Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and other interested parties for information only.
Summary: New category: Endovascular insertion of stent graft for iliac artery aneurysm
Why is the request for change required?: Increasingly clinicians are using the term EVAR to include endovascular insertion of stent graft for iliac aneurysms where the procedure is essentially the same/similar to that for an AAA. But the aneurysm is in the iliac and not the abdominal aorta. This is causing particular problems with the Nationally reported clinical AAA database as this includes all EVARs. There is currently no available code to specifically describe the procedure.
Intervention: Change in clinical practice: Isolated common iliac artery aneurysm is a rare condition that is treated aggressively because of its high risk of rupture. Endovascular AAA repair has been extended to the clinical management of the iliac artery aneurysm. Stent grafts have been used successfully to exclude iliac artery aneurysms.
Please fully describe Intervention: Anatomy: Iliac artery Action performed: Insertion Extent: Priority: Emergency, Urgent and Routine Revision status: Primary or possibly revision Approach: Endovascular Pathology: Iliac artery aneurysm
Other actions performed as part of intervention: Image control in addition embolisation may be performed.
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes: Now routinely performed.
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatients
Based on classification/data collection problem?: The clinical practice has moved on
Summary: New code: Graft to external nose
Why is the request for change required?: Graft and or flap repairs are now commonly done in conjunction with excision or destruction of lesions of the nose (BCC/SCC). Currently the specific graft or flap code has to be used as a subsidiary code with E09.8 other specified operations on external nose. Data retrieval is more difficult because of the need to look at combination of codes and audit and feedback suggest that not all coders are attaching the S code to E09.8. It would be helpful to have a code to cover reconstruction of external nose as per C14 reconstruction of eyelid. E09.7 is not currently used so this could be reconstruction of external nose HFQ.
Intervention: The method of reconstruction is covered by the codes already available in chapter S.
Please fully describe Intervention: Anatomy: External nose Action performed: reconstruction (using flap or graft) Extent: Priority: Routine Revision status: Primary or revision Approach: N/A Pathology: Lesion
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes - a very commonly undertaken procedure
Does it require understanding of a definition to ensure correct usage?: No:
Applicable to specific settings?: Inpatient or daycase
Based on classification/data collection problem?: Really it is a problem around the ability to accurately extract and analyse data (particularly because of inconsistency in code allocation and the fact that patients often have multiple lesion dealt with at the same admission.
Summary: New codes: Attention to gastric band port, attention to gastric band connecting tube, resiting of gastric band port, replacement of gastric band port
Why is the request for change required?: No code exists in OPCS for attention to or maintenance for the port of a gastric band as opposed to the band itself. Sometimes the port becomes blocked and it is not the gastric band that we are maintaining but the port itself. Problems with the port and/or the tube connecting the port and band - The port can flip over so that the membrane can no longer be accessed with a needle from the outside (this often goes hand in hand with a tube kink, and may require repositioning as a minor surgical procedure under local anaesthesia); the port may get disconnected from the tube or the tube may be perforated in the course of a port access attempt (both would result in loss of fill fluid and restriction, and likewise require an intervention/operation). Sometimes the port becomes dislodged or infected which requires the port to be sited and replaced. There is no way of showing these procedures. There is a huge risk that coders may end up coding these as maintenance of the gastric band which is an entirely different scenario.
Intervention: These procedures cannot currently be coded using OPCS.
Please fully describe Intervention: Anatomy: Subcutaneous tissue Action performed: Attention to , maintenance, replacement, renewal, resiting. Priority: Urgent or Routine Revision status: As all of these would be associated with a complication of some sort they are not primary in the clinical sense Approach: Open
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes: All hospitals providing a bariatric service
Does it require understanding of a definition to ensure correct usage?: Coder needs to understand the difference between the port, the connecting tube and the gastric band itself
Applicable to specific settings?: Inpatient, daycase and possibly outpatients
Based on classification/data collection problem?: Yes: There is currently no ability to capture these procedures. It also creates a dilemma as to whether the coder should use an other specified category somewhere in chapter G or to try and find something in chapter S.
Summary: The request is for a code for subcutaneous implantation of a defibrillator (ICD).
Why is the request for change required?: The code is required because the only available category for implantation of cardioverter defibrillator in OPCS is K59 which specifies that the device is introduced through the vein.
Intervention: The subcutaneous implantable defibrillator uses a lead which implanted just under the skin (along the bottom of the rib cage and breast bone). Because the lead is placed under the skin rather than through a vein into the heart, the clinician can implant the device without accessing a patient’s blood vessels or heart and without the need for fluoroscopy. For an S-ICD system both the pulse generator and the electrode are implanted subcutaneously on the chest. Both components are implanted just under the skin.
Please fully describe Intervention: Anatomy: Heart Action performed: Implantation Extent: Priority: Routine Revision status: Approach: Percutaneous Pathology: Heart failure and arrhythmia and dysrhythmia, life threatening ventricular tachyarrhythmia
Other actions performed as part of intervention: None
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes - being carried out at a number of NHS Trusts including Papworth and Taunton and Somerset
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient, daycase, and outpatient
Based on classification/data collection problem?: Yes: There is currently no mechanism to record this.
Summary: Upgrade of pacemaker to a CRTD device (cardiac resynchronisation therapy device) or Upgrade from existing cardiac pacemaker system to cardioverter-defribrillator
Why is the request for change required?: We now have a patients who rather than having a removal of a pacemaker and replacement with a CRTD device, have an upgrade to a CRTD device. This usually involves placement of one extra lead and a new box. An implanted cardiac resynchronization device resynchronizes the contractions of the hearts ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently. CRT defibrillators (CRT-D) also incorporate the additional function of an implantable cardioverter-defibrillator, to quickly terminate an abnormally fast, life-threatening heart rhythm. CRT and CRT-D have become increasingly important therapeutic options for patients with moderate and severe heart failure.
Intervention: The procedure involves swapping the pacemaker box for the cardioverter device and insertion of one new lead.
Please fully describe Intervention: Anatomy: Heart Action performed: Revision Extent: Priority: Routine Revision status: Revision Approach: Endovascular Pathology: Heart failure
Other actions performed as part of intervention: Possible replacement of existing lead. Image control
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Daycase, inpatient and potentially outpatient
Based on classification/data collection problem?: Yes: there is no mechanism within the existing codes to identify this intervention
Summary: Ankle replacement: This request is for a set of codes that will allow total prosthetic replacement of ankle procedures to be coded using ankle-specific procedure codes in the same way as shoulder, elbow, hip and knee prosthetic replacements.
Why is the request for change required?: There are an estimated 29,000 people in the UK with end-stage, symptomatic osteoarthritis of the ankle. Approximately 3,000 definitive operations to treat end-stage ankle osteoarthritis take place annually in the UK. The operation data was obtained from HES data by the NHS Information Centre for Health and Social Care. It is estimated by members of the British Orthopaedic Foot and Ankle Society that the numbers may be as high as 10,000p.a. The National Joint Registry currently captures 560 cases of Total Ankle Replacement (TAR)annually. An informal estimate suggests that there are likely to be between 1,200 and 2,000 cases of TAR annually. An attempt by the National Joint Registry (NJR) to find TAR incidence using Hospital Episode Statistics (HES) data was compromised by the lack of specific procedure codes for TAR. The first attempt, using the expected code combinations for prosthetic replacement of other joint with secondary site codes for ankle, resulted in finding only 360 cases of TAR. Attempts to improve on these findings involved creating complicated formulae to account for a wide variety of code combinations and sequencing possibilities. The NJR currently maps total hip replacement and total knee replacement procedures submitted to NJR back to HES using specific procedure codes as part of their data validation processes. Without specific primary procedure codes for TAR they have no reliable way of using HES data to find TAR cases that have not been submitted to NJR. Since 2010 TAR data has been recorded on National Joint Registry, mandated by the Department of Health. Compliance is low and there is no way for the NJR to chase and improve this compliance in the absence of a specific set of codes for TAR. BUPA and other PMI insurers have had a code for TAR for the last 5 years. Professor Sir Bruce Keogh is extremely keen to ensure that the NJR covers all total joint replacements and has indicated support for the need for a specific TAR code.
Intervention: A Total Ankle Replacement is made up of three components: two metal (tibial component and talar component) separated by a plastic mobile component. TARs are almost always uncemented (there are only 8 instances of TAR involving cement on the NJR records. Cement can be used on either component but probably should not be used for Primary TAR. Cement use on one or both components is more likely for revisional TAR. TAR may be performed as a revision of previous metalwork (for trauma or previous osteotomy). Failed TAR can be revised but are unlikely to be revised more than once. Failed TAR may be converted to an ankle fusion. TARs are unlikely to be carried out as an emergency or to treat acute trauma.
Please fully describe Intervention: Anatomy: ankle joint - distal tibia, top of talus, fibula that articulates with the bottom of the tibia. Action: replacement. Extent: N/A Priority: Routine Revision status: primary or revision Approach: Open Pathology: likely osteoarthritis
Other actions performed as part of intervention: There may be tendon procedures, removal of osteophytes etc involved.
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes - see attached
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: The classification allows the recording of TAR using multiple codes but that makes data retrieval complicated particularly because tendon procedures etc may be performed at the same time leading to the site code not being immediately sequenced after the unspecified joint replacement code.
Summary: Complex (challenging) abdominal wall defect repair (including complex ventral/incisional hernia repair). We would be happy to engage in further discussion about potential changes that could be made to enable these patients to be identified as there are a number of potential solutions. E.g. it may be that the most appropriate way to identify these patients and to ensure that appropriate reimbursement is made is to create a subsidiary code for high cost implant, it may be appropriate to create a code for biological mesh in a similar way to high cost drugs, it may be that existing procedures are considered adequate to cover these complex procedures and that it would be possible to create an algorithm to allow for appropriate reimbursement by taking into account specific diagnosis codes. Another option would be to create a specific subsidiary code(s) to allow for the identification of the size of the defect that requires repair either by diameter or cm squared or combination of solution thereof. It might also be the case that a new category for repair of challenging abdomen is created because there will be a limited number of centres undertaking this work and specialist funding is available for these patients.
Why is the request for change required?: We need to develop the ability to identify these very expensive and clinically complex patients. The cost is not only the huge cost of the bio matrix involved but that these patients have significant comorbidity, extensive hospital stay and require complex care (i.e. high level nursing, parenteral nutrition, psychosocial input and rehabilitation).
Intervention: The goal of the surgeon in managing a complex (challenging) abdominal wall defect is to restore the structural and functional continuity of the muscle-fascia system and to provide stable and durable wound coverage. There has been a significant increase in the number of patients who present with challenging abdomen. It is expected that the numbers of patients will increase by around 1-2% per year primarily do to the growing age of the population, increasing rates of obesity and diabetes, improved survival from intra-abdominal cancers, and improvements in care of the critically injured patient, yielding greater survival of patients following abdominal catastrophe. These factors have produced a large subset of clinically complicated patients with structurally complex abdominal wall defects/herniation’s.
Please fully describe Intervention: Anatomy: Abdomen wall and intestine Action performed: Complex reconstruction Extent: Radical Priority: Routine Revision status: Likely revisional Approach: Open Pathology: Herniation, fistulisation and need for TPN
Other actions performed as part of intervention: The major repair/reconstruction can include component separation, removal of infected mesh and debridement of infected non-viable abdominal wall tissue and additional intestinal procedures will be performed for which we have existing codes.
Request Related to a unique situation?: Yes: This is about differentiating for severity and cost where the patients at the challenging end of the spectrum clinically bear no resemblance to those at the simple end.
Evidence to show part of usual NHS activity: Yes: A number of hospitals carry out this activity. We know there are in excess of 500 procedures a year and possibly up to 2000.
Does it require understanding of a definition to ensure correct usage?: Yes: It requires an understanding of a number of concepts including the term challenging abdomen, defect size, component separation, and the hernia grading system.
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: Yes: We try to describe complexity by using lots of additional codes but this doesn’t work in this instance.
Summary: In order to clarify the use of the term insert of natural material in relation to hernia repairs an it would be helpful to have either an inclusion or bracketed text at the .1s in the hernia repair categories to indicate that this is the appropriate place to include biological insert.
Why is the request for change required?: It is most likely that a biological insert (particularly a biological mesh) will be used for more challenging/complex cases. Patients having a biological insert should already be coded to the .1 categories and should therefore be identifiable. However, clarification would be extremely helpful because coders seeing the term biological mesh may only focus on the word mesh and therefore misclassify to .2 insert of prosthetic material. Use of biological inserts is also significantly more expensive than other forms of repair. (linen insert is now an obsolete procedure which means that use of a biological mesh should account for the majority of procedures classified to .1).
Intervention: N/A
Please fully describe Intervention: N/A
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes. 100s of this procedure are performed every year. Total number of hernia repairs using natural material (2011-2012 HES data), do not reflect the level of activity that is known to be taking place. (This may be indicative of coder confusion).
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: Yes.
Summary: OPCS codes are required for resiting of stoma and resiting with reinforcement of stoma.
Why is the request for change required?: Currently to code a resiting of a stoma it is necessary to use separate codes for closure of an existing stoma site (as opposed to closure of the ostomy) (usually with a repair of a parastomal hernia) and the codes for the creation of a new stoma site. This means that it is difficult to retrieve information about the frequency of these major procedures. There is also a risk that the figures for standard stoma creations and closure can be distorted. Because of the significant complication rates for patients with stomas, there has been an increased interest in analysing the data, establishing best practice and creating outcome measures. It is extremely difficult to progress with this in a situation where the relevant patient cohort cannot reliably be identified.