Know The Requirements

QOF review indicators have two types of ‘requirements’ that should be considered.

First there are the essential required elements where a code is required for the review to count towards the QOF achievement.  Failing to code an essential element is a common problem that may lead to patients receiving multiple invites despite having already attended for their review earlier in the year or even being booked in for more than one annual review.
Secondly there are the clinical recommendations listed within the QOF guidance and linking back to NICE guidance.  It is important to look at these as coding that a review has happened where the review does not meet these recommendations may be questioned if audited.
To identify patients who may have attended for review, but who are not currently contributing to the achievement due to missing codes the PCIT 004 GP Contract Pro/ 004B Routine QOF work | Indicator Navigator folder includes a number of DQ or ‘data quality’ searches for each disease. 

AST007 Asthma Review –This indicator includes essential elements that also need to be coded within a specific time frame relative to the review.
It is essential to code:
o Asthma review
o Written asthma care plan coded on the same day as the review
o Number of exacerbations coded up to 1 month before or on the same day as the review

The written asthma care plan must be coded on the same day as the review.  The recording of the number of exacerbations must be coded up to 1 month before or on the same day as the review. In 004 GP Contract Pro / 004B Routine QOF work | Indicator Navigator – AST | DQ | Asthma with incomplete review will show these outstanding elements.

COPD010 COPD Review – This also needs a record of the number of exacerbations and assessment of breathlessness using the MRC scale.  Unlike asthma, these elements do not need to be within a certain timeframe around the review and just have to be coded at any point in the QOF year.

Essential to code:
o COPD review
o Number of exacerbations
o Assessment of breathlessness (MRC scale)
Again, the 004B Routine QOF work | Indicator Navigator folder for COPD offers a report to help quickly identify missing elements so they can be actioned before 31^st March.

DEM004 Dementia Care Plan –The essential element for this indicator is a code showing a dementia care plan has been agreed or reviewed. There is not a requirement to code a dementia review alongside this.

However, the QOF guidance indicates that this care plan is expected to be part of a formal review which should include a number of other elements including:
· Physical, mental health and social assessments
· Medication review
· Record of patient’s named coordinator or key worker and contact info
· Record of any legal power of attorney in place
· End of life preferences with consideration to whether patient should be on the palliative register
· Review of NICE recommended interventions
· Identification of patient’s carer and offer of a carer health check if appropriate

The codes for these elements are not explicitly required for the patient to be included in the QOF indicator achievement and would depend on the needs of the patient. The dementia page of the QOF template offers coding options for all of the above elements.  The clinician performing the review should be aware of the QOF and NICE guidance to ensure the review and associated care plan covers all appropriate elements.

DM012 Diabetic Foot Check –This indicator has a single essential element which is the diabetic foot check.  There is no requirement for an annual review alongside this. Be aware that this indicator is due to change in 2026/27 so look out for information on this with the 2026/27 QOF Update.

HF007 Heart Failure Review – This indicator requires a heart failure review and a medication review both within the QOF year.  There is no requirement for the medication review to be on the same date or close to the review.

It is essential to code
o Heart failure review
o Medication review
The Indicator Navigator HF searches identify patient who have had one of the essential elements coded but are missing the other code.

Much like DEM004 there is an expectation that the heart failure review is conducted in line with NICE recommendations.  The QOF guidance specifically recommends evidence of an assessment of functional capacity.  The Heart Failure page of our QOF template provides the appropriate New York Heart Association Classification codes to support this, but these are not essential codes for achievement of the indicator.

MH002 Mental Health Care Plan – This indicator requires a single code indicating that a care plan has been agreed or reviewed within the QOF year.

For patients on this register the care plan is often part of wider multidisciplinary support, and the QOF guidance does allow for documenting of a care plan that has been reviewed by community health services if the patient is under their care.  If the patient is not under the care of community health services, then the guidance advises that the care plan should be part of a primary care consultation.
TOP TIP – Make sure that coders are aware of the need to code care plans agreed or reviewed by the community mental health team to avoid duplication of work.
Although the care plan may be agreed or reviewed outside of an annual health check it is often useful to consider the combined mental health indicators as an annual review for the purposes of planning.

HI03 (IIF) Learning Disability Health Check – This is an IIF indicator rather than a QOF indicator, but it is important to include it when planning annual reviews.

This indicator has 3 essential elements:
· A learning disabilities health assessment in the QOF year
· A review or completion of a LD health action plan in the QOF year (must be done on the same date or after the health assessment, not before)
· A record of ethnicity (does not need to be repeated each year)

IIF searches are in folder 025 PCN Contracts with IIF Reporting searches showing achievement and IIF Data Quality has searches identifying patients who have had the assessment or action plan coded but have not had all 3 essential elements recorded.

PCIT QOF template

PCIT offers a dedicated QOF template designed to streamline your workflow and support accurate achievement across each disease area. This template includes only the essential clinical codes required to meet QOF indicators, helping to keep consultations focused, efficient, and compliant. Each disease area has been separated into its own dedicated page, and the template intelligently displays only the conditions relevant to the patient record retrieved. By removing unnecessary fields and codes, this approach helps reduce errors, minimise incorrect coding, and create a clearer, more user-friendly experience.
To further support clinical decision-making, each disease area includes a dedicated view displaying key patient information relevant to that specific indicator. PCIT has also included quick links to a detailed exception reporting template, containing all appropriate exception codes alongside a tailored view to support safe and informed exception reporting. In addition, users can access a more comprehensive condition-specific template directly from each disease page, making it easy to move from focused QOF coding to a full, in-depth review whenever required.

Identify outstanding patients

In Q4 it is important to have a targeted approach to identify patients who are outstanding and currently affecting the practice’s potential achievement.
The first step is to make sure that any Data Quality reports have been reviewed and actioned to check that patients have not already attended for a review.  This helps to avoid sending recalls when the work has already been done.
Once the Data Quality report has been reviewed and actioned, the next step is to ensure that all remaining patients have had 2 invitations.  This will mean that any patients who do not attend for a review by 31^st March will not count against the practice achievement as an automatic PCA will be applied.

In the Indicator Navigator folder, PCIT has provided searches for patients who have received only one invitation and are still outstanding.  Once a second invitation has been sent to everyone on this list then there should be very few patients left outstanding on the indicators listed here.

IMPORTANT – HI03 for LD Heath Checks does NOT have an exclusion rule for invitations.  The only PCA for this indicator is that the health check has been explicitly declined by the patient or an appropriate 3^rd party.

For this indicator it is again important to start with the Data Quality report and ensure that all health checks have been fully coded.

Once the Data Quality work has been completed, there is a search to identify all remaining patients who are outstanding a LD health check in 025B PCN DES / 025B PCN DES Health Inequalities / Work to do | Needs LD health check.

These patients are likely to need individual consideration rather than bulk text invites as they may have flags or alerts for reasonable adjustments.  Patients on this register are also at higher risk for safeguarding concerns so any patients who have not responded at all to invitations may need to be considered in this light. A useful option can be to reach out to other agencies involved such as the Community LD Team or discuss patients at multidisciplinary meetings as there may be alternative options for discussing the review with the patient or their carer.

Remember that LD health checks are also part of an ES which has a separate payment per health check.  This means practices may wish to prioritise completing outstanding health checks before 31^st March to achieve this additional funding.