exceptions
(EPICCAEXC)
EP003
8IAh.
8IB3.
Pre-conception advice for patients with epilepsy declined
Pre-conception advice for patients with epilepsy not indicated
Pregnancy advice exceptions (EPILPAEXC)
EP003
8IAi.
8IB4.
Pregnancy advice for patients with epilepsy declined
Pregnancy advice for patients with epilepsy not indicated
L3985
Delivery by caesarean hysterectomy
7E04% (excluding
7E04D)
Abdominal excision of uterus
7E05%
7F1A0
7L0A%
ZV6G8
Vaginal excision of uterus
Caesarean hysterectomy
Clearance of pelvis
[V]Acquired absence of uterus
7E10%
7E111
7E113
7E115
7E15%
7E160
7E162
7E1C%
7E1D0
159A.
ZV25x
ZV252
Bilateral excision of adnexa of uterus
Salpingoophorectomy of remaining solitary fallopian tube and ovary
Salpingectomy of remaining solitary fallopian tube NEC
Oophorectomy of remaining solitary ovary NEC
Open bilateral occlusion of fallopian tubes
Open ligation of remaining solitary fallopian tube
Open clipping of remaining solitary fallopian tube
Endoscopic bilateral occlusion of fallopian tubes
Endoscopic occlusion of remaining solitary fallopian tube
H/O: tubal ligation
[V]Other sterilisation
[V]Sterilisation
Hysterectomy codes (HYST2)
Sterilisation codes (STERIL)
EP003
EP003
Patients require all three codes entered within the last 12 months to meet the indicator. It is not necessary
for these all to be on the same day
To exception code from any one of these items the patient must have either an exception code or a code to
meet the indicator for each of the 3 types of advice.
Permanent exclusion from indicator
Permanent exclusion from indicator
28
Code
G58%
Heart Failure (HF)
HF001
HEART FAILURE
Code
Breakdown
G58..
G580.
G5800
G5801
G5802
G5803
G581.
G5810
G582.
G583.
G584.
G58z.
G1yz1
662f.-662i.
662f.
662g.
662h.
662i.
G58%
G58..
G580.
G5800
G5801
G5802
G5803
G581.
G5810
G582.
G583.
G584.
G58z.
Heart Failure due to LVSD
G1yz1
662f.-662i.
662f.
662g.
662h.
662i.
G5yy9
all except HF001
9hH%
Echo Declined (ECEXC)
Ace inhibitor contraindications: persistent
(XACE)
HF002
HF002
HF003(S) and
HF004(S)
Heart failure
Congestive heart failure
Acute congestive heart failure
Chronic congestive heart failure
Decompensated cardiac failure
Compensated cardiac failure
Left ventricular failure
Acute left ventricular failure
Acute heart failure
Heart failure with normal ejection fraction
Right ventricular failure
Heart failure NOS
Rheumatic left ventricular failure
New York Heart Assoc. classification - class I
New York Heart Assoc. classification - class II
New York Heart Assoc. classification - class III
New York Heart Assoc. classification - class IV
Exception reporting: heart failure quality indicators
Excepted from heart failure quality indicators: Patient unsuitable
Excepted from heart failure quality indicators: Informed dissent
U-S heart scan
Echocardiogram abnormal
Echocardiogram shows left ventricular systolic dysfunction
Echocardiogram shows left ventricular diastolic dysfunction
Echocardiogram equivocal
Echocardiogram requested
Transoesophageal echocardiography
Diagnostic echocardiography
Transthoracic echocardiography
Transoesophageal echocardiography
Stress echocardiography
Referral for echocardiography
8HTL.
Referral to heart
failure clinic
8HTL0
Referral to rapid
access heart
failure clinic
R1320
R1322
5531.
5533.
5538.
79380
79382
7P0H6
[D]Echocardiogram abnormal
[D]Ultrasound cardiogram abnormal
Angiocardiography awaited
Angiocardiography abnormal
Angiocardiography equivocal
Angiocardiography of both right and left sides of heart
Angiocardiography of left side of heart NEC
Contrast echocardiography
8A544
Monitoring of cardiac output using echocardiography
8H4R.
8HVJ.
8H44.
Ref to cardio spec interest GP
Private referral to cardiologist
Cardiological referral
8H7o0
Fast track heart failure referral for transthoracic two dimensional echocardiogram
56F1.
5534.
Echocardiogram declined
Angiocardiography declined
14LM.
K0430
H/O: angiotensin converting enzyme inhibitor allergy
Acute renal failure due to ACE inhibitor
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in therapeutic
use
[V]Personal history of angiotensin-converting-enzyme inhibitor allergy
Adverse reaction to captopril
Adverse reaction to enalapril
Adverse reaction to ramipril
U60C4
ZV14D
TJC77
TJC78
TJC79
cdeset changed for 2013-14. Includes wider list of codes.
Left ventricular systolic dysfunction
9hH..
9hH0.
9hH1.
5853.
58531
585f.
585g.
5C20.
33BD.
79352
7P0H.
7P0H0
7P0H1
7P0H4
8HQ7.
Echocardiogram (ECOG)
Comments v26
Heart failure
Congestive heart failure
Acute congestive heart failure
Chronic congestive heart failure
Decompensated cardiac failure
Compensated cardiac failure
Left ventricular failure
Acute left ventricular failure
Acute heart failure
Heart failure with normal ejection fraction
Right ventricular failure
Heart failure NOS
Rheumatic left ventricular failure
New York Heart Assoc. classification - class I
New York Heart Assoc. classification - class II
New York Heart Assoc. classification - class III
New York Heart Assoc. classification - class IV
Echocardiogram shows left ventricular systolic dysfunction
585f.
Heart Failure Exceptions (HFEXC)
To Index
Term
29
Code
Heart Failure cont.
Code
Breakdown
To Index
Term
Ace inhibitor contraindications: expiring
(TXACE)
HF003(S) and
HF004(S)
8I28.
8I3D.
8I64.
8I74.
AII antagonist contraindications: persisting
(XAII)
HF003(S) and
HF004(S)
14LN.
U60CB
ZV14E
H/O: angiotensin II receptor antagonist allergy
[X]Angiotensin II receptor antagonists causing adverse effects in therapeutic use
[V]Personal history of angiotensin II receptor antagonist allergy
AII antagonist contraindications: expiring
(TXAII)
HF003(S) and
HF004(S)
8I2H.
8I3P.
8I6C.
8I75.
Angiotensin II receptor antagonists contraindicated
Angiotensin II receptor antagonist declined
Angiotensin II receptor antagonist not indicated
Angiotensin II receptor antagonist not tolerated
Angiotensin converting enzyme inhibitors contraindicated
Angiotensin converting enzyme inhibitor declined
Angiotensin converting enzyme inhibitor not indicated
Angiotensin converting enzyme inhibitor not tolerated
Comments v26
ACE inhibitor prescriptions (ACE)
HF003(S) and
HF004(S)
Prescribed in last 6 months
A II antagonist prescription codes (AII)
HF003(S) and
HF004(S)
Prescribed in last 6 months.
14LL.
TJC00
TJC02
TJC6%
Beta Blocker contraindications:persistent
(XLBB)
HF004(S)
TJC6.
TJC61
TJC62
TJC63
TJC64
TJC65
TJC66
TJC67
TJC68
TJC6z
U60B7
U60B9
U60BA
U60BB
ZV14C
ZVu6i
ZVu6o
ZVu6q
8I26.
8I2g.-8I2i
8I2g.
8I2h.
8I2i.
8I36.
8IAS. - 8IAV
Beta Blocker contraindications:expiring
(TXBB)
HF004(S)
8IAS.
8IAT.
8IAV.
8I62.
8I6i. - 8I6k.
8I6i.
8I6j.
8I6k.
8I73.
8I7K.-8!7M.
Prescription codes for licensed Beta blocker
(LBB)
HF004(S)
Prescription codes for unlicensed Beta blocker
HF004(S)
(ULBB)
8I7K.
8I7L.
8I7M.
H/O: betablocker allergy
Adverse reaction to practolol
Adverse reaction to propranolol
Adverse reaction to betablockers
Adverse reaction to acebutolol
Adverse reaction to atenolol
Adverse reaction to labetalol
Adverse reaction to metoprolol
Adverse reaction to nadolol
Adverse reaction to oxprenolol
Adverse reaction to sotalol
Adverse reaction to timolol
Adverse reaction to betablockers NOS
[X]Beta-adrenoreceptor antagonists causing adverse effects in therapeutic use, not
elsewhere classified
[X]Adverse reaction to bisoprolol
[X]Adverse reaction to carvedilol
[X]Adverse reaction to nebivolol
[V]Personal history of betablocker allergy
[X]Personal history of allergy to bisoprolol
[X]Personal history of allergy to carvedilol
[X]Personal history of allergy to nebivolol
Beta blocker contraindicated
Bisoprolol contraindicated
Carvedilol contraindicated
Nebivolol contraindicated
Beta blocker therapy refused
Bisoprolol therapy refused
Carvedilol therapy refused
Nebivolol therapy refused
Beta blocker not indicated
Bisoprolol not indicated
Carvedilol not indicated
Nebivolol not indicated
Beta blocker not tolerated
Bisoprolol not tolerated
Carvedilol not tolerated
Nebivolol not tolerated
BISOPROLOL FUMARATE
CARVEDILOL
NEBIVOLOL
Prescribed in last 6 months
All other Beta-Adrenoceptor Blockers apart for licensed ones above
Patient can remain on an unlicensed B-blocker if they were on this in the 6 months prior to Heart Failure
diagnosis (ie. it may not be clinically appropriate to change to a licensed brand)
30
Code
HYPERTENSION
Code
Breakdown
G2...
G20%
Hypertension (HYP)
HYP001
Gyu2.
Gyu20
Hypertensive disease
Essential hypertension
Secondary malignant hypertension
Secondary malignant hypertension NOS
Secondary benign hypertension
Secondary benign hypertension NOS
Hypertension secondary to endocrine disorders
Secondary hypertension NOS
Secondary renovascular hypertension NOS
Secondary hypertension NOS
Stage 1 hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Severe hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Stage 2 hypertension (NICE - National Institute for Health and Clinical Excellence
2011)
Other specified hypertensive disease
Hypertensive disease NOS
[X]Hypertensive diseases
[X]Other secondary hypertension
21261
212K.
Hypertension resolved
Hypertension resolved
G24..-G2z..
(excluding G24z1,
G2400, G2410,
G27..)
G240.
G240z
G241.
G241z
G244.
G24z.
G24z0
G24zz
G25..
G26..
G28..
G2y..
G2z..
Hypertension resolved
To Index
Term
9h3..
9h31.
9h32.
Comments v26
Exception reporting: hypertension quality indicators
Excepted from hypertension quality indicators: Patient unsuitable
Excepted from hypertension quality indicators: Informed dissent
Hypertension Exception Codes (HYPEXC)
all except HYP001 9h3%
BP Recording Codes (BP)
HYP002(S)
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
BP Recording Exception Codes (BPEX)
HYP002(S)
8I3Y.
Blood pressure procedure refused
Maximal BP therapy (HTMAX)
HYP002(S)
8BL0.
Patient on maximal tolerated antihypertensive therapy
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values. Requuires entry in the previous 9 months
31
Code
Hypothyroid (THY)
THY001
HYPOTHYROID
Code
Breakdown
C04%
C03%
To Index
Term
Comments v26
Acquired hypothyroidism
Congenital hypothyroidism
Prescribed in the previous 6 months.
Hypothyroid Medication prescription
Hypothyroid Exception Codes (THYEXC)
all except THY001 9h7%
Thyroid function test codes (TFT)
THY002
442%
9h7..
9h71.
9h72.
Exception reporting: thyroid quality indicators
Excepted from thyroid quality indicators: Patient unsuitable
Excepted from thyroid quality indicators: Informed dissent
Thyroid hormone tests
32
Learning disabilities
Code
To Index
Code
Breakdown
Term
Comments v26
Age>=18
E3%
Eu7%
Learning disabilities (LD)
LD001
Eu7..
Eu70%
Eu71%
Eu72%
Eu73%
Eu7y%
Eu7z%
Eu814
Eu815
Eu816
Eu817
Eu81z
918e.
Mental retardation
[X]Mental retardation
[X]Mild mental retardation
[X]Moderate mental retardation
[X]Severe mental retardation
[X]Profound mental retardation
[X]Other mental retardation
[X]Unspecified mental retardation
[X]Moderate learning disability
[X]Severe learning disability
[X]Mild learning disability
[X]Profound learning disability
[X]Developmental disorder of scholastic skills, unspecified
On learning disability register
Learning disabilities Exception Codes
(LDEXC)
all except LD001
9hL%
9hL..
9hL0.
9hL1.
Exception reporting: learning disability quality indicators
Excepted from learning disability quality indicators: informed dissent
Excepted from learning disability quality indicators: patient unsuitable
Downs Syndrome (DS)
LD002
PJ0%
PJ0..
PJ00.
PJ01.
PJ02.
PJ0z.
Down's syndrome - trisomy 21
Trisomy 21, meiotic nondisjunction
Trisomy 21, mosaicism
Trisomy 21, translocation
Down's syndrome NOS
Hypothyroid (THY)
LD002
C04%
C03%
Acquired hypothyroidism
Congenital hypothyroidism
442%
Thyroid hormone tests
Hypothyroid Medication prescription (THYR) LD002
Thyroid function test codes (TFT)
LD002
A previous diagnosis of hypothyroidism + on medication will exclude patient from indicator LD2 unless the
hypothyroid diagnosis has been made within the last 12 months. Prescription of levothyroxine requires to be
in the previous 6 months
Prescribed in the previous 6 months.
33
Code
Mental Health
Code
Breakdown
E10%
E110%
E111%
E1124
E1134
E114.-E117z
E11y% (excluding
E11y2)
Eu2..
Eu20%
Eu21.
Eu22%
Eu23%
Eu24.
Eu25%
Eu26%
Eu2y.
Eu2z.
Eu30.
Eu300
Eu301
Eu302
Eu30y
Eu30z
Eu31.
Schizophrenic disorders
Manic disorder, single episode
Recurrent manic episodes
Single major depressive episode, severe, with psychosis
Recurrent major depressive episodes, severe, with psychosis
Bipolar affective disorder, currently manic
Bipolar affective disorder, currently depressed
Mixed bipolar affective disorder
Unspecified bipolar affective disorder
Other and unspecified manic-depressive psychoses
Unspecified manic-depressive psychoses
Atypical manic disorder
Other mixed manic-depressive psychoses
Other and unspecified manic-depressive psychoses NOS
Other and unspecified affective psychoses
Unspecified affective psychoses NOS
Other affective psychosis NOS
Paranoid states
Other nonorganic psychoses
Reactive depressive psychosis
Acute hysterical psychosis
Reactive confusion
Acute paranoid reaction
Psychogenic paranoid psychosis
Other reactive psychoses
Nonorganic psychosis NOS
Schizotypal personality
[X]Schizophrenia, schizotypal and delusional disorders
[X]Schizophrenia
[X]Schizotypal disorder
[X]Persistent delusional disorders
[X]Acute and transient psychotic disorders
[X]Induced delusional disorder
[X]Schizoaffective disorders
[X]Nonorganic psychosis in remission
[X]Other nonorganic psychotic disorders
[X]Unspecified nonorganic psychosis
[X]Manic episode
[X]Hypomania
[X]Mania without psychotic symptoms
[X]Mania with psychotic symptoms
[X]Other manic episodes
[X]Manic episode, unspecified
[X]Bipolar affective disorder
Eu310
[X]Bipolar affective disorder, current episode hypomanic
Eu311
[X]Bipolar affective disorder, current episode manic without psychotic symptoms
Eu312
[X]Bipolar affective disorder, current episode manic with psychotic symptoms
Eu313
[X]Bipolar affective disorder, current episode mild or moderate depression
E114%
E115%
E116%
E117%
E11y.
E11y0
E11y1
E11y3
E11yz
E11z.
E11z0
E11zz
E12%
E13% (excluding
E135.)
E13..
E130.
E131.
E132.
E133.
E134.
E13y%
E13z.
E2122
Eu2%
Psychosis, Schizophrenia + bipolar affective
disease codes (MH)
MH001
Eu30%
Eu31%
To Index
Term
Eu314
Eu315
Comments v26
Patients are in the Mental Health population if they have one of these diagnosis codes or they are on
Lithium.
[X]Bipolar affective disorder, current episode severe depression without psychotic
symptoms
[X]Bipolar affective disorder, current episode severe depression with psychotic
symptoms
Eu316
[X]Bipolar affective disorder, current episode mixed
Eu317
Eu318
Eu319
Eu31y
Eu31z
[X]Bipolar affective disorder, currently in remission
[X]Bipolar affective disorder type I
X]Bipolar affective disorder type II
[X]Other bipolar affective disorders
[X]Bipolar affective disorder, unspecified
Eu323
[X]Severe depressive episode with psychotic symptoms
Eu328
[X]Major depression, severe with psychotic symptoms
Eu329
[X]Single major depressive episode, severe, with psychosis, psychosis in remission
Eu32A
[X]Recurrent major depressive episodes, severe, with psychosis, psychosis in
remission
Eu333
[X]Recurrent depressive disorder, current episode severe with psychotic symptoms
34
Code
Lithium Prescription codes (LIT + ELIT))
MH001
Stopped Lithium (excluded)
Remission from severe Mental Illness
(MHREM+MHREM2)
MH002-MH008
Mental Health cont.
Code
Breakdown
all except MH001
Comments v26
d6%
LITHIUM SALTS
prescribed in the last 6 months
665B.
Lithium stopped
Excludes patient if entered after the last prescription date
E1005
E1015
E1025
E1035
E1055
E1075
E1106
E1116
E1146
E1156
E1166
E1176
Eu223
Eu26.
Eu317
Eu329
Schizophrenia in remission
Hebephrenic schizophrenia in remission
Catatonic schizophrenia in remission
Paranoid schizophrenia in remission
Latent schizophrenia in remission
Schizo-affective schizophrenia in remission
Single manic episode in full remission
Recurrent manic episodes, in full remission
Bipolar affective disorder, currently manic, in full remission
Bipolar affective disorder, currently depressed, in full remission
Mixed bipolar affective disorder, in full remission
Unspecified bipolar affective disorder, in full remission
[X]Paranoid state in remission
[X]Nonorganic psychosis in remission
[X]Bipolar affective disorder, currently in remission
[X]Single major depressive episode, severe, with psychosis, psychosis in remission
[X]Recurrent major depressive episodes, severe, with psychosis, psychosis in
remission
Exception codes patients permanently from the indicators but not from the MH overall population. If a later
dated MH code is added this will over-ride the remission code. New information in guidance document
about what constitutes 'remission'
Eu32A
Mental Health Exception codes (MHEXC)
To Index
Term
9h9%
9h9..
9h91.
9h92.
Exception reporting: mental health quality indicators
Excepted from mental health quality indicators: Patient unsuitable
Excepted from mental health quality indicators: Informed dissent
8CG6%
8CG6.
8CG60
8CG61
8CG62
8CY..
Care Programme Approach review
Initial Care Programme Approach review
Ongoing Care Programme Approach review
Discharge Care Programme Approach review
Review of mental health care plan
Agreeing on mental health care plan
Mental Health Care Programme Approach
Lithium level test (SLIT)
MH010
44W8%
44vE.
R1053
Serum lithium level
Lithium level therapeutic
[D]Lithium, blood level abnormal
Lithium level values should also be recorded for the Contract and your software system will have a system to
deal with Read coding of Values. Requires entry within previous 4 months
Lithium level Therapeutic (TLIT)
MH010
44W80
44vE.
Lithium level therapeutic
Lithium level therapeutic
This code is not required if Lithium values are within the therapeutic range (0.4 - 1.0).
Serum Creatinine (CRE)
MH009
44J3%
44JC.
44JD.
44JF.
Serum creatinine
Corrected plasma creatinine level
Corrected serum creatinine level
Plasma creatinine level
Creatinine test results required in the last 9 months
TSH test (TSH)
MH009
442A%
442K.-442T.
442W.
442X.
442e.
TSH - thyroid stim. hormone
30 minute plasma TSH level
Serum TSH level
Plasma TSH level
Blood spot TSH level
MH Care plan (MHP)
MH002
8CMG1
8CS7.
TSH test results required in the last 9 months
There are others in this range for different times of testing
35
Mental Health cont.
Code
Breakdown
136..
1361.
1362.
1363.
1364.
1365.
1366.
1367.
136A.
136C.
136C.
136D.
136E.
136F.
136G.
136% (excluding
136H.
1368., 1369., 136M.,
136I.
136W, 136Y., 136b.,
136J.
136e.)
136K.
136L.
136N.
136O.
136P.
136Q.
136R.
136S.
136T.
136V.
136X.
136Z.
136a.
136c.
136d.
Alcohol consumption
Teetotaller
Trivial drinker - <1u/day
Light drinker - 1-2u/day
Moderate drinker - 3-6u/day
Heavy drinker - 7-9u/day
Very heavy drinker - >9u/day
Stopped drinking alcohol
Ex-trivial drinker (<1u/day)
Ex-moderate drinker - (3-6u/d)
Ex-moderate drinker - (3-6u/d)
Ex-heavy drinker - (7-9u/day)
Ex-very heavy drinker-(>9u/d)
Spirit drinker
Beer drinker
Drinks beer and spirits
Drinks wine
Social drinker
Alcohol intake above recommended sensible limits
Alcohol intake within recommended sensible limits
Light drinker
Moderate drinker
Heavy drinker
Very heavy drinker
Binge drinker
Hazardous alcohol use
Harmful alcohol use
Alcohol units per week
Alcohol units consumed on heaviest drinking day
Alcohol consumption NOS
Increasing risk drinking
Higher risk drinking
Lower risk drinking
To Index
Code
Term
Comments v26
Alcohol consumption (ALC)
MH007
Alcohol Consumption screening declined
(ALCEX)
MH007
136e.
8IA7.
8IAF.
8IAt.
9k19.
Declines to state current alcohol consumption
Alcohol consumption screening test declined
Brief intervention for excessive alcohol consumption declined
Extended intervention for excessive alcohol consumption declined
Alcohol assessment declined - enhanced services administration
BMI Codes (BMI)
MH006
22K% (excluding
22K9., 22K90,
22KA.)
Body Mass Index
BP Recording Codes (BP)
MH003
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values.
BP Recording Exception Codes
MH003
8I3Y.
Blood pressure procedure refused
Requires recording within the previous 12 months
MH004
44PF.
44l2.
44lF.
44lG.
Total cholesterol:HDL ratio
Cholesterol/HDL ratio
Serum cholesterol/HDL ratio
Plasma cholesterol/HDL ratio
Applies only to patients age 40 and over. Patients with pre-existing, hypertension, diabetes, CHD, PVD,
Stroke or TIA, familial hypercholesterolaemia, or CKD are excluded from requiring Tot Chol/HDL test.
C3200
C3201
C3203
C3204
C3205
C3220
Familial hypercholesterolaemia
Hyperbetalipoproteinaemia
Low-density-lipoprotein-type (LDL) hyperlipoproteinaemia
Fredrickson's hyperlipoproteinaemia, type IIa
Familial defective apolipoprotein B-100
Familial combined hyperlipidaemia
Excludes from requiring Tot Chol/HDL test.
Requires entry in the previous 12 months
0
Total Cholesterol:HDL (TCHOLHDL)
Familial Hypercholesterolaemia (FHYP)
36
Code
Mental Health cont.
Code
Breakdown
44TM.
44f%
44g%
44T1. - 44T3.
44T1.
44T10
44T11
44T12
44T2.
44T3.
44TA.
Glucose (GLC)
MH005
44TE. - 44TK.
(excluding 44TJO44TJ7)
44TE.
44TF.
44TG.
44TH.
44TI.
44TJ.
44TK.
44U% (except
44Uz.)
To Index
Term
Blood glucose series
Serum glucose level
Plasma glucose level
Random blood sugar
Random blood sugar normal
Random blood sugar low
Random blood sugar raised
Fasting blood sugar
2 hours post food blood sugar
Plasma glucose
30 minute blood glucose level
60 minute blood glucose level
90 minute blood glucose level
120 minute blood glucose level
150 minute blood glucose level
Blood glucose level
Fasting blood glucose level
44V6.
7P172
R102.
R10D.
R1057
IFCC HbA1c levels (IFCCHBA)
MH005
42W5.
Haemoglobin A1c level - IFCC standardised
Glucose test exception code (GLUCEXC)
MH005
8IEG.
Blood glucose test declined
MH008
685H.
685I.
685K.
9O8Y.
7E05%
7E040
7E042
7E043
7E046
7E049
7E04B
7E04G
7L0A%
26L3.
No smear - benign hysterectomy
No smear-amputation of cervix
No smear - no cervix
No cervical smear required - no uterus
Vaginal excision of uterus
Abdominal hysterocolpectomy and excision of periuterine tissue
Abdominal hysterocolpectomy NEC
Total abdominal hysterectomy NEC
Radical hysterectomy
Total abdominal hysterectomy and bilateral salpingoophorectomy
Laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy
Total abdominal hysterectomy with conservation of ovaries
Clearance of pelvis
Uterine cervix absent
Hysterectomy and equivalent codes (HYST)
Applies only to patients age 40 and over. Patients with diabetes diagnosed more that 12 months ago are
excluded.
Blood glucose result
44V..
44V1.
44V2.
44V3.
Glucose tolerance test
Glucose tolerance test normal
Glucose tol. test impaired
Glucose tol. test diabetic
Extended glucose tolerance test
Glucose tolerance test
[D]Glucose tolerance test abnormal
[D]Elevated blood glucose level
[D]Glucose, blood level abnormal
44V.. - 44V3.
Comments v26
Permanent exclusion from indicator MH16
37
Mental Health cont.
Code
Breakdown
4K22.
4K23.
4K24.
4K25.
4K22. - 2K29.
4K26.
4K27.
4K28.
4K29.
4K2C.
4K2H.
4K2F.
4K2G.
4KA1.
4KA3.
4KA4.
6856.
6859.
685B.
685B. - 685D.
685C.
685D.
685R.
7E2A2
7E2A3
ZV762
7E2A0
4K3E.
Cervical smear: negative
Cerv.smear: mild dyskaryosis
Cerv.smear: severe dyskaryosis
Cerv.smear:severe dysk.?inv.ca
Cervical smear: ? gland neopl.
Cervical smear:atrophic change
Cerv.smear: mod.dyskaryosis
Cerv.smear: borderline changes
Smear NAD - no endocervical cells
Cervical smear epithelial cells absent
Cervical smear pus cells present
Cervical smear red blood cells present
Vaginal vault smear negative
Vaginal vault smear-atrophic
Vaginal vault smear abnormal
Ca cervix screen - up to date
Ca cervix - screen done
Ca cervix screen normal
Ca cervix screen abnormal
Ca cervix screen + fee claim
Liquid based cervical cytology screening
Papanicolau smear NEC
Vaginal vault smear
[V]Screening for malignant neoplasm of cervix
Examination of female genital tract under anaesthetic and Papanicolau smear
HPV - Human papillomavirus test negative
6853.
685L.
8I6K.
9O8Q.
Ca cervix screen - not wanted
Cervical smear refused
Cervical smear not indicated
Cerv.smear disclaimer received
To Index
Code
Cervical Smear (SMEAR)
MH008
Cervical cytology exceptions (CYTEXC)
MH008
Term
Comments v26
In Scotland for females age 20 - 60. Requires entry within the previous 5 yrs.
Requires entry within the previous 5 years
38
Code
Obesity
Code
Breakdown
To Index
Term
Comments v26
Age >=16
22K5.
22K7.
Obesity
Body mass index 30+ - obesity
Body mass index 40+ - severely obese
22K..
(If has attached
Body Mass Index
value of >=30)
22KB.
(If has attached
Baseline body mass index
value of >=30)
OB001
Need to be recorded in the last 12 months
only if value attached of >=30 and recorded in the last 12 months.
39
Osteoporosis: Secondary prevention of Fragility fractures
Code
Code
Breakdown
New Area for 2012-13
There are two populations for osteoporosis 1. age 50-74, require codes for fragility fracture after 1.4.12 and diagnosis of osteoporosis and DEXA scan code.
fragility fracture.
Fragility fracture (FF)
OST001
N331N
N331M
N330% (excluding
N3308, N3309)
Osteoporosis
OST001
N331H - N331M
Comments v26
2. Those age 75+ require code for
Fragility fracture
Fragility fracture due to unspecified osteoporosis
N330.
N3300
N3301
N3302
N3303
N3304
N3305
N3306
N3307
N330A
N330B
N330C
N330D
N330z
N3312
N3313
N3314
N3315
N3316
N3318 - N331B
To Index
Term
N3318
N3319
N331A
N331B
N331H
N331J
N331K
N331L
N331M
N3746
NyuB0
NyuB1
NyuB2
NyuB8
9hP..
9hP0.
9hP1.
Osteoporosis
Osteoporosis, unspecified
Senile osteoporosis
Postmenopausal osteoporosis
Idiopathic osteoporosis
Dissuse osteoporosis
Drug-induced osteoporosis
Postoophorectomy osteoporosis
Postsurgical malabsorption osteoporosis
Osteoporosis in endocrine disorders
Vertebral osteoporosis
Osteoporosis localized to spine
Osteoporosis due to corticosteroids
Osteoporosis NOS
Postoophorectomy osteoporosis with pathological fracture
Osteoporosis of disuse with pathological fracture
Postsurgical malabsorption osteoporosis with pathological fracture
Drug-induced osteoporosis with pathological fracture
Idiopathic osteoporosis with pathological fracture
Osteoporosis + pathological fracture lumbar vertebrae
Osteoporosis + pathological fracture thoracic vertebrae
Osteoporosis + pathological fracture cervical vertebrae
Postmenopausal osteoporosis with pathological fracture
Collapse of cervical vertebra due to osteoporosis
Collapse of lumbar vertebra due to osteoporosis
Collapse of thoracic vertebra due to osteoporosis
Collapse of vertebra due to osteoporosis NOS
Fragility fracture due to unspecified osteoporosis
Osteoporotic kyphosis
[X]Other osteoporosis with pathological fracture
[X]Other osteoporosis
[X]Osteoporosis in other disorders classified elsewhere
[X]Unspecified osteoporosis with pathological fracture
Exception reporting: osteoporosis quality indicators
Excepted from osteoporosis quality indicators: patient unsuitable
Excepted from osteoporosis quality indicators: informed dissent
Osteoporosis exception codes (OSTEOEXC)
all except OST001
9hP%
DEXA scan (without score)
OST001
58EG.
58EM.
58EV.
Hip DXA scan result osteoporotic
Lumbar DXA scan result osteoporotic
Femoral neck DEXA scan result osteoporotic
Dexa scan (with T score value < -2.5)
OST001
58EE.
58EK.
58ES.
Hip DXA scan T score
Lumbar spine DXA scan T score
Femoral neck DEXA scan T score
40
Code
Osteoporosis cont.
Code
Breakdown
To Index
Term
Comments v26
14LT.
ZV14K
14La.
14Lb.
14LW.
ZV14H
14Lc.
14LT0
14LT1
14LT2
14LT3
14LT4
H/O: bisphosphonate allergy
[V]Personal history of bisphosphonate allergy
H/O: raloxifene allergy
H/O: teriparatide allergy
H/O: strontium ranelate allergy
[V]Personal history of strontium ranelate allergy
H/O denosumab allergy
H/O ibandronic acid allergy
H/O zoledronic acid monohydrate allergy
H/O disodium etidronate allergy
H/O alendronic acid allergy
H/O risedronate sodium allergy
Bone sparing agents contra-indicated, expiring
OST002, OST003
(TXBSACAT)
8I3e.
8I6R.
8I7E.
8I2V.
8I6p.
8I7P.
8IEH.
8I2l.
8I6q.
8I7Q.
8IED.
8I2m.
8I3h.
8I6V.
8I7H.
8I2Y.
8I2p.
8I2V0
8IEW.
8I3e0
8I7S.
8I7E0
8I612
8I6R0
8I2V3
8I3e3
8I6R3
8I7E3
8I2V2
8I3e2
8I6R2
8I7E2
8I2V4
8I3e4
8I6R4
8I7E4
8I3e1
8I6R1
8I7E1
8I2V1
Bisphosphonates declined
Bisphosphonates not indicated
Bisphosphonates not tolerated
Bisphosphonates contraindicated
Raloxifene not indicated
Raloxifene not tolerated
Raloxifene declined
Raloxifene contraindicated
Teriparatide not indicated
Teriparatide not tolerated
Teriparatide declined
Teriparatide contraindicated
Strontium ranelate declined
Strontium ranelate not indicated
Strontium ranelate not tolerated
Strontium ranelate contraindicated
Denosumab contraindicated
Ibandronic acid contraindicated
Denosumab declined
Ibandronic acid declined
Denosumab not tolerated
Ibandronic acid not tolerated
Denosumab not indicated
Ibandronic acid not indicated
Alendronic acid contraindicated
Alendronic acid declined
Alendronic acid not indicated
Alendronic acid not tolerated
Disodium etidronate contraindicated
Disodium etidronate declined
Disodium etidronate not indicated
Disodium etidronate not tolerated
Risedronate sodium contraindicated
Risedronate sodium declined
Risedronate sodium not indicated
Risedronate sodium not tolerated
Zoledronic acid monohydrate declined
Zoledronic acid monohydrate not indicated
Zoledronic acid monohydrate not tolerated
Zoledronic acid monohydrate contraindicated
Requires entry within the last 12 months
OST002, OST003
fo1%
fo4%
fo6%
fo7%
fo8%
fv1%
fu3%
fu5%
fu9%
8BP1.
8B6c.
8B6b.
DISODIUM ETIDRONATE
ALENDRONIC ACID
RISEDRONATE SODIUM
ZOLEDRONIC ACID
IBANDRONIC ACID
RALOXIFENE HYDROCHLORIDE
TERIPARATIDE
STRONTIUM
DENOSUMAB
Teriparatide therapy
Intravenous bisphosphonate prophylaxis
Osteoporosis medication prophylaxis
Requires entry in last 6 months
Bone sparing agents contra-indicated,
persisting (XBSACAT)
Bone sparing agent prescriptions (BSA)
OST002, OST003
prescription
codes
Code
Palliative Care
Code
Breakdown
1Z01.
2JE..
8B2a.
8BA2.
8BAP.
8BAS.
Specialist palliative care treatment - outpatient
8BAe.
8BJ1.
8CM1.
Anticipatory palliative care
Palliative treatment
On gold standards palliative care framework
8CM10
Gold standards framework supportive care stage 1 - advancing disease
8CM11
8CM1% (excluding
8CM15)
8CM12
Gold standards framework supportive care stage 2 - increasing decline
8CM13
8CM14
8CM4.
8CME.
8CMQ.
8CMW3
8CMb.
8H6A.
8H7L.
8H7g.
8HH7.
8IEE
Comments v26
Terminal illness - late stage
Last days of life
Prescription of palliative care anticipatory medication
Terminal care
Specialist palliative care
Specialist palliative care treatment - daycare
8BAT.
PC001
To Index
Term
Gold standards framework supportive care stage 3 - last days: category C - weeks
prognosis
Gold standards framework supportive care stage 3 - last days: category D - days
prognosis
Gold standards framework supportive care stage 3 - last days: category B - months
prognosis
Liverpool care pathway for the dying
Has end of life advanced care plan
On Liverpool care pathway for the dying
End of life care pathway
Integrated care priorities for end of life
Refer to terminal care consult
Refer for terminal care
Referral to palliative care service
Referred to community specialist palliative care team
9367.
Referral to community palliative care team declined
Patient held palliative care record
9EB5.
DS 1500 Disability living allowance (terminal care) completed
9G8..
Ambulance service notified of patient on end of life care register
9K9..
9NNd.
9NNf0
9Ng7.
9NgD.
9c0L0
9c0M.
9c0P.
9c0N.
ZV57C
Palliative care handover form completed
Under care of palliative care specialist nurse
Under care of palliative care physician
On end of life care register
Under care of palliative care service
Planned palliative oncology treatment
Planned supportive care for terminal illness
Current palliative oncology treatment
Current supportive care for terminal illness
[V]Palliative care
Population is patients coded since 1.4.2008.
41
Peripheral Arterial Disease
Code
To Index
Code
Breakdown
G73..
G734.
G73y.
Term
Comments v26
Gyu74
Other peripheral vascular disease
Peripheral arterial disease
Other specified peripheral vascular disease
Peripheral vascular disease NOS
Intermittent claudication
Peripheral vascular disease NOS
[X]Other specified peripheral vascular diseases
9hS..
Exception reporting: peripheral arterial disease quality indicators
9hS0.
Excepted from peripheral arterial disease quality indicators: patient unsuitable
9hS1.
Excepted from peripheral arterial disease quality indicators: informed dissent
PAD002
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values.
BP Recording Exception Codes (BPEX)
PAD002
8I3Y.
Blood pressure procedure refused
Requires recording within the previous 12 months
Maximal BP therapy (HTMAX)
PAD002
8BL0.
Patient on maximal tolerated antihypertensive therapy
Total Cholesterol Codes (CHOL2)
PAD003
44OE.
44P..
44PH.
44PJ.
44PK.
662a.
Plasma total cholesterol level
Serum cholesterol
Total cholesterol measurement
Serum total cholesterol level
Serum fasting total cholesterol
Pre-treatment serum cholesterol level
Exception from serum cholesterol target persisting (CHEXC)
U60CA
[X]Statin causing adverse effect in therapeutic use
PAD003
TJC24
TJC25
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Exception from serum cholesterol target expiring (TCHEXC)
PAD003
8BL1.
8I3C.
8I27.
8I63.
8I76.
Patient on maximal tolerated lipid lowering therapy
Statin declined
Statins contraindicated
Statin not indicated
Statin not tolerated
Peripheral Arterial Disease (PAD)
PAD Exception codes (PAD£XC)
BP Recording Codes (BP)
PAD001
all except PAD001
G73z% (excluding
G73z1)
G73z.
G73z0
G73zz
Cholesterol values should also be recorded for the Contract and your software system will have a system to
deal with Read coding of Values.
Requires recording within the previous 12 months
42
Peripheral Arterial Disease cont.
Code
Code
Breakdown
To Index
Term
Comments v26
Salicylate prescriptions (SAL)
PAD004
Clopidogrel prescriptions and code (CLO)
PAD004
8B6P.
Clopidogrel prophylaxis
Prescribed in In last 12 months
Warfarin Prescriptions and Code (WAR)
PAD004
8B2K.
Anticoagulant prescribed by third party
Prescribed in In last 12 months. Warfarin acts as an exclusion for being given aspirin or other anti-platelet
medication. Therefore there are no exception codes for warfarin therapy.
OTC salicylate codes (OSAL)
PAD004
67I8.
8B63.
8B3T.
Advice about taking aspirin
Salicylate prophylaxis
Over the counter aspirin therapy
Salicylate contra-indications:persistent
(XSAL)
PAD004
14LK.
ZV148
U6051
TJ53.
H/O: aspirin allergy
[V]Personal history of aspirin allergy
[X]Salicylates causing adverse effects in therapeutic use
Adverse reaction to salicylates
Salicylate contra-indications:expiring
(TXSAL)
PAD004
8I24.
8I38.
8I66.
8I70.
Aspirin prophylaxis contra-indicated
Aspirin prophylaxis refused
Aspirin not indicated
Aspirin not tolerated
Clopidrogel contraindications:persistent
(XCLO)
PAD004
14LQ.
U6048
ZV14B
H/O: clopidogrel allergy
[X]Clopidogrel causing adverse effects in therapeutic use
[V]Personal history of clopidogrel allergy
Clopidrogel contraindications:expiring
(TXCLO)
PAD004
8I2K.
8I3R.
8I6B.
8I72.
Clopidogrel contraindicated
Clopidogrel declined
Clopidogrel not indicated
Clopidogrel not tolerated
Prescribed in In last 12 months
Requires recording within the previous 12 months
Requires recording within the previous 12 months
43
Public Health - Blood Pressure
Code
BP Recording Codes (BP)
BP001
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
Code
Breakdown
To Index
Term
O/E - blood pressure reading
Comments v26
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values. Requires entry for all age 40+ within the previous 5 years
44
Rheumatoid Arthritis
Code
To Index
Code
Breakdown
Term
Comments v26
New for 2013-14
For Patients age 16 and over
N040%
N041.
N047.
N04X.
N04y0
N04y2
Nyu11
Nyu12
Nyu1G
Nyu10
Rheumatoid arthritis
Felty's syndrome
Other rheumatoid arthropathy with visceral or systemic involvement
Rheumatic carditis
Rheumatoid lung disease
Rheumatoid nodule
Rheumatoid arthropathy with visceral or systemic involvement NOS
Seropositive errosive rheumatoid arthritis
Seropositive rheumatoid arthritis, unspecified
Rheumatoid lung
Adult-onset Still's disease
[X]Other seropositive rheumatoid arthritis
[X]Other specified rheumatoid arthritis
[X]Seropositive rheumatoid arthritis, unspecified
[X]Rheumatoid arthritis with involvement of other organs or systems
all except RA001
9hR..
9hR0.
9hR1.
Exception reporting: rheumatoid arthritis quality indicators
Excepted from rheumatoid arthritis quality indicators: patient unsuitable
Excepted from rheumatoid arthritis quality indicators: informed dissent
RA003
38DP.
QRISK2 cardiovascular disease 10 year risk score
38D6.
Assessing cardiovascular risk using Scottish Intercollegiate Guidelines Network Arrangements being made in Scotland to include this code in specifications. Advice to use website version
score
and can use Diabetes as a proxy for RA untl updates to ASSIGN tool occur.
8IEV.
QRISK2 cardiovascular disease risk assessment declined
9NSB.
Unsuitable for QRISK2 cardiovascular disease risk assessment
38DB.
World Health Organisation FRAX 10 year hip fracture probability score
N042%
Rheumatoid Arthritis diagnosis (RARTH)
RA001
RA Exception codes (RARTHEXC)
CVD Assessment tool adjusted for RA
(CVDASSRA)
CVD Assessment tool adjusted for RA
exception codes (CVDASSRAEXC)
38DB1
RA004
38DC.
38DC0
38DC1
World Health Organisation FRAX 10 year osteoporotic fracture probability score
QFracture risk calculator
Osteoporosis risk assessment refused
9OdC.
Osteoporosis risk assessment defaulted
RA002
66HB0
Rheumatoid arthritis annual review
RA003
C3200
C3201
C3203
C3204
C3205
C3220
Familial hypercholesterolaemia
Hyperbetalipoproteinaemia
Low-density-lipoprotein-type (LDL) hyperlipoproteinaemia
Fredrickson's hyperlipoproteinaemia, type IIa
Familial defective apolipoprotein B-100
Familial combined hyperlipidaemia
RA Review (RARTHRVW)
For patients age 50-90, required in the last 24 months. Patients with osteoporosis or negative bone scan in
the last 24 months, or on osteoporosis prevention therapy in last 6 months, are excluded.
World Health Organisation FRAX 10 year osteoporotic fracture probability score with
bone mineral density
World Health Organisation FRAX 10 year osteoporotic fracture probability score with
body mass index
9OdB.
RA004
Familial Hypercholesterolaemia
World Health Organisation FRAX 10 year hip fracture probability score with bone
mineral density
World Health Organisation FRAX 10 year hip fracture probability score with body
mass index
38GR.
Fracture risk assessment tool adjusted for RA
exception codes (FRCASSRAEXC)
For patients age 30-85 requires entry in last 12 months. Patients with CVD, Stroke or familial
hypercholesterolaemia removed from this requirement
Requires entry in last 12 months. Application made for new codes to act as exceptions for ASSIGN tool.
RA003
38DB0
Fracture risk assessment tool adjusted for RA
(FRCASSRA)
N042.
N0420
N0421
N0422
N042z
Requires entry within the last 12 months
Excludes from the population if diagnosed before the hypertension diagnosis date.
45
Code
SMOKING
Code
Breakdown
To Index
Term
Comments v26
Patients with any one of CHD,Stroke or TIA, PAD, Hypertension, Diabetes (Age>=17), COPD, Asthma (with medication in the last year and age >=20), CKD (age >=18) or on the Mental
health Register (Schizophrenia, Psychosis or Bipolar disorder) count as the population for indicators SMOK002 and SMOK005
137..
1371.
1372.
1373.
1374.
1375.
1376.
1377.
1378.
1379.
137A.
137B.
137C.
137D.
137F.
137G.
137H.
137j.
137l.
137m.
137n.
137o.
Tobacco consumption
Never smoked tobacco
Trivial smoker - < 1 cig/day
Light smoker - 1-9 cigs/day
Moderate smoker - 10-19 cigs/d
Heavy smoker - 20-39 cigs/day
Very heavy smoker - 40+cigs/d
Ex-trivial smoker (<1/day)
Ex-light smoker (1-9/day)
Ex-moderate smoker (10-19/day)
Ex-heavy smoker (20-39/day)
Ex-very heavy smoker (40+/day)
Keeps trying to stop smoking
Admitted tobacco cons untrue ?
Ex-smoker - amount unknown
Trying to give up smoking
Pipe smoker
Cigar smoker
Stopped smoking
Rolls own cigarettes
Ex pipe smoker
Ex cigar smoker
Cigarette smoker
Smoking started
Current smoker
Ex smoker
Date ceased smoking
Smoking reduced
Cigarette consumption
Cigar consumption
Tobacco consumption NOS
Pipe tobacco consumption
Ready to stop smoking
Thinking about stopping smoking
Not interested in stopping smoking
Smoking restarted
Reason for restarting smoking
Cigarette pack-years
Minutes from waking to first tobacco consumption
Ex-cigarette smoker
Ex roll-up cigarette smoker
Failed attempt to stop smoking
Total time smoked
Waterpipe tobacco consumption
1371.
Never smoked tobacco
137..-137D.
137F.-137H.
137J.
137K.
Smoking Habit Codes (SMOK)
137M.-137T.
137M.
137N.
137O.
137P.
137Q.
137R.
137S.
137T.
137V.
137X.-137h.
Never Smoked (NSMOK)
SMOK001
+SMOK002
1377-137B
Ex-Smoker (EXSMOK + EXSMOK2 +
LEXSMOK))
SMOK001
+SMOK002
137X.
137Y.
137Z.
137a.
137b.
137c.
137d.
137e.
137f.
137g.
137h.
1377.
1378.
1379.
137A.
137B.
137F.
137K.
137N. - 137O.
137S. - 137T.
137j.
137l.
137N.
137O.
137S.
137T.
Ex-trivial smoker (<1/day)
Ex-light smoker (1-9/day)
Ex-moderate smoker (10-19/day)
Ex-heavy smoker (20-39/day)
Ex-very heavy smoker (40+/day)
Ex-smoker - amount unknown
Stopped smoking
Ex pipe smoker
Ex cigar smoker
Ex smoker
Date ceased smoking
Ex-cigarette smoker
Ex roll-up cigarette smoker
Requires entry in last 12months if aged 15 to 25. If aged over 25 requires entry once ever dated after patients
25th birthday and after their diagnosis date if in a disease group
Complex. Requires entry in last 12 months OR, if entered more than a 12 months ago, requires 3 ex-smoker
entries dated over a 3 year period with no 'smoker' code subsequently entered.
46
Code
SMOKING cont.
Code
Breakdown
1372.
1373.
1374.
1375.
1376.
137C.
137D.
137G.
137H.
all
9hG0.
9hG1.
137k.
Except smok qual ind: Pt uns
Except smok qual ind: Inf diss
Refusal to give smoking status
Note - overall exception codes for the individual disease areas will not exclude patients from the Smoking
criteria and these codes will also need entry.
SMOK004 +
SMOK005
8CAL.
8HTK.
8HkQ.
8H7i.
8IAj.
8IEK.
8T08.
8IEo.
9N2k.
13p50
9Ndf.
9Ndg.
Smoking cessation advice
Referral to stop-smoking clinic
Referral to NHS stop smoking service
Referral to smoking cessation advisor
Smoking cessation advice declined
Smoking cessation programme declined
Referral to smoking cessation service
Referral to smoking cessation service declined
Seen by smoking cessation advisor
Practice based smoking cessation programme start date
Consent given for follow-up by smoking cessation team
Declined consent for follow-up by smoking cessation team
only one codeid required frm either Support and refer, or pharmacotherapy from either group is now
required. Support required in last 24 months but in last 12 months if has one of the specified chronic
diseases.
Smoking cessation therapy
Nicotine replacement therapy using nicotine patches
Nicotine replacement therapy using nicotine gum
Nicotine replacement therapy using nicotine inhalator
Nicotine replacement therapy using nicotine lozenges
Other specified smoking cessation therapy
Smoking cessation therapy NOS
Nicotine replacement therapy provided free
Nicotine replacement therapy
Over the counter nicotine replacement therapy
Smoking cessation drug therapy declined
only one codeid required frm either Support and refer, or pharmacotherapy from either group is now
required.
137C.-137D.
137G.-137H.
137J.
137M.
SMOK001
+SMOK002
+SMOK004
137P.-137R.
Support and Refer Stop Smoking Service/
Adviser (REFERSSSA)
745H%
Pharmacotherapy (prescriptions + codes)
137P.
137Q.
137R.
137V.
137X.-137f.
Smoking Exception reporting codes
Comments v26
137h.
137m.
137o.
1372.-1376.
Current Smoker Code (CSMOK)
To Index
Term
Trivial smoker - < 1 cig/day
Light smoker - 1-9 cigs/day
Moderate smoker - 10-19 cigs/d
Heavy smoker - 20-39 cigs/day
Very heavy smoker - 40+cigs/d
Keeps trying to stop smoking
Admitted tobacco cons untrue ?
Trying to give up smoking
Pipe smoker
Cigar smoker
Rolls own cigarettes
Cigarette smoker
Smoking started
Current smoker
Smoking reduced
Cigarette consumption
Cigar consumption
Tobacco consumption NOS
Pipe tobacco consumption
Ready to stop smoking
Thinking about stopping smoking
Not interested in stopping smoking
Smoking restarted
Reason for restarting smoking
Minutes from waking to first tobacco consumption
Failed attempt to stop smoking
Waterpipe tobacco consumption
SMOK004 +
SMOK005
8B3f.
8B2B.
8B3Y.
8IEM.
137X.
137Y.
137Z.
137a.
137b.
137c.
137d.
137e.
137f.
745H.
745H0
745H1
745H2
745H3
745Hy
745Hz
Requires entry within last 12 months.
47
Code
STROKE / TIA
Code
Breakdown
G61% (Except
G617.)
G63y0
G63y1
G64%
STIA001
Cerebral infarct due to thrombosis of precerebral arteries
Cerebral infarction due to embolism of precerebral arteries
Cerebral arterial occlusion
Stroke and cerebrovascular accident unspecified
G6760
G6W..
G6X..
Gyu62
Gyu63-Gyu66
Gyu63
Gyu64
Gyu65
Gyu66
Gyu6F
TIA Codes (TIA)
STIA001
G656.-G65zz
G65..
G650.
G651.
G6510
G652.
G653.
G654.
G656.
G657.
G65y.
G65z.
G65z0
G65z1
G65zz
Transient cerebral ischaemia
Basilar artery syndrome
Vertebral artery syndrome
Vertebro-basilar artery syndrome
Subclavian steal syndrome
Carotid artery syndrome hemispheric
Multiple and bilateral precerebral artery syndromes
Vertebrobasilar insufficiency
Carotid territory transient ischaemic attack
Other transient cerebral ischaemia
Transient cerebral ischaemia NOS
Impending cerebral ischaemia
Intermittent cerebral ischaemia
Transient cerebral ischaemia NOS
[X]Other transient cerebral ischaemic attacks and related syndromes
[V]Personal history of transient ischaemic attack
9h2..
9h21.
9h22.
Exception reporting: stroke quality indicators
Excepted from stroke quality indicators: Patient unsuitable
Excepted from stroke quality indicators: Informed dissent
Fyu55
ZV12D
Stroke Exception Codes (STREXC)
all except STIA001 9h2%
Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
[X]Other intracerebral haemorrhage
[X]Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
[X]Other cerebral infarction
[X]Occlusion and stenosis of other precerebral arteries
[X]Occlusion and stenosis of other cerebral arteries
[X]Intracerebral haemorrhage in hemisphere, unspecified
If known, Strokes should be coded as Ischaemic or Haemorrhagic rather than unspecified.
[X]Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
Gyu6G
G65..-G654
Comments v26
Intracerebral haemorrhage
G66% (excluding
G669.)
Stroke Disease Codes (STRT)
To Index
Term
48
Code
STROKE / TIA cont.
Code
Breakdown
G63y0 - G63y1
Non-haemorrhagic Stroke (OSTR)
G63y0
G63y1
G64%
G665.
G666.
G6760
G6W..
STIA005, STIA007
G6X..
Gyu63 - Gyu66
Gyu63
Gyu64
Gyu65
Gyu66
To Index
Term
[X]Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
Gyu6G
567..
5671.
5672.
5673.
569..
5691.
5692.
5693.
5675.
567C.
5694.
569F.
569K0
5C00.
5C12.
8HQ3.
8HQ4.
8HBJ.
8HTQ.
Computerised axial tomography
CAT scan requested
CAT scan normal
CAT scan abnormal
Nuclear magnetic resonance
Nuclear magn.reson.requested
Nuclear magn reson normal
Nuclear magn.reson. abnormal
CAT scan - brain
CAT scan brain - abnormal
Magnetic resonance imaging of brain abnormal
Magnetic resonance imaging of brain normal
Magnetic resonance imaging of brain
CT scan brain - normal
Computerised tomography brain scan abnormal
Refer for NMR scanning
Refer for CAT scanning
Stroke / transient ischaemic attack referral
Referral to stroke clinic
STIA002(S)
5695.
56F0.
Magnetic resonance imaging scan declined
CT scan brain declined
STIA003(S)
246%(Except 2460.,
2468., 246H., 246I.,
246K., 246L.,
246M., 246h., 246i.,
246j., 246k.)
O/E - blood pressure reading
BP Recording Exception Codes (BPEX)
STIA003(S)
8I3Y.
Blood pressure procedure refused
Maximal BP therapy (HTMAX)
STIA003(S)
8BL0.
Patient on maximal tolerated antihypertensive therapy
567..-5673.
569..-5693.
MRI / CT Scan codes (SCAN)
STIA002(S)
MRI / CT Declined (SCEXC)
BP Recording Codes (BP)
44OE.
44PH.
44PJ.
44PK.
Plasma total cholesterol level
Serum cholesterol
Serum cholesterol normal
Serum cholesterol borderline
Serum cholesterol raised
Serum cholesterol very high
Total cholesterol measurement
Serum total cholesterol level
Serum fasting total cholesterol
44OE.
44P..
44PH.
44PJ.
Plasma total cholesterol level
Serum cholesterol
Total cholesterol measurement
Serum total cholesterol level
44P.. - 44P4.
Total Cholesterol Codes (CHOL)
Cholesterol code with a value (CHOL2)
STIA004
STIA005
Comments v26
Cerebral infarct due to thrombosis of precerebral arteries
Cerebral infarction due to embolism of precerebral arteries
Cerebral arterial occlusion
Pure motor lacunar syndrome
Pure sensory lacunar syndrome
Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
[X]Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
[X]Other cerebral infarction
[X]Occlusion and stenosis of other precerebral arteries
[X]Occlusion and stenosis of other cerebral arteries
44P..
44P1.
44P2.
44P3.
44P4.
Blood Pressure values should also be recorded for the Contract and your software system will have a system
to deal with Read coding of Values.
Cholesterol values should also be recorded for the Contract and your software system will have a system to
deal with Read coding of Values.
For patients with a non-haemorrhagic stroke or TIA (target Chol<=5)
49
44PK.
662a.
Serum fasting total cholesterol
Pre-treatment serum cholesterol level
50
Code
STROKE / TIA cont.
Code
Breakdown
To Index
Term
U60CA
TJC24
TJC25
[X]Statin causing adverse effect in therapeutic use
Adverse reaction to simvastatin
Adverse reaction to pravastatin
8BL1.
Patient on maximal tolerated lipid lowering therapy
8I3C.
8I27.
8I63.
8I76.
Statin declined
Statins contraindicated
Statin not indicated
Statin not tolerated
STIA007(S)
14LK.
ZV148
U6051
TJ53.
H/O: aspirin allergy
[V]Personal history of aspirin allergy
[X]Salicylates causing adverse effects in therapeutic use
Adverse reaction to salicylates
Salicylate contra-indications:expiring
(TXSAL)
STIA007(S)
8I24.
8I38.
8I66.
8I70.
Aspirin prophylaxis contra-indicated
Aspirin prophylaxis refused
Aspirin not indicated
Aspirin not tolerated
Warfarin contraindications: persistent
(XWAR)
STIA007(S)
Exception from serum cholesterol target persisting (CHEXC)
STIA005
Exception from serum cholesterol target expiring (TCHEXC)
STIA005
Salicylate contra-indications:persistent
(XSAL)
14LP.
U6042
ZV14A
H/O: warfarin allergy
Adverse reaction to anticoagulants
Adverse reaction to warfarin sodium
Adverse reaction to nicoumalone
Adverse reaction to phenindione
Adverse reaction to anticoagulants NOS
[X]Anticoagulants causing adverse effects in therapeutic use
[V]Personal history of warfarin allergy
Warfarin contraindicated
Warfarin declined
Warfarin not indicated
Warfarin not tolerated
Anticoagulation contraindicated
Anticoagulation declined
Anticoagulation not indicated
Anticoagulation not tolerated
Dabigatran contraindicated
Dabigatran declined
Dabigatran not indicated
Dabigatran not tolerated
TJ42% (except
TJ420)
TJ42.
TJ421
TJ422
TJ423
TJ42z
Warfarin contraindications: expiring
TXWAR)
STIA007(S)
8I25.
8I3E.
8I65.
8I71.
8I2R.
8I3d.
8I6N.
8I7A.
8I2o.
8IES.
8I611
8I7R.
Clopidrogel contraindications:persistent
(XCLO)
STIA007(S)
14LQ.
U6048
ZV14B
H/O: clopidogrel allergy
[X]Clopidogrel causing adverse effects in therapeutic use
[V]Personal history of clopidogrel allergy
Clopidrogel contraindications:expiring
(TXCLO)
STIA007(S)
8I2K.
8I3R.
8I6B.
8I72.
Clopidogrel contraindicated
Clopidogrel declined
Clopidogrel not indicated
Clopidogrel not tolerated
Dipyridamole CI persisting (XDIPY)
STIA007(S)
14LX.
TJC44
H/O: dipyridamole allergy
Adverse reaction to dipyridamole
[X]Coronary vasodilators causing adverse effects in therapeutic use, not elsewhere
classified
U60C3
Dipyridamole CI expiring (TXDIPY)
STIA007(S)
8I2b.
8I3n.
8I6a.
8I7J.
Dipyridamole contraindicated
Dipyridamole declined
Dipyridamole not indicated
Dipyridamole not tolerated
OTC salicylate codes (OSAL)
STIA007(S)
67I8.
8B63.
8B3T.
Advice about taking aspirin
Salicylate prophylaxis
Over the counter aspirin therapy
Comments v26
If exception coding, patients require an exception code for Dypyridamole, Aspirin, Warfarin and
Clopidogrel to be excluded.
51
Code
Salicylate prescriptions (SAL)
STROKE / TIA cont.
Code
Breakdown
To Index
Term
Comments v26
STIA007(S)
Clopidogrel prescriptions and code (CLO)
STIA007(S)
Dipyridamole prescriptions (DIPY)
STIA007(S)
8B6P.
Clopidogrel prophylaxis
Warfarin Prescriptions and Code (WAR)
STIA007(S)
8B2K.
Anticoagulant prescribed by third party
Flu vaccine contraindications: persisting
(XFLU)
STIA006(S)
14LJ.
U60K4
ZV14F
H/O: influenza vaccine allergy
[X]Influenza vaccine causing adverse effects in therapeutic use
[V]Personal history of influenza vaccine allergy
Flu vaccine contraindications: expiring
(TXFLU)
STIA006(S)
8I2F0
8I6D0
68NE.
68NE0
9OX51
Seasonal influenza vaccination contraindicated
Seasonal influenza vaccination not indicated
No consent - influenza imm.
No consent for seasonal influenza vaccination
Seasonal influenza vaccination declined
STIA006(S)
65ED.
65E20
65ED0
Seasonal influenza vaccination
Flu vaccine prescriptions and codes (FLU)
For patients with a non-haemorrhagic stroke or TIA .Prescribed in last 12 months
Seasonal influenza vaccination given by other healthcare provider
Seasonal influenza vaccination given by pharmacist
Prescribed in the previous 1st September to 31st March.
52