Get the coding right for QOF and enhanced services

Dr Miles Carter and Dr Merlin Dunlop advise practices using EMIS clinical software on how they can maximise QOF and enhanced service earnings.

Dr Carter (L) and Dr Dunlop: QOF and enhanced services coding wizards
Dr Carter (L) and Dr Dunlop: QOF and enhanced services coding wizards

Since the QOF was introduced in 2004, it has evolved considerably and now contains 22 clinical areas, each with different targets.

Also, the directed, local and national enhanced services (DESs, LESs and NESs) have added further targets. Many of these rely on correct coding of the patient record, something that is by no means universally achieved.

As the QOF has become complex it is harder for practices to remain in control of their QOF achievement without dedicating a large amount of time to the task.

QOF registers

We are two GPs who work in large, well-organised practices that use EMIS software and have dedicated admin staff and sensible clinicians.

We were confident that both practices’ QOF registers would be accurate and reflect our true chronic disease prevalence. After writing some targeted searches, we soon learned that this was not the case.

We were losing large amounts of QOF and enhanced services income simply because many of the patients were missing codes for work already done or had codes not valid under QOF and enhanced service specifications.

Coding pitfalls

Three of the most common coding pitfalls are with:

  • Episode type
  • Codes not valid for QOF
  • Enhanced services specific codes

Episode type

Historically, many chronic diseases have been recorded by default as a ‘minor problem’ lasting 28 days.

Unless clinicians have corrected this when they record their consultations, then a clinical record may have multiple episodes of a single disease.

Hypertension is one example of where this has happened frequently.

There are several QOF indicators that require specific actions when a new episode/new diagnosis of a disease is recorded.

Each new episode of hypertension, for example, requires a QRISK (cardiovascular disease risk) score. If hypertension is coded incorrectly as a new episode, your CVD PP1 (primary prevention 1) target becomes harder to achieve.

Codes not valid for QOF

The Read code system appears to offer several different codes for the same diseases. Unless you have a good understanding of how this coding system works, it is easy to assume that adding the ‘[M] renal cell carcinoma’ code, for example, will place the patient on the QOF cancer register.

In fact this code is not a diagnostic but a code describing the morphology of the cancer. Therefore it will not place a patient on the cancer register.

Now that prevalence of chronic disease directly affects the value of QOF points it has become more important to ensure your QOF domains reflect your true practice prevalence of chronic disease.

Enhanced services specific codes

Coding pitfalls do not end with the QOF. Enhanced services often require specific codes to be recorded in the patient record to monitor activity.

It can be easy to overlook this area as EMIS Web does not include tools to monitor all enhanced service activity.

The pertussis NES, for example, requires a specific vaccination code to be recorded to trigger payment. It is not immediately obvious which code this is as the vaccine itself can be correctly recorded using several different codes.

Preventing future slip-ups

Running retrospective searches will identify past mistakes and the trick is to prevent these mistakes happening in future.

This is where EMIS Web’s highly ‘customise-able’ protocols makes a difference.

A protocol can be considered to be a mini-program running within EMIS Web that monitors what the user is doing and performs certain actions when required.

A simple protocol could run when a clinician adds a ‘[M] Renal Cell Carcinoma’ code and a pop-up warns this code is not valid for QOF.

A more advanced protocol might run when a clinician issues an emergency contraceptive that checks ‘in the background’ if advice about LARCs also has been given. If it has not, the protocol would prompt the clinician to offer advice.

Writing protocols in EMIS Web can be straightforward but requires some care. It is important to ensure that pop-up messages only appear in appropriate circumstances. If not, clinicians will ignore them.

Protocols can also be used to improve practice efficiency. The most popular protocol we have written is our seasonal flu protocol, which orchestrates the entire influenza, pneumococcal and pertussis vaccination programme.

When run, this protocol checks in the background for eligible patients for:  

  • Flu vaccination and contraindications
  • Pneumonia vaccination and for contraindications
  • Pertussis vaccination in line with the NES specifications.

The clinician is prompted to give the relevant vaccines and they are recorded with three mouse clicks (batch numbers and expiry dates are automatically coded).

Mastering the QOF

It has taken us over 150 hours to write our searches and protocols which cover all the QOF and (for England) enhanced service areas.

Having saved our own practices several thousand pounds in unclaimed income, we launched our QOF Masters business to help other EMIS Web practices that may not have the time or skills to write the searches and protocols they need to keep ahead on QOF coding.

  • Dr Dunlop and Dr Carter are GPs in Oxford. Their website QOF Masters can be found at

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