Several validation and pre-processing stages take place before the actual grouping takes place whereby HRG codes are assigned to patient record data.
The stages are:
- Input data – patient activity (episode or spell data)
- Radiology pre-processing
- Pre-processing (combinations)
- Unbundled activity
- Grouping – multiple trauma, procedure driven, global exception (such as PPNCD)
After grouping, Best Practice Tariff (BPT), Specialised Service Code (SSC) and Programme Budgeting Category (PBC) flags are assigned.
The data is then output as patient activity with assigned HRGs and flags.
Validation checks are built into the local payment grouper and are applied prior to the HRG code being assigned to a patient record. This checks the Office of Population Censuses and Surveys (OPCS) codes to ensure they are valid.
Reasons why a code may not be seen as valid include:
- logical inconsistency (for example a paediatric procedure being given to someone over 18 years old)
- an invalid or missing code being assigned (for example a treatment function code that does not exist or is clinically irrelevant for grouping, such as family history of diabetes)
- if a deliberately ambiguous OPCS code is used (for example diagnosis/procedure ‘unspecified’)
Pre-processing occurs for radiology activity because it must be mapped to reference data before processing.
Pre-processing involves creation of combination procedure codes, and logical deletes.
Unbundled procedures are processed separately to derive unbundled HRGs (See unbundled HRGs). The grouper then ignores these unbundled components when deriving the core HRG.
When all significant procedures in an admitted patient care episode or spell are unbundled, diagnosis is used to derive a core HRG for the episode. For outpatient care, if all procedures are unbundled the episode is allocated one of the eight relevant non-admitted care attendance HRGs as a core HRG.
There can be one or more ‘unbundled’ HRG codes assigned that can be used to identify the use of repeating resource use such as scans.
Grouping is the main stage of the process in which one HRG code is assigned to the spell. This is referred to as the core HRG. Patient record data items, such as procedures, diagnoses, age and length of stay are used to determine the appropriate HRG code for the Spell.
Assign flags (BPT, SSC, PBC)
Best Practice Tariff (BPT)
Most Best Practice Tariff flags are generated by OPCS and ICD10 (International Classification of Diseases) codes. These may be required in combination and may also require qualification by other codes, for example site or approach codes.
Only certain HRGs can be flagged as best practice. In addition, age criteria and type of admission will determine whether activity can be flagged as best practice.
Specialised Service Codes (SSC)
SSCs are assigned based on the record meeting predefined reference criteria.
Programme Budgeting Categories (PBC)
The grouper maps the primary diagnosis of a patient record to a Programme Budgeting Category (PBC) which is then output by the grouper. There is no direct mapping of HRGs to PBCs. The programme budget category allows high level reporting on the amount of money being spent on specific treatments, such as cancer or heart disease.