Critical care

Reimbursement for critical care activity is negotiated locally. This is because there is currently no national tariff for critical care. However, SUS supports local contract negotiation by:

• applying Payment by Results (PbR) processing rules to submitted critical care activity

• calculating total critical care days
• deriving and assigning HRGs
• providing a dedicated PbR critical care extract

Where critical care activity is present in submitted patient data, the Spell Length of Stay, used in calculations, is adjusted to account for it. This adjustment enables correct derivation of HRGs and ensures that critical care activity is reimbursed outside of PbR and the National Tariff Payment System.

SUS+ has raised the threshold for the number of critical care periods that can ‘overlap’ a single day from two to three. The effect is that slightly fewer spells are treated as having critical care errors in SUS+.

Rather than ignore all critical care processing, legacy SUS only ignored overlapping episodes. SUS+ ignores all critical care and more accurately reflects the processing requirement.

These two changes in processing can impact on prices for spells with critical care problems. Overall spell length of stay can be adjusted down by critical care which can lead to an impact on excess bed-day calculations and HRGs resulting in higher average national pricing in SUS+. For more information, please refer to the SUS+ pricing differences.

A minor change has also been made in the handling of genuine duplicate critical care periods. Where duplicate critical care periods are present on the critical care record, the critical care extract will only output a single critical care period in SUS+. In legacy SUS, the duplicate critical care critical care periods were output.

The critical care extract provides a stable, defined snapshot of data containing the original submitted activity, along with additional derived and calculated data items, adjustments and grouping information.

A single scheduled extract, containing all types of critical care activity, is produced at reconciliation and post-reconciliation points to provide a transparent view of:

• episode-level allocation of critical care days and HRGs
• assigned PbR critical care indicators (to describe validation failure)
• spell and episode IDs (to enable linkage with parent activity data)

When accessing the critical care extract via the portal, it should be remembered that it still uses the same snapshot as in the preceding reconciliation point. It does not provide a ‘current view’ of submitted critical care activity.

The PbR critical care extract reports all types of critical care activity:

• ACC (Adult Critical Care)
• NCC (Neonatal Critical Care)
• PCC (Paediatric Critical Care)

ACC activity is recorded and submitted at critical care period level (consisting of one or more days) whereas NCC and PCC activity is recorded and submitted at daily record level.

Critical Care Period (CCP)

In order to allow period and daily record-level information to be displayed in a single extract, a system-generated Critical Care Period (CCP) row is produced for NCC and PCC only. This system generated CCP row contains aggregated daily record data and derived PbR related data items.

CCP records are based on critical care start and critical care discharge dates from the CDS record for the Critical Care Period. The CCP row is directly followed by its associated daily records.

The example shows that in the extract the component PCC records appear directly under the aggregated CCP. Therefore values such as ‘Generated record ID’ are the same for all associated rows.

ACC (Adult Critical Care)

An ACC period which lies entirely within a single episode’s boundaries is represented as a single row against the Episode ID. Where an ACC period contains days allocated to two or more episodes (meaning it spans episode boundary), the period is recorded separately for each episode.

NCC (Neonatal Critical Care) and PCC (Paediatric Critical Care)

An NCC or PCC period has a single CCP level row which provides a summary line containing aggregated critical care information of the submitted daily records and derived PbR data items.

Derived PbR data items

In addition to the submitted activity data, derived PbR related data items, which help support local negotiation and planning, are included in the PbR critical care extract.

CC patient type

CC patient type refers to the age group that the patient belongs to. A value of ADU, CHI or OTH is assigned accordingly. Derivation logic uses the first episode in the spell (lowest episode number).

CC Days for LoS (Length of Stay)

CC days for LoS (ACC and CCP level) is a count of distinct critical care days allocated to each episode from each critical care period. It is used for spell length of stay adjustment.

This value is used to adjust the spell LoS to ensure the correct HRG and tariff are assigned to that part of the spell (if any) that was delivered outside critical care.

CC days for tariff

CC days for tariff is a count of distinct calendar days spent in critical care.

For ACC, HRGs are generated at period rather than daily level, and so a per diem multiplier is applied to produce the equivalent of a daily HRG. This is the per diem multiplier value for ACC HRGs.

This value can also include ‘error HRG’ (UZ01Z) and therefore should be considered as a count of all HRGs, not just valid HRGs.

PbR CC indicator

PbR critical care indicators identify why a record has failed validation. These are described in the following pbr critical care indicators section.

Excluded reason

In the context of the critical care extract, Excluded Reason indicates why the record has been excluded from critical care processing. It does not refer to PbR policy-based activity exclusions.

CC unbundled HRG

The derived critical care unbundled HRG based on critical care period data for ACC and daily activity for NCC and PCC.

Linkage to episode and spell extracts

The PbR critical care extract can be linked to the PbR APC spell and PbR APC episodes extracts using the corresponding unique record identifiers spell identifier and episode ID (which contains the SUS ‘Generated record ID’) that are output in each extract. This enables clearer analysis and reconciliation.

For more information on critical care extract data items, please refer to the extract specification.

Critical care processing

SUS processes activity identified as critical care, regardless of whether the associated activity record is excluded from national tariff. The process is as follows:

1. Data in
2. Validation of submitted data and assignment of PbR critical care indicators
3. Counting and allocation of critical care days to episodes
4. Set episode level critical care days
5. Assign unbundled HRGs
6. Produce critical care extract

In most cases, where critical care data fails validation, critical care processing stops.

However, the spell continues to be processed. Only critical care processing stops as a result of this type of validation failure and it is therefore possible for a spell length of stay to be output that has not been adjusted for critical care days.

‘First strike’ rule

Critical care validation operates on a ‘first strike’ basis. After failing one check, no further checks are performed for that record, irrespective of whether further validation failures may exist within it. Critical care processing stops at this point.

PbR critical care indicators

PbR critical care indicators (assigned during processing and output in extracts) identify why submitted data has failed critical care validation checks. This helps users to address data quality issues, identify incomplete submissions and take the necessary corrective action to enable successful resubmission. Please refer to the PbR critical care indicators section for further information.

When allocating CC days to episodes for use with PbR adjustments, only distinct CC days should be counted. So, where multiple critical care periods occur on a single day or critical care periods are overlapped by more than one day, the critical care day is only counted once, even though multiple unbundled HRGs may be derived for that day.

Examples

The following examples demonstrate data that can be received in SUS, including incorrect or incomplete data.

Unbundled HRGs are the ‘currency’ for critical care reimbursement. They are generated based on the critical care period (CCP) in Adult Critical Care (ACC), and for each recorded day in Paediatric and Neonatal Critical Care (PCC and NCC).

All critical care specific HRGs are unbundled. An unbundled HRG is assigned to each instance of critical care received.

Critical care unbundled HRGs are output, regardless of whether that activity is excluded from PbR.

Grouping logic

Critical care grouping logic works differently to Admitted Patient Care (APC) or outpatient (OP) grouping and is based primarily on data items from the corresponding critical care data set (Neonatal, Paediatric and Adult). Critical Care Activity Code is the main ‘driver’ for NCC and PCC grouping, whereas ACC is based on the number of supported organs.

For detailed information about HRG Critical Care grouping logic, please refer to the Casemix local grouper documentation and the HRG chapter summaries on the Casemix pages.

NCC and PCC daily records

NCC and PCC activity is captured at daily record-level. Grouping produces an unbundled HRG for each day recorded in the critical care period.

ACC ‘per diem’ multiplier

When grouped, a single ACC period will produce only one HRG but this is replicated in SUS for each distinct day in the ACC period when calculating numbers of days.

Overlapping in grouping

Where two critical care periods overlap by one day (critical care period 1 discharge date = critical care period 2 start date) there is clear distinction between:

• counting for PbR length of stay adjustment, and
• counting of critical care HRGs for payment

When counting and allocating critical care days for PbR length of stay adjustment, the overlapping day is only counted once.

For payment purposes the day is allocated to both critical care periods resulting in the allocation of two HRGs for the overlapping day.

PbR Final Adjusted Length of Stay is a spell-level derived data item containing the adjusted length of stay for use with PbR and grouping. Distinct counts of critical care days, as well as rehabilitation (RH) and specialist palliative care (SPC) days, are subtracted from the episode duration.

PbR Final Adjusted Length of Stay is found in the PbR APC spells extract only. It is not output in the PbR critical care extract.

Calculation

PbR Final Adjusted Length of Stay is calculated using Episode Duration and Total CC Days for each included episode.

SUM ((Episode Duration – (Total Episode Level CC Days for LOS + RH + SPC)) floor zero)

Where Episode Duration = (Episode End date - Episode Start date)

Zero floor limit

Due to the way the calculation works, a negative value can occur if an entire episode is within critical care. A ‘zero floor’ limit is therefore used to ensure that negatives cannot be calculated. In the event of a negative being returned, it is replaced with a value of zero, meaning that no adjustment is made.

PbR adjustment

Spell LoS calculation is only done for included episodes based on critical days within those episodes. In the following situations, the PbR adjustment calculation is not made.

• Critical care processing stops due to validation failure.

• Critical care is allocated to episodes whose activity is excluded from PbR.
• Critical care cannot be assigned to an episode due to missing or incomplete data.

Overlapping critical care periods

The rules used in spell length of stay adjustment for overlapping critical care periods are the same as those used in validation. Please refer to PbR CC indicator 7 for further details.

Multiple critical care periods, submitted with the same start and discharge dates, are considered a single critical care period for the purposes of LoS adjustment. Spell LoS is therefore adjusted by the number of distinct days on the latest critical care period. However, if a record fails overlapping critical care validation, (for example 1 day is covered by 3 distinct critical care periods) no LoS adjustments are made.

Where the critical care period spans 2 episodes, the overlapping day is used only once for allocation of critical care to episodes and only once in adjusting Spell LoS.

Location in extracts

The derived data item ‘Episode duration’ is contained in the parent record in the main APC extracts.

The SPC days and REHAB days CDS 6.2 data items have been incorporated into the APC episodes and APC spells managed service extracts and APC full online service extracts using the spare 1 and spare 2 data items.

PbR Critical Care Indicators identify why a record has failed validation. They are assigned at the point of failure and output in the critical care extract. The 11 indicators are:

• PbR Critical Care Indicator 1 - missing or additional daily PCC/NCC records
• PbR Critical Care Indicator 2 - critical care period outside of spell boundaries
• PbR Critical Care Indicator 3 - CC start date is null and CC discharge date is not null
• PbR Critical Care Indicator 4 - invalid critical care combinations
• PbR Critical Care Indicator 5 - NCC data group inconsistent with patient age
• PbR Critical Care Indicator 6 - NCC and PCC records outside critical care period
• PbR Critical Care Indicator 7 - overlapping critical care periods
• PbR Critical Care Indicator 8 - episode start date greater than episode end date
• PbR Critical Care Indicator 9 - CC start date null and CC disc date null
• PbR Critical Care Indicator 10 - CC start date is not null and CC disc date null
• PbR Critical Care Indicator 11 - critical care start date greater than critical care discharge date

PbR Critical Care Indicator 1 - missing or additional daily PCC/NCC records

The number of PCC/NCC daily records (DR) is validated against the number of critical care days in the critical care period.

Where the number of daily records is fewer than the number of critical care days, PbR Critical Care Indicator 1 is assigned and the spell length of stay is adjusted by the number of days in the critical care period.

This will cause a mismatch to exist between the number of HRGs and the number of critical care days because HRGs are derived based on the number of daily records for NCC/PCC.

PbR Critical Care Indicator 2 - critical care period outside of spell boundaries

Critical care period start and discharge dates are validated against spell admission and discharge dates to ensure critical care periods lie within the spell boundary.

Where a critical care period lies outside the spell boundary, PbR Critical Care Indicator 2 is assigned to the record and critical care processing stops. The following examples would fail validation:

• the critical care start and discharge dates are both before the spell admission date
• the critical care start and discharge dates are both after the spell discharge date
• the critical care start date is before the spell admission date, but the critical care discharge date is within the spell
• the critical care discharge date is after the spell discharge date, but the critical care start date is within the spell

PbR Critical Care Indicator 3 - critical care start date is null and critical care discharge date is not null

Null critical care start dates are invalid. If any critical care period in the spell contains a null start date, critical care processing stops and PbR Critical Care Indicator 3 is assigned to the record.

Please refer to PbR Critical Care Indicator 9 (CC start date null and CC disc date null) and 10 (CC start date is not null and CC disc date null) for further rules regarding null date values.

PbR Critical Care Indicator 4 - invalid critical care combinations

Logical combination validation performs checks for consistency between critical care type and patient age.

A combination of Adult Critical Care (ACC) and Neonatal Critical Care (NCC) is not possible and therefore, where a spell contains a combination of ACC, PCC or NCC, only valid combinations are processed.

ACC+PCC and PCC+NCC are valid but ACC+NCC (or ACC+PCC+NCC) are invalid. Critical care processing stops and PbR Critical Care Indicator 4 is assigned to the record.

Where the derived patient type for a record is ERR (patient age between 131 and 998), critical care processing stops and PbR Critical Care Indicator 4 is assigned.

The spell core HRG is UZ01Z, but because the record has failed validation and critical care processing has stopped unbundled critical care HRGs are not derived or assigned.

PbR Critical Care Indicator 5 - NCC data group inconsistent with patient age

Where records contain one or more NCC data groups, patient age is validated using the derived data item CC Patient Type, which identifies patient age group with a value of ADU (adult), CHI (child) or OTH (other). The episode with the lowest episode number in the spell is used to determine the age on admission and assign the correct value.

Any record containing NCC data that does not have CC Patient Type of CHI is assigned PbR Critical Care Indicator 5.

PbR Critical Care Indicator 6 – NCC and PCC daily records outside critical care period

All NCC or PCC daily records must lie within critical care period boundaries (between the critical care start and discharge dates). This validation is performed using submitted data item Activity Date (Critical Care).

All daily records are processed, but where one or more daily NCC or PCC records lie outside of the boundaries, the HRG for that day is replaced with an ‘error HRG’; UZ01Z and PbR Critical Care Indicator 6 is assigned. However, HRGs are assigned in the normal way for records that are within the critical care period boundaries.

PbR Critical Care Indicator 7 - overlapping critical care periods

Depending on the submitted information, overlapping critical care periods may be considered valid or invalid.

Valid

Where an overlap is considered valid, critical care processing continues and HRGs are assigned for each period.

The following examples are valid:

1) Two single day repeats          

Two one-day critical care periods with the same start and discharge dates are considered valid. Unbundled HRGs are generated for each period.

2) Multi-day repeats         

Multi-day ‘repeats’ are records containing two or more critical care periods with a duration greater than one day, all of which have the same start and discharge dates.

XML accepts up to a maximum of nine multi-day ‘repeats’ and therefore processing rules allow for this data to be interpreted rather than rejected. In these cases only the latest submitted critical care period is processed, resulting in the appropriate HRGs being assigned for that critical care period.

The remainder are considered duplicates because they are typically partially complete records that are superseded by more complete submissions. The preceding periods are therefore ignored in terms of processing but do not cause the record to fail validation.

Not valid

Where an overlap is not considered valid, critical care processing stops, PbR Critical Care Indicator 7 is assigned and no unbundled HRGs are assigned. Spell processing continues but without critical care length of stay adjustments.

The following examples are not valid:

1) Three or more single day repeats

Three or more one day critical care periods submitted for the same day (same start and discharge dates).

2) Two or more non-repeats overlapping by more than one day

Two or more overlapping critical care periods with different start and discharge dates and a duration of more than one day, and an overlap of more than one day.

3) Single day covered by two or more periods of more than one day

A one-day critical care period covered by two or more critical care periods with different start and discharge dates.

Overlapping daily records

No validation exists to specifically identify overlapping daily records. Users are therefore encouraged not to submit more than one daily record per day of critical care. Doing so can have 2 effects:

1. Data item CC Days for Tariff will not be consistent with the critical care period because HRGs are assigned based on daily records for NCC and PCC.
2. Repeat daily records are often caused by the submission of partially completed records. An error HRG (UZ01Z) may therefore be assigned due to there being insufficient accompanying information within the record.

PbR Critical Care Indicator 8 - episode start date greater than episode end date

Where episode start date is later than episode end date, processing stops and PbR Critical Care Indicator 8 is assigned.

PbR Critical Care Indicator 9 - critical care start date null and critical care disc date null

If any critical care period has both a null critical care start date and a null critical care discharge date, critical care processing stops, and PbR Critical Care Indicator 9 is assigned.

PbR Critical Care Indicator 10 - critical care start date is not null and critical care disc date null

Where critical care period has a null discharge date, but start date is not null, only that critical care period is ignored. PbR Critical Care Indicator 10 is assigned to the record but other critical care periods in the spell are processed normally. This is an exception to the general rule where validation failure stops critical care processing for the spell.

PbR Critical Care Indicator 11 - critical care start date greater than critical care discharge date

Where critical care start date is later than the critical care discharge date, critical care processing stops, and PbR Critical Care Indicator 11 is assigned.