- Effective use of Read Codes -

- Effective use of Read Codes - Effective use of Read Codes --

PRIMISPRIMIS

NHS CumbriaNHS Cumbria

Read Code TrainingRead Code Training

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The aims of this session…The aims of this session…

Understand the Read Code hierarchyUnderstand the Read Code hierarchy

To build confidence in using read codesTo build confidence in using read codes

Find most appropriate read codeFind most appropriate read code

Know which codes to use for which purpose Know which codes to use for which purpose

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Why Read Code?Why Read Code? Accurate data entry helps improve patient care indirectly by ensuring that clinicians are always basing their judgements on the best possible information available at the timeAccurate data entry helps improve patient care indirectly by ensuring that clinicians are always basing their judgements on the best possible information available at the time

Accurate data entry will enable the transition to Paperlight working and a complete electronic patient recordAccurate data entry will enable the transition to Paperlight working and a complete electronic patient record

Facilitates future audit and reporting requirementsFacilitates future audit and reporting requirements

QOFQOF

Allergies / Adverse Reactions

Diagnoses

Family History

Past Symptoms

Relevant Tests & Investigations

Immunisations

Monitoring

Operations

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What are Read Codes?What are Read Codes?

Set of clinical codes designed for Primary Set of clinical codes designed for Primary Care to record the every day care of a Care to record the every day care of a PatientPatient

Developed by Dr James Read (GP, Developed by Dr James Read (GP, Loughborough)Loughborough)

Recognised standard for General PracticeRecognised standard for General Practice

Hierarchical structureHierarchical structure

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Key aspects to understandingKey aspects to understandingRead CodesRead Codes

Sorted into categories and chaptersSorted into categories and chapters

Hierarchical structureHierarchical structure

Combination of letters and numbersCombination of letters and numbers

CaSe-SeNsItIveCaSe-SeNsItIve

Maximum of 5 charactersMaximum of 5 characters

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Read Code ChaptersRead Code Chapters

Three categories:Three categories: DiagnosesDiagnoses Processes of CareProcesses of Care MedicationMedication

These categories are further divided These categories are further divided into sub-chaptersinto sub-chapters

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Read Code Chapters cont’dRead Code Chapters cont’d

DiagnosesDiagnoses Codes all begin with a capital letterCodes all begin with a capital letter e.g. e.g. HH33 (Asthma), 33 (Asthma), CC10E (Type 1 diabetes mellitus)10E (Type 1 diabetes mellitus)

Processes of CareProcesses of Care Codes all begin with a numberCodes all begin with a number Used to record history, symptoms, examinations, tests, Used to record history, symptoms, examinations, tests,

screening, operations and patient administration etcscreening, operations and patient administration etc e.g. e.g. 444P (Serum cholesterol), 4P (Serum cholesterol), 665E (Influenza vaccination)5E (Influenza vaccination)

MedicationMedication Codes all begin with a small case letterCodes all begin with a small case letter Automatically entered into the patient record when any Automatically entered into the patient record when any

treatment is prescribedtreatment is prescribed e.g. e.g. bbu25 (Aspirin 75mg tablets)u25 (Aspirin 75mg tablets)

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Processes of CareProcesses of Care DiagnosesDiagnoses MedicationMedication

00 OccupationsOccupations AA Infectious /parasitic diseaseInfectious /parasitic disease ‘‘aa Gastro-intestinalGastro-intestinal

BB NeoplasmsNeoplasms ..bb CardiovascularCardiovascular

11 History / SymptomsHistory / Symptoms CC Endocrine, Nutritional etcEndocrine, Nutritional etc ..cc RespiratoryRespiratory

DD Diseases of the bloodDiseases of the blood ..dd Central Nervous SystemCentral Nervous System

22 Examinations & SignsExaminations & Signs EE Mental disordersMental disorders ..ee Drugs used in InfectionsDrugs used in Infections

FF Nervous SystemNervous System ..ff Endocrine drugsEndocrine drugs

33 Diagnostic proceduresDiagnostic procedures GG Circulatory SystemCirculatory System ..gg Obs, gynae, UTIObs, gynae, UTI

HH Respiratory SystemRespiratory System ..hh Chemotherapy etcChemotherapy etc

44 Laboratory proceduresLaboratory procedures JJ Digestive SystemDigestive System iiii Haemotology / dieteticHaemotology / dietetic

KK Genitourinary SystemGenitourinary System ..jj MusculoskeletalMusculoskeletal

55 Radiology / Physics in MedicineRadiology / Physics in Medicine LL Compl. Of child birth etcCompl. Of child birth etc ..kk EyeEye

MM Skin / sub-cutaneous tissueSkin / sub-cutaneous tissue ..ll ENTENT

66 Preventive proceduresPreventive procedures NN Musculoskeletal diseasesMusculoskeletal diseases ..mm SkinSkin

PP Congenital conditionsCongenital conditions ..nn Immunology / vaccinesImmunology / vaccines

77 Operations, procedures, sitesOperations, procedures, sites QQ Perinatal conditionsPerinatal conditions ..oo AnaestheticAnaesthetic

RR Signs, ill-defined conditionsSigns, ill-defined conditions ..pp Appliances & ReagantsAppliances & Reagants

88 Other therapeutic proceduresOther therapeutic procedures SS Injury & poisoningInjury & poisoning ..qq Incontinence appliancesIncontinence appliances

TT Causes injury & poisoning Causes injury & poisoning ..ss Stoma appliancesStoma appliances

99 AdministrationAdministration UU Ext. causes morbidity / Ext. causes morbidity / mortalitymortality

..uu Contrast mediaContrast media

ZZ Unspecified conditionsUnspecified conditions ..yy Drug release administrationDrug release administration

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Read Code HierarchyRead Code Hierarchy

There are different levels of detail within each There are different levels of detail within each read code chapter (5-byte = up to 5 levels)read code chapter (5-byte = up to 5 levels)

These different levels of detail are organised These different levels of detail are organised logicallylogically by means of the Read Code Hierarchy by means of the Read Code Hierarchy

““Higher level” codes are more generalHigher level” codes are more general

““Lower level” codes are more detailed and Lower level” codes are more detailed and preciseprecise

The first digit of a Read Code says a lot about the The first digit of a Read Code says a lot about the meaning of the Read Code, and it is important to meaning of the Read Code, and it is important to be aware of this when selecting Read Codes to be aware of this when selecting Read Codes to record datarecord data

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Read Code Hierarchy cont’dRead Code Hierarchy cont’d

Example:Example:CC Endocrine, nutritional, metabolic and immunity Endocrine, nutritional, metabolic and immunity

disordersdisordersC1C1 Other endocrine gland diseasesOther endocrine gland diseasesC10C10 Diabetes mellitusDiabetes mellitusC10EC10E Type 1 diabetes mellitusType 1 diabetes mellitusC10E7C10E7 Type 1 diabetes mellitus with retinopathyType 1 diabetes mellitus with retinopathy

Could refer to these as “families” of codes – Parent and Child Could refer to these as “families” of codes – Parent and Child CodesCodes

C10 is a parent code to C10E. It is also a child code to C1C10 is a parent code to C10E. It is also a child code to C1

Each code begins the same way as the one before but Each code begins the same way as the one before but contains an extra layer of detailcontains an extra layer of detail

This pattern repeats across all chaptersThis pattern repeats across all chapters

Enables data to be entered at the required level of detailEnables data to be entered at the required level of detail

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Read Code Tree

C Endocrine, nutritional, metabolic and immunity

disorders

C1 Other endocrine gland diseases

C10 Diabetes mellitus

C10E Type 1 Diabetes mellitus

C10F Type 2 Diabetes mellitus

C10E7 Type 1 Diabetes mellitus with retinopathy

C10E0 Type 1 Diabetes mellitus

with renal complications

66 Chronic disease

monitoring

663 Respiratory disease

monitoring

6 Preventative procedures

6637 Inhaler technique observed

667 Epilepsy monitoring

66H Rheumatology

disorder monitoring

663N Asthma disturbing

sleep

663N0 Asthma causing night

wakening

663N1 Asthma disturbs sleep

weekly

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Combination of letters and Combination of letters and numbersnumbers

Read codes are Read codes are onlyonly made up of the following made up of the following characters:characters:

Letters (upper & lower case)Letters (upper & lower case)

NumbersNumbers

Users may have noticed the % sign sometimes Users may have noticed the % sign sometimes following codes in MIQUEST queries and QOF following codes in MIQUEST queries and QOF criteria. This is used for administrative criteria. This is used for administrative purposes to indicate that the rest of the purposes to indicate that the rest of the hierarchy is included. e.g. C10% means every hierarchy is included. e.g. C10% means every code beginning “C10”.code beginning “C10”.

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Case-SensitiveCase-Sensitive

Read Codes are case sensitive and entering the Read Codes are case sensitive and entering the code incorrectly can completely alter the code incorrectly can completely alter the meaning meaning

Be careful! Be careful!

Example:Example:8HTK.8HTK. Referral to stop-smoking clinicReferral to stop-smoking clinic8HTk.8HTk. Referral to diabetic eye clinicReferral to diabetic eye clinic

9H8..9H8.. On severe mental illness registerOn severe mental illness register9h8..9h8.. Exception reporting: cancer quality Exception reporting: cancer quality

indicatorsindicators

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Maximum of 5 charactersMaximum of 5 characters

Read codes can be one to five characters longRead codes can be one to five characters long

The more characters, the greater level of detail in the The more characters, the greater level of detail in the codecode

Referred to as “5-Byte” read codesReferred to as “5-Byte” read codes

Users may have noticed some read codes followed by a Users may have noticed some read codes followed by a “-0”, “-1”, or “-2” etc“-0”, “-1”, or “-2” etc

This is used to denote a Preferred or Synonymous This is used to denote a Preferred or Synonymous Term and is called the “Term Code”Term and is called the “Term Code”

It does not constitute the main body of the Read CodeIt does not constitute the main body of the Read Code

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Preferred and Synonymous TermsPreferred and Synonymous Terms

Preferred terms are the Preferred terms are the mainmain descriptions descriptions

Synonymous terms are Synonymous terms are alternatealternate descriptions descriptions of the Preferred termof the Preferred term

Example:Example:

Acute MIAcute MI G30G30 PP

Attack – HeartAttack – Heart G30-1G30-1 SS

Coronary ThrombosisCoronary Thrombosis G30-2G30-2 SS

Heart AttackHeart Attack G30-4G30-4SS

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How to select the ‘right’ Read How to select the ‘right’ Read CodeCode

Direct code entryDirect code entry Entering the code itself if it is known (e.g. C10 for Diabetes)Entering the code itself if it is known (e.g. C10 for Diabetes) Accurate and quick – if you know the code!Accurate and quick – if you know the code!

Searching by keywordSearching by keyword Entering the full term, first few letters, or abbreviation (e.g. diabetes mellitus, Entering the full term, first few letters, or abbreviation (e.g. diabetes mellitus,

diab, diab mel, dm for Diabetes), and then making a selection from the list of diab, diab mel, dm for Diabetes), and then making a selection from the list of codes the clinical system has provided based on the keyword enteredcodes the clinical system has provided based on the keyword entered

Being more specific will bring up a more concise listBeing more specific will bring up a more concise list Simplest and most common approach – user has to decide which code Simplest and most common approach – user has to decide which code

description is most accurate and which chapter the code should originate fromdescription is most accurate and which chapter the code should originate from

Browsing the Read Code hierarchyBrowsing the Read Code hierarchy Searching for codes by moving up and down the Read Code hierarchy until the Searching for codes by moving up and down the Read Code hierarchy until the

appropriate code is found. E.g. choosing a chapter from which to start and appropriate code is found. E.g. choosing a chapter from which to start and then find the appropriate read code by “drilling down” through the hierarchythen find the appropriate read code by “drilling down” through the hierarchy

More reliable - as correct chapter is chosen initially but requires some More reliable - as correct chapter is chosen initially but requires some knowledge of medical terminology to navigate read code hierarchy knowledge of medical terminology to navigate read code hierarchy

Using Templates/GuidelinesUsing Templates/Guidelines Allows quick and standard data entryAllows quick and standard data entry

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Templates/GuidelinesTemplates/Guidelines

For routine data entry, templates can be very useful to:For routine data entry, templates can be very useful to: Speed data entrySpeed data entry Ensure that all appropriate information about a patient is Ensure that all appropriate information about a patient is

obtained (especially useful in clinic environment)obtained (especially useful in clinic environment) Ensure that patient information is recorded consistently Ensure that patient information is recorded consistently

across the practiceacross the practice

However…However… No use for non-routine data entryNo use for non-routine data entry Limited to a pre-defined list of read codesLimited to a pre-defined list of read codes Any error in the template will be reproduced in all Any error in the template will be reproduced in all

subsequent uses of the templatesubsequent uses of the template

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00 OccupationsOccupations AA Infectious /parasitic diseaseInfectious /parasitic disease ‘‘aa Gastro-intestinalGastro-intestinal


11 History / SymptomsHistory / Symptoms CC Endocrine, Nutritional etcEndocrine, Nutritional etc ..cc RespiratoryRespiratory








55 Radiology / Physics in Radiology / Physics in MedicineMedicine

LL Compl. Of child birth etcCompl. Of child birth etc ..kk EyeEye

MM Skin / sub-cutaneous tissueSkin / sub-cutaneous tissue ..ll ENTENT

66 Preventive proceduresPreventive procedures NN Musculoskeletal diseasesMusculoskeletal diseases ..mm SkinSkin


77 Operations, procedures, sitesOperations, procedures, sites QQ Perinatal conditionsPerinatal conditions ..oo AnaestheticAnaesthetic

RR Signs, ill-defined conditionsSigns, ill-defined conditions ..pp Appliances & ReagantsAppliances & Reagants

88 Other therapeutic proceduresOther therapeutic procedures SS Injury & poisoningInjury & poisoning ..qq Incontinence appliancesIncontinence appliances

TT Causes injury & poisoning Causes injury & poisoning ..ss Stoma appliancesStoma appliances



ZZ Unspecified conditionsUnspecified conditions ..yy Drug release administrationDrug release administration

Think Chapters, think Context!

All information entered into the Patient Record is done so within a Context whether it be recording a diagnosis, screening or family history. Chapters allow users to keep this sense of context when Read coding.

For Example, take the word Asthma. This appears in more than one read code chapter depending on the context from which the information originates.

Asthma (Diagnosis) – H33

Suspected asthma – 1J70

Asthma monitoring – 663

Asthma leaflet given – 8CE2

Seen in Asthma Clinic – 9N1d

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Useful Read Code AbbreviationsUseful Read Code Abbreviations

O/EO/EC/OC/OH/OH/OFHFHNOSNOSOSOSNFQNFQHFQHFQNECNECNOCNOC[SO][SO][D][D][M][M][V][V][X][X]

on examinationon examinationcomplaining ofcomplaining ofhistory ofhistory offamily history offamily history ofnot otherwise specifiednot otherwise specifiedotherwise specifiedotherwise specifiednot further qualifiednot further qualifiedhowever further qualifiedhowever further qualifiednot elsewhere classifiednot elsewhere classifiednot otherwise classifiablenot otherwise classifiablesite ofsite ofworking diagnosisworking diagnosismorphology of neoplasmsmorphology of neoplasms(from ICD)(from ICD)(from ICD-10)(from ICD-10)

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Common ErrorsCommon Errors

Without an understanding of Read Codes it Without an understanding of Read Codes it is very easy to enter patient information is very easy to enter patient information incorrectly onto the Clinical Systemincorrectly onto the Clinical System

Observe the following examples of Observe the following examples of common read coding errors and consider common read coding errors and consider what measures have been taken in your what measures have been taken in your practice to prevent them from occurringpractice to prevent them from occurring

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Common Errors 1Common Errors 1


00 OccupationsOccupations AA Infectious /parasitic Infectious /parasitic diseasedisease

‘‘aa Gastro-intestinalGastro-intestinal


11 History / SymptomsHistory / Symptoms CC Endocrine, Nutritional Endocrine, Nutritional etcetc

..cc RespiratoryRespiratory










MM Skin / sub-cutaneous Skin / sub-cutaneous tissuetissue

..ll ENTENT

66 Preventive proceduresPreventive procedures NN Musculoskeletal Musculoskeletal diseasesdiseases

..mm SkinSkin


77 Operations, procedures, Operations, procedures, sitessites

QQ Perinatal conditionsPerinatal conditions ..oo AnaestheticAnaesthetic

RR Signs, ill-defined Signs, ill-defined conditionsconditions

..pp Appliances & ReagantsAppliances & Reagants

88 Other therapeutic Other therapeutic proceduresprocedures

SS Injury & poisoningInjury & poisoning ..qq Incontinence appliancesIncontinence appliances

TT Causes injury & Causes injury & poisoning poisoning

..ss Stoma appliancesStoma appliances



ZZ Unspecified conditionsUnspecified conditions ..yy Drug release Drug release administrationadministration

One of the most common errors with Read Coding involves selecting a read code from an inappropriate chapter

Example: Recording a Diagnosis of Diabetes Mellitus as a History of Diabetes

1434 – H/O Diabetes Mellitus

C10 – Diabetes Mellitus

The consequences of making this sort of mistake are serious.

1. The record will be inaccurate. The patient will not be coded as a diagnosed diabetic.

2. The patient will not be counted on the Diabetic Register and may not be monitored appropriately.

3. Even if the Practice do monitor the patient appropriately, the work will not be rewarded in the QOF.

4. DO NOT USE H/O Codes to record a current diagnosis!

2222

















..ll ENTENT


..mm SkinSkin













This issue of confusing Read Code chapters can be applied to entering a morbidity instead of an immunisation or test

A37 – Tetanus

Example: Recording a Diagnosis of Tetanus instead of a Vaccination for Tetanus

656 – Tetanus Vaccination


2323

















..ll ENTENT


..mm SkinSkin













Example: recording neonatal problems to Mother’s record or recording birth details in the baby’s record

L395 – Forceps delivery

(For the Mother)

14Y1 – Born by Forceps delivery

(For the Child)


2424

















..ll ENTENT


..mm SkinSkin













Example: recording male problems/codes on female records (and vice versa)

7C110 – Bilateral vasectomy for contraception

(For the Man) 6124 – Partner had vasectomy

61G – Contraception: vasectomy

(For the Woman)


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Common Errors cont’dCommon Errors cont’d Using a diagnosis code to record that a patient does Using a diagnosis code to record that a patient does

notnot have a particular condition by typing “not present” have a particular condition by typing “not present” or something to that effect in the text boxor something to that effect in the text box

Example:Example:

C10 Diabetes Mellitus Not present

Using the text box to record data that should be separately read codedUsing the text box to record data that should be separately read coded

Example:Example:

instead of:instead of:

137R Current smoker Advised patient to stop smoking

137R Current smoker

8CAL Smoking cessation advice

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Common Errors cont’dCommon Errors cont’d

These examples are bad practice because:These examples are bad practice because:

codes have been used in the wrong context and imply a codes have been used in the wrong context and imply a different meaningdifferent meaning

as far as the clinical system is concerned, whatever is as far as the clinical system is concerned, whatever is typed in free text does not affect the application of the typed in free text does not affect the application of the read coderead code

information recorded in free text cannot be searched on information recorded in free text cannot be searched on later for audit and reporting requirements because it is later for audit and reporting requirements because it is not read codednot read coded

any values recorded in free text do not filter into the any values recorded in free text do not filter into the appropriate location on the system for reference purposes appropriate location on the system for reference purposes (e.g. Blood Pressure, eGFR) and so record is incomplete (e.g. Blood Pressure, eGFR) and so record is incomplete

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General Guidance on Read CodesGeneral Guidance on Read Codes

Understand the Read Code Structure and context of codes when Understand the Read Code Structure and context of codes when using themusing them

Use Read Code guidance where availableUse Read Code guidance where available

Templates/Guidelines facilitate multiple data entries in a standard Templates/Guidelines facilitate multiple data entries in a standard and quick wayand quick way

Use diagnosis codes rather than H/O codes for current diagnosesUse diagnosis codes rather than H/O codes for current diagnoses

Don’t use a diagnosis code with free text to record a negative Don’t use a diagnosis code with free text to record a negative entryentry

Once a diagnosis code has been recorded, use a procedure code Once a diagnosis code has been recorded, use a procedure code rather than the diagnosis code for future monitoringrather than the diagnosis code for future monitoring

Be as specific as you like when recording Read Codes, the Be as specific as you like when recording Read Codes, the structure allows thisstructure allows this

Try not to use in-house created codes or synonymous termsTry not to use in-house created codes or synonymous terms

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Recommendations for PracticesRecommendations for Practices

Staff TrainingStaff Training Know your Read CodesKnow your Read Codes Keep it simple & Keep it simple &

relevantrelevant Be consistentBe consistent Procedures and Procedures and

protocolsprotocols Clinicians to record Clinicians to record

their own consultationstheir own consultations

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The aims of this session…The aims of this session…

Understand the Read Code hierarchyUnderstand the Read Code hierarchy

To build confidence in using read codesTo build confidence in using read codes

Find most appropriate read codeFind most appropriate read code

Know which codes to use for which purpose Know which codes to use for which purpose

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Thank you for listeningThank you for listening

Any questions? Any questions?

- Effective use of Read Codes -

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