Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: New category: Endovascular insertion of stent graft for iliac artery aneurysm
Why is the request for change required?: Increasingly clinicians are using the term EVAR to include
endovascular insertion of stent graft for iliac aneurysms where the procedure is essentially the
same/similar to that for an AAA. But the aneurysm is in the iliac and not the abdominal aorta. This is
causing particular problems with the Nationally reported clinical AAA database as this includes all
EVARs. There is currently no available code to specifically describe the procedure.
Intervention: Change in clinical practice: Isolated common iliac artery aneurysm is a rare condition that
is treated aggressively because of its high risk of rupture. Endovascular AAA repair has been extended
to the clinical management of the iliac artery aneurysm. Stent grafts have been used successfully to
exclude iliac artery aneurysms.
Please fully describe Intervention: Anatomy: Iliac artery Action performed: Insertion Extent: Priority:
Emergency, Urgent and Routine Revision status: Primary or possibly revision Approach: Endovascular
Pathology: Iliac artery aneurysm
Other actions performed as part of intervention: Image control in addition embolisation may be
performed.
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes: Now routinely performed.
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatients
Based on classification/data collection problem?: The clinical practice has moved on
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: New code: Graft to external nose
Why is the request for change required?: Graft and or flap repairs are now commonly done in
conjunction with excision or destruction of lesions of the nose (BCC/SCC). Currently the specific graft or
flap code has to be used as a subsidiary code with E09.8 other specified operations on external nose.
Data retrieval is more difficult because of the need to look at combination of codes and audit and
feedback suggest that not all coders are attaching the S code to E09.8. It would be helpful to have a
code to cover reconstruction of external nose as per C14 reconstruction of eyelid. E09.7 is not currently
used so this could be reconstruction of external nose HFQ.
Intervention: The method of reconstruction is covered by the codes already available in chapter S.
Please fully describe Intervention: Anatomy: External nose Action performed: reconstruction (using
flap or graft) Extent: Priority: Routine Revision status: Primary or revision Approach: N/A Pathology:
Lesion
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes - a very commonly undertaken procedure
Does it require understanding of a definition to ensure correct usage?: No:
Applicable to specific settings?: Inpatient or day case
Based on classification/data collection problem?: Really it is a problem around the ability to
accurately extract and analyse data (particularly because of inconsistency in code allocation and the fact
that patients often have multiple lesion dealt with at the same admission.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: New codes: Attention to gastric band port, attention to gastric band connecting tube, resiting
of gastric band port, replacement of gastric band port
Why is the request for change required?: No code exists in OPCS for attention to or maintenance for
the port of a gastric band as opposed to the band itself. Sometimes the port becomes blocked and it is
not the gastric band that we are maintaining but the port itself. Problems with the port and/or the tube
connecting the port and band - The port can flip over so that the membrane can no longer be accessed
with a needle from the outside (this often goes hand in hand with a tube kink, and may require
repositioning as a minor surgical procedure under local anaesthesia); the port may get disconnected
from the tube or the tube may be perforated in the course of a port access attempt (both would result in
loss of fill fluid and restriction, and likewise require an intervention/operation). Sometimes the port
becomes dislodged or infected which requires the port to be sited and replaced. There is no way of
showing these procedures. There is a huge risk that coders may end up coding these as maintenance of
the gastric band which is an entirely different scenario.
Intervention: These procedures cannot currently be coded using OPCS.
Please fully describe Intervention: Anatomy: Subcutaneous tissue Action performed: Attention to ,
maintenance, replacement, renewal, resiting. Priority: Urgent or Routine Revision status: As all of these
would be associated with a complication of some sort they are not primary in the clinical sense
Approach: Open
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes: All hospitals providing a bariatric service
Does it require understanding of a definition to ensure correct usage?: Coder needs to
understand the difference between the port, the connecting tube and the gastric band itself
Applicable to specific settings?: Inpatient, day case and possibly outpatients
Based on classification/data collection problem?: Yes: There is currently no ability to capture these
procedures. It also creates a dilemma as to whether the coder should use an other specified category
somewhere in chapter G or to try and find something in chapter S.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: The request is for a code for subcutaneous implantation of a defibrillator (ICD).
Why is the request for change required?: The code is required because the only available category
for implantation of cardioverter defibrillator in OPCS is K59 which specifies that the device is introduced
through the vein.
Intervention: The subcutaneous implantable defibrillator uses a lead which implanted just under the
skin (along the bottom of the rib cage and breast bone). Because the lead is placed under the skin
rather than through a vein into the heart, the clinician can implant the device without accessing a
patient’s blood vessels or heart and without the need for fluoroscopy. For an S-ICD system both the
pulse generator and the electrode are implanted subcutaneously on the chest. Both components are
implanted just under the skin.
Please fully describe Intervention: Anatomy: Heart Action performed: Implantation Extent: Priority:
Routine Revision status: Approach: Percutaneous Pathology: Heart failure and arrhythmia and
dysrhythmia, life threatening ventricular tachyarrhythmia
Other actions performed as part of intervention: None
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes - being carried out at a number of NHS Trusts
including Papworth and Taunton and Somerset
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient, day case, and outpatient
Based on classification/data collection problem?: Yes: There is currently no mechanism to record
this.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: Upgrade of pacemaker to a CRTD device (cardiac resynchronisation therapy device) or
Upgrade from existing cardiac pacemaker system to cardioverter-defribrillator
Why is the request for change required?: We now have a patients who rather than having a removal
of a pacemaker and replacement with a CRTD device, have an upgrade to a CRTD device. This usually
involves placement of one extra lead and a new box. An implanted cardiac resynchronization device
resynchronizes the contractions of the hearts ventricles by sending tiny electrical impulses to the heart
muscle, which can help the heart pump blood throughout the body more efficiently. CRT defibrillators
(CRT-D) also incorporate the additional function of an implantable cardioverter-defibrillator, to quickly
terminate an abnormally fast, life-threatening heart rhythm. CRT and CRT-D have become increasingly
important therapeutic options for patients with moderate and severe heart failure.
Intervention: The procedure involves swapping the pacemaker box for the cardioverter device and
insertion of one new lead.
Please fully describe Intervention: Anatomy: Heart Action performed: Revision Extent: Priority:
Routine Revision status: Revision Approach: Endovascular Pathology: Heart failure
Other actions performed as part of intervention: Possible replacement of existing lead. Image
control
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Day case, inpatient and potentially outpatient
Based on classification/data collection problem?: Yes: there is no mechanism within the existing
codes to identify this intervention
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: Ankle replacement: This request is for a set of codes that will allow total prosthetic
replacement of ankle procedures to be coded using ankle-specific procedure codes in the same way as
shoulder, elbow, hip and knee prosthetic replacements.
Why is the request for change required?: There are an estimated 29,000 people in the UK with endstage, symptomatic osteoarthritis of the ankle. Approximately 3,000 definitive operations to treat endstage ankle osteoarthritis take place annually in the UK. The operation data was obtained from HES
data by the NHS Information Centre for Health and Social Care. It is estimated by members of the
British Orthopaedic Foot and Ankle Society that the numbers may be as high as 10,000p.a. The
National Joint Registry currently captures 560 cases of Total Ankle Replacement (TAR) annually. An
informal estimate suggests that there are likely to be between 1,200 and 2,000 cases of TAR annually.
An attempt by the National Joint Registry (NJR) to find TAR incidence using Hospital Episode Statistics
(HES) data was compromised by the lack of specific procedure codes for TAR. The first attempt, using
the expected code combinations for prosthetic replacement of other joint with secondary site codes for
ankle, resulted in finding only 360 cases of TAR. Attempts to improve on these findings involved
creating complicated formulae to account for a wide variety of code combinations and sequencing
possibilities. The NJR currently maps total hip replacement and total knee replacement procedures
submitted to NJR back to HES using specific procedure codes as part of their data validation processes.
Without specific primary procedure codes for TAR they have no reliable way of using HES data to find
TAR cases that have not been submitted to NJR. Since 2010 TAR data has been recorded on National
Joint Registry, mandated by the Department of Health. Compliance is low and there is no way for the
NJR to chase and improve this compliance in the absence of a specific set of codes for TAR. BUPA and
other PMI insurers have had a code for TAR for the last 5 years. Professor Sir Bruce Keogh is
extremely keen to ensure that the NJR covers all total joint replacements and has indicated support for
the need for a specific TAR code.
Intervention: A Total Ankle Replacement is made up of three components: two metal (tibial component
and talar component) separated by a plastic mobile component. TARs are almost always uncemented
(there are only 8 instances of TAR involving cement on the NJR records. Cement can be used on either
component but probably should not be used for Primary TAR. Cement use on one or both components
is more likely for revisional TAR. TAR may be performed as a revision of previous metalwork (for trauma
or previous osteotomy). Failed TAR can be revised but are unlikely to be revised more than once. Failed
TAR may be converted to an ankle fusion. TARs are unlikely to be carried out as an emergency or to
treat acute trauma.
Please fully describe Intervention: Anatomy: ankle joint - distal tibia, top of talus, fibula that
articulates with the bottom of the tibia. Action: replacement. Extent: N/A Priority: Routine Revision
status: primary or revision Approach: Open Pathology: likely osteoarthritis
Other actions performed as part of intervention: There may be tendon procedures, removal of
osteophytes etc involved.
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Yes - see attached
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: The classification allows the recording of TAR
using multiple codes but that makes data retrieval complicated particularly because tendon procedures
etc may be performed at the same time leading to the site code not being immediately sequenced after
the unspecified joint replacement code.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: Complex (challenging) abdominal wall defect repair (including complex ventral/incisional
hernia repair). We would be happy to engage in further discussion about potential changes that could be
made to enable these patients to be identified as there are a number of potential solutions. E.g. it may
be that the most appropriate way to identify these patients and to ensure that appropriate
reimbursement is made is to create a subsidiary code for high cost implant, it may be appropriate to
create a code for biological mesh in a similar way to high cost drugs, it may be that existing procedures
are considered adequate to cover these complex procedures and that it would be possible to create an
algorithm to allow for appropriate reimbursement by taking into account specific diagnosis codes.
Another option would be to create a specific subsidiary code(s) to allow for the identification of the size
of the defect that requires repair either by diameter or cm squared or combination of solution thereof. It
might also be the case that a new category for repair of challenging abdomen is created because there
will be a limited number of centres undertaking this work and specialist funding is available for these
patients.
Why is the request for change required?: We need to develop the ability to identify these very
expensive and clinically complex patients. The cost is not only the huge cost of the bio matrix involved
but that these patients have significant comorbidity, extensive hospital stay and require complex care
(i.e. high level nursing, parenteral nutrition, psychosocial input and rehabilitation).
Intervention: The goal of the surgeon in managing a complex (challenging) abdominal wall defect is to
restore the structural and functional continuity of the muscle-fascia system and to provide stable and
durable wound coverage. There has been a significant increase in the number of patients who present
with challenging abdomen. It is expected that the numbers of patients will increase by around 1-2% per
year primarily do to the growing age of the population, increasing rates of obesity and diabetes,
improved survival from intra-abdominal cancers, and improvements in care of the critically injured
patient, yielding greater survival of patients following abdominal catastrophe. These factors have
produced a large subset of clinically complicated patients with structurally complex abdominal wall
defects/herniation’s.
Please fully describe Intervention: Anatomy: Abdomen wall and intestine Action performed: Complex
reconstruction Extent: Radical Priority: Routine Revision status: Likely revisional Approach: Open
Pathology: Herniation, fistulisation and need for TPN
Other actions performed as part of intervention: The major repair/reconstruction can include
component separation, removal of infected mesh and debridement of infected non-viable abdominal wall
tissue and additional intestinal procedures will be performed for which we have existing codes.
Request Related to a unique situation?: Yes: This is about differentiating for severity and cost where
the patients at the challenging end of the spectrum clinically bear no resemblance to those at the simple
end.
Evidence to show part of usual NHS activity: Yes: A number of hospitals carry out this activity. We
know there are in excess of 500 procedures a year and possibly up to 2000.
Does it require understanding of a definition to ensure correct usage?: Yes: It requires an
understanding of a number of concepts including the term challenging abdomen, defect size,
component separation, and the hernia grading system.
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: Yes: We try to describe complexity by using lots
of additional codes but this doesn’t work in this instance.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: In order to clarify the use of the term insert of natural material in relation to hernia repairs an
it would be helpful to have either an inclusion or bracketed text at the .1s in the hernia repair categories
to indicate that this is the appropriate place to include biological insert.
Why is the request for change required?: It is most likely that a biological insert (particularly a
biological mesh) will be used for more challenging/complex cases. Patients having a biological insert
should already be coded to the .1 categories and should therefore be identifiable. However, clarification
would be extremely helpful because coders seeing the term biological mesh may only focus on the word
mesh and therefore misclassify to .2 insert of prosthetic material. Use of biological inserts is also
significantly more expensive than other forms of repair. (linen insert is now an obsolete procedure which
means that use of a biological mesh should account for the majority of procedures classified to .1).
Intervention: N/A
Please fully describe Intervention: N/A
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: N/A
Evidence to show part of usual NHS activity: Yes. 100s of this procedure are performed every year.
Total number of hernia repairs using natural material (2011-2012 HES data), do not reflect the level of
activity that is known to be taking place. (This may be indicative of coder confusion).
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: Yes.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: OPCS codes are required for resiting of stoma and resiting with reinforcement of stoma.
Why is the request for change required?: Currently to code a resiting of a stoma it is necessary to
use separate codes for closure of an existing stoma site (as opposed to closure of the ostomy) (usually
with a repair of a parastomal hernia) and the codes for the creation of a new stoma site. This means
that it is difficult to retrieve information about the frequency of these major procedures. There is also a
risk that the figures for standard stoma creations and closure can be distorted. Because of the
significant complication rates for patients with stomas, there has been an increased interest in analysing
the data, establishing best practice and creating outcome measures. It is extremely difficult to progress
with this in a situation where the relevant patient cohort cannot reliably be identified.
Intervention: The procedure involves a laparotomy to take down the existing stoma, mobilisation of the
limb of the stoma and placement of the limb to the opposite side of the abdomen where a new stoma
site is created. The resited limb may be supported with a mesh insert (biological)(reinforcement) in order
to reduce risk of herniation at the new stoma site. The previous stoma site will require closure and may
include hernia repair if this was part of the reason for the resiting. The procedure may be carried out
laparoscopically, laparoscopically with a mini laparotomy or as an open procedure and it may be done
as an emergency (when a patient comes in with an incarcerated hernia), urgent and routine.
Please fully describe Intervention: Anatomy: Abdominal wall Action performed: Closure and
secondary creation OR resiting Extent: N/A Priority: Emergency, urgent or routine Revision status: It is
clinically a secondary or revisional procedure but it could be considered a primary or secondary resiting
from a classifications perspective if a new category was created.
Other actions performed as part of intervention: Mobilisation of the limb of the stoma may require
extensive division of adhesions. The limb may also need cutting down as it can become damaged
during mobilisation particularly in patients with adhesions.
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: Because of the way this has to be coded at the
moment it is impossible to deduce from HES data the number of patients involved. But it is not an
uncommon procedure.
Does it require understanding of a definition to ensure correct usage?: No
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: Yes because whilst individual components
classified it is not possible to describe this procedure in any meaningful way.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: An entire new category for parastomal repair.
Why is the request for change required?: Repair of parastomal hernia is fundamentally different from
the other hernia repairs. As soon as a stoma is constructed, a potential site of weakness in the
abdominal wall is instantly produced. Parastomal hernia occurs when weakness in the abdominal wall is
sufficient to permit abdominal contents, usually the intestine, to protrude through the fascial defect
around the stoma and into the subcutaneous tissue, creating a bulge on the abdomen. Its reported
incidence varies from 30% to 50%. Loop ileostomy has the lowest risk, followed by end ileostomy, and
loop colostomy. End colostomy carries the highest risk for parastomal hernia of around 48%. There are
three techniques that are currently used for repairing a parastomal hernia: 1) localized fascial repair, 2)
localized fascial repair with mesh, and 3) relocation of the stoma. Surgical options for treating primary
large symptomatic parastomal hernias include local repair with mesh implantation and stomal relocation.
Stomal relocation is a major surgery with laparotomy and necessitates moving the stoma to another site
on the abdomen and repairing the hernia at the old site. Recurrent hernias are best treated by local
repair with mesh implantation. The use of mesh over and beyond the weakened area reinforces the
weakened muscle structure and spreads the mechanical load over a larger area. It is impossible to
extract reliable data about prevalence of parastomal hernias and their repair because neither ICD-10 or
OPCS classifies them as an entity in their own right. It is likely that the problem is made worse because
a parastomal hernia would be classified as a ventral hernia in ICD-10 which can mislead coders into
then choosing the ventral hernia repair rather than the incisional hernia repair category in OPCS.
Intervention: A biological insert material may be used which has a preconfigured incision within it to
allow the passage of the intestine through the insert. (The incision may be extended to accommodate
the larger intestine, the outer edges may be trimmed to ease placement.) The insert material is passed
through the skin opening (or from within the abdominal space). The insert material is placed across the
ostomy tract and the distal end of the intestine is pulled through the incision in the insert material and
through the ostomy tract. The insert material is secured to the abdominal wall.
Please fully describe Intervention: Anatomy: abdominal wall Action performed: repair Extent: N/A
Priority: routine Revision status: Primary or revision Approach: open or endoscopic Pathology:
parastomal hernia
Other actions performed as part of intervention: N/A
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: The 2011-2012 HES data shows in excess of 4000
intestinal stoma creations which even allowing that half of these may be reversed (closed) is likely to
equate to a minimum 600 and possibly as many as 1000 parastomal herniations per year. An exact
figure is not possible as there is currently no mechanism to identify these.
Does it require understanding of a definition to ensure correct usage?: No:
Applicable to specific settings?: Inpatient
Based on classification/data collection problem?: There is no mechanism currently to
identify/classify parastomal herniation in OPCS.
Submission for inclusion in OPCS 4.7 on behalf of the PACC-UK working with clinicians, members and
other interested parties for information only.
Summary: New code request: Tracheo-oesophageal puncture without the insertion of a speech
prosthesis.
Why is the request for change required?: There is no mechanism to identify where a tracheooesophageal puncture has been performed with the intention of placing a speech prosthesis such as a
Blomsinger valve at a later stage. This is a commonly performed procedure which it is not currently
possible to encode in any meaningful way. The specific problem is that because the rubric E41 Open
placement of prosthesis in trachea in which one might expect this procedure to fall actually includes
placement of prosthesis in the rubric title, meaning that the other specified option cannot be used. The
coder is then left in a dilemma because this is a procedure across two body systems. It appears logical
to use a code from chapter E because that is where the tracheo-oesophageal puncture with placement
of prosthesis has been placed. But there is nothing that appears appropriate and certainly nothing that
would allow retrieval of information about this procedure. A tracheo-oesophageal puncture is a
surgically created hole between the trachea and the oesophagus in a person who has had a total
laryngectomy, The purpose of the puncture is to restore a persons ability to speak after the vocal cords
have been removed. This involves the creation of a fistula between the trachea and oesophagus,
puncturing the short common wall that divides the two structures. A voice prosthesis is inserted into this
puncture either at the same time or at a later stage.
Intervention: Tracheo-oesophageal puncture (TEP or TOP) is the most common way to restore speech
following laryngectomy. TEP can be performed at the same time as a layrngectomy but is often done at
a later date. The TEP involves creating a fistula at the back of the tracheostomy to create an opening
between the trachea and the oesophagus. A tube (catheter) may be inserted into the fistula to keep it
open or a small valve (voice prosthesis) may be immediately inserted into the fistula (we have a code for
this E41.4). If a fistula is created without immediate prosthesis placement or catheter the patient will
need a nasogastric feeding tube. Once the area of the fistula has healed the catheter is removed and
the small one-way valve is inserted.
Please fully describe Intervention: Anatomy: Oesophagus and trachea. Action performed: Puncture
(creation of fistula) Extent: N/A Priority: Routine Revision status: Primary or revision (can be both)
Approach: Open via stoma or endoscopic (can be both) Pathology: Most likely diagnosis laryngeal
cancer
Other actions performed as part of intervention: No other actions
Request Related to a unique situation?: No
Evidence to show part of usual NHS activity: This is something that comes up on a regular basis. It
is difficult to quantify as there is no single code that can be looked at to retrieve data. However, HES
data for 2011-2012 indicates that over 300 total layngectomies were performed and it is likely that a
significant number of these patient will have had some sort of speech prosthesis. 2011-2012 data also
shows 97 admissions for E41.4. We suspect that some of these will not have included the speech
prosthesis implantation as coders may have used this code as there is currently no alternative code in
OPCS.
Does it require understanding of a definition to ensure correct usage?: No.
Applicable to specific settings?: Inpatient setting
Based on classification/data collection problem?: This is a problem with the category E41 Open
placement of prosthesis in trachea.