Exclusions

Excluded activity is activity that is not priced by SUS+.

There are 2 causes of exclusion: national policy and data quality.

It is important to note the difference between these 2 causes. Activity excluded by policy has no national price and the payment mechanism is agreed locally between providers and commissioners. Activity excluded for data quality reasons does not carry enough information to derive an HRG and is marked as with the ungrouped HRG “UZ01Z” which has zero price.

For Admitted Patient Care activity exclusions can be applied at the whole spell level or against individual component episodes. Where partial exclusion of a spell is found, the included episodes will be considered together to give a single HRG and price for the included part of the spell. The spell PbR Qualified Indicator is set as appropriate:

• QUALIFIED = 0
• PARTIALLY_INCLUDED = 1
• ALL_EPISODES_EXCLUDED = 2

Activity that has no national price is marked as excluded by Payment by Results. SUS+ PbR processing is applied according to published policy and effectively handles all CDS submitted activity that is subject to policy exclusion. To effectively reconcile local systems with SUS+, providers and commissioners must account properly for this activity.

A complete list of the published exclusions for each financial year can be found in the National Tariff Payment System guidance on the NHS England website. The specific criteria for exclusion are contained in the tariff reference data.

The source documents can be found on the past national tariffs page of the NHS England website.

“Equals sign” exclusions are identified by the provider before submission of CDS. Policy guidance allows for categories of activity to be marked as excluded by using an equals sign (“=”) as the last significant character of the COMMISSIONING SERIAL NUMBER data item. This mechanism is required because in these cases it is not possible to distinguish the activity for exclusion by using other items within the CDS. This device should only be used when either of the following apply.

• the activity is covered in the policy document and identified in tariff reference data as appropriate for use of the equals sign
• a specific local agreement is in place to vary from the national price

Policy exclusion reasons include:

• MAIN_SPECIALTY_CODE
• CORE_HRG_TFC_EXCLUSION
• PATIENT_CLASSIFICATION
• ADMINISTRATIVE_CATEGORY
• COMMISSIONING_SERIAL_NUMBER
• CORE_HRG_EXCLUSION
• FIRST_ATTENDANCE
• ATTENDANCE_STATUS_EXCLUSION
• AE_DEPARTMENT_TYPE_EXCLUSION
• STREAMED

Where data is of insufficient quality to derive an HRG it is effectively excluded from PbR and a zero price (£0) is applied. An exclusion reason will be provided:

• MISSING_EPISODE
• CROSS_CHECK_EXCLUSION
• OVERLAPPING_EPI_IN_SPELL
• MULTIPLE_LAST_EPISODES_IN_SPELL
• MULTIPLE_PATIENTS_IN_SPELL

Cross check exclusions are caused by:

• one or more episodes having an end date after the spell discharge date
• date of birth being greater than the spell discharge date
• the episode start date being after episode end date
• the episode start date being earlier than the spell admission date
• an episode where the admission method has a valid unknown code
• an episode where the patient classification is incompatible with the admission method
• discharge ready date being greater than the spell discharge date
• discharge date being before the spell admission date