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InterQual Clinical Revisions

Commercially developed clinical review criteria utilized by JHHC include the current version of InterQual®. JHHC annually purchases the full range of tools offered through McKesson. 
 
JHHC annually reviews the UM criteria and the procedures for applying them, and updates the criteria when appropriate.  All commercial clinical review criteria are reviewed by JH Scientific Evidence Evaluation and Policy Advisory Committee (SEEPAC) and approved by the JH Medical Policy Committee (MPC), prior to adoption.  May and June 2015, these Committees approved the change to the most recent InterQual 2015 for Utilization Management and policy decisions.
 

InterQual 2015 Summary of Clinical Revisions 

The summary outlines the revisions from McKesson of the InterQual 2015 criteria.  These revisions are based upon the latest changes in clinical evidence. The list below is not meant to represent all inclusive changes. The 2015 clinical revisions documents are available on the McKesson Customer Hub and can be found in the books.

Johns Hopkins HealthCare LLC license includes the following criteria:

  • Acute Adults/Pediatric
  • Rehabilitation (Inpatient) 
  • Subacute/Skilled Nursing Facility (SNF)
  • Home Care/Durable Medical Equipment (DME)
  • Outpatient Rehabilitation and Chiropractice Care
  • Surgery and Procedures
  • Behavior Health
    • Adults Psychiatric
    • Child Psychiatry
    • Adolescent Psychiatric
    • Residential & Community-Based Treatment
    • Substance Use Disorders & Dual Diagnosis
    • Geriatric Psychiatric

For 2015, the following subsets were added, reorganized, and criteria were updated to reflect the latest changes in the clinical evidence, to ensure consistency among subsets, and to clarify intent of the criteria as indicated:

Acute Adult & Pediatric Criteria

 

Added a new subset for Syncope

 

Anemia/Bleeding

 

o  

Added bladder irrigation

 

Arrhythmia subset

 

o  

Observation level of care is met for A fib/A flutter once resolved following ibutilide administration

 

Asthma subset

 

o  

Added ongoing dyspnea and abnormal vital signs to partial responder

 

Bronchiolitis criteria

 

o  

Criteria no longer support the use of continuous pulse oximetry in infants and children diagnosed with bronchiolitis based upon the AAP guidelines

 

COPD

 

o  

Included comorbid conditions

 

o  

Decreased bronchodilators administration to 4X/24h and added Clinical Assessment criteria similar to Asthma

 

Heart Failure subset

 

o  

Added criteria to address comorbid conditions

 

o  

Removed requirement for left v. right sided failure with  focus on the interventions (O2 sat, dyspnea, HR & weight gain)

 

Hypertensive Disorders of pregnancy

 

o  

Changed B/P monitoring from 6X/24H to at least 3X/24H

 

Inflammatory Bowel Disease

 

o  

Updated  each episode day to require both immunosuppressant, & IV or parenteral nutrition

 

Infection subsets

 

o  

Updated criteria for patients with failed outpatient RX

 

o  

Added:  Ebola, Dengue Fever, and Typhoid Fever

 

Pancreatitis subset

 

o  

The NPO requirement was removed  but patient must require IV support

 

o  

The Pediatric Age specific criteria was changed from >3 YRS to  age > 3 YRS

 

General Medical Criteria

 

o  

Detox/Withdrawal Management criteria identifying the type of withdrawal based on the physically addicting substance used

 

o  

Anaphylaxis was separated from Angioedema, and both conditions focus on specific conditions and interventions

 

o  

Hypokalemia was moved to the Observation level of care, and criteria for ”failed Out-Patient management (OBS)“ was added to the Acute level of care

 

o  

Nursery subset

 

 

§   

Age parameters were removed and criteria now refer to infant’s gestational age with an explanatory note to indicate parameters    

 

 

Rehabilitation Criteria (Inpatient)

 

Under IS (Intensity of Service)

 

o  

Changed pain or spasm to: pain and spasm under the initial evaluation

 

o  

Under Partial responder, multiple changes were made to clarify the intent of the criteria:

 

 

1.

Changed functional mobility (transfers, ambulation, or wheelchair mobility) to: functional mobility >  One:  transfers, ambulation, or wheelchair mobility

 

 

2.

Changed DVT (new) treatment to: DVT

 

 

3.

Changed Dyspnea (new onset) to: Dyspnea

 

 

4.

Changed Hypoglycemic symptoms requiring adjustment in insulin, TPN, tube feed, or diet to: Hypoglycemic symptoms requiring adjustment, One: Insulin, diet, TPN, PPN, or enteral feedings

 

 

5.

Added: Medication induced

 

 

6.

Under Infection, actual or suspected now requires a WBC >13.0 and a new onset of temp >99.4 and precipitating drug discontinued < 3d

 

 

7.

Changed R/O fracture after fall > 1d and imaging studies scheduled or pending to: R/O fracture after fall and imaging studies scheduled or pending > 1d

 

 

 

8.

Acute Adult subsets

 

 

 

a.

Changed chest pain (new onset) to: Chest pain (excludes suspected or known cardiac etiology)

 

 

 

b.

Changed Hypoglycemic symptoms requiring adjustment in insulin, TPN, tube feed, or diet to: Hypoglycemic symptoms requiring adjustment > One: Insulin, Diet, TPN, PPN, or enteral feedings

 

 

 

c.

Changed O2 sat < 90% (0.90) with minimal exertion and O2 supplement to: O2 sat < 90% (0.90) with minimal exertion requiring supplemental oxygen

 

 

 

d.

Changed Sustained chest pain, dyspnea, syncope, or pre-syncope requiring diagnostic evaluation, medication or intervention to: Sustained or prolonged symptoms requiring diagnostic evaluation, medication, or intervention >  One: Dyspnea, Syncope, Pre-syncope

 

 

 

e.

Added Postural hypotension, Both: Sustained drop in blood pressure within 3 min of sitting or standing and blood pressure >  One: Systolic BP drop > 20 mmHg or Diastolic BP drop > 10 mmHg

 

Under DS (Discharge screens)

 

o  

Added to Skilled Medical or Therapy and also added to Subacute Medical or Therapy, prior to facility transfer, completion is required for: comprehensive written discharge and teaching instructions, medication reconciliation, facility forms, obtaining and transmitting a discharge summary to facility and medical practitioner, and arranging transportation

 

 

Subacute/Skilled Nursing Facility (SNF) Criteria

 

Under SI (Severity of Illness)

 

o  

Added Diabetic Ulcer

 

o  

Changed venous status ulcer to: peripheral vascular ulcer

 

o  

Changed loss or damage of skin > 15%  to: > 10%

 

o  

Changed post craniotomy to: post cranial surgery

 

o  

Hepatic encephalopathy, stage II requires > symptom: Asterixis, drowsiness, intermittent disorientation, lethargy or slurred speech

 

o  

Infection now only requires anti-infective 

 

o  

Changed cardiac or peripheral vascular or respiratory condition > 1 to: Cardiovascular, peripheral vascular or respiratory condition > 1

 

o  

Changed Heart Failure (HF) or CAD to: HF and CAD

 

o  

Changed COPD or interstitial lung disease to: COPD and interstitial lung disease

 

o  

Wound (surgical, traumatic, or malignant) changed to selecting criteria for specific wound type

 

Under DS (Discharge screens)

 

o  

Clinical stability from > 48 to > 2d

 

o  

Medical reconciliation is to be completed prior to discharge to include the following: Follow-up care planned, written discharge & teaching instruction reviewed, where to seek medical help, transportation needs are to be identified and addressed

 

 

Home Care

 

Durable Medical Equipment (DME)

 

Added a subset: Continuous Glucose Monitors

 

Streamlined review process to allow users to conduct a single review that includes all skilled disciplines  as opposed to separate reviews for each requested service

 

Pediatrics - Removed recommendation “Transport Chair”

 

Added indicators: Cardioverter Defibrillator Wearable –“initial request”, ongoing and replacement parts only

 

Added indicators: Patient Lift-System-Senior

 

Changed: Cardiopulmonary To: Cardiopulmonary with impaired endurance

 

Changed: Encephalitis To: CNS infection

 

Changed: Ventilator dependent To: Tracheostomy or ventilator dependent

 

Added: Fluency Resonance

 

Changed: Cognitive techniques To: Cognitive-communication techniques

 

Changed: Augmentative communication To: Augmentative or alternative communication

 

Changed: Dysarthria therapy To: Apraxia or dysarthria therapy

 

Added: ADL and/or IADL

 

Changed: Autism/Pervasive Developmental Disorder To: Autism Spectrum Disorder

 

Added: Initiate or continue teaching of alternative communication or speech generating device

 

 

Outpatient Rehabilitation & Chiropractic Care

 

Added: a subset for pulmonary rehabilitation

 

Ligamentous injury, Ankle Rehabilitation

 

o  

Grade II/III instability of LCL/deltoid ligament To: Grade II or III lateral ankle sprain

 

o  

Added balance to therapeutic exercise

 

Ligamentous/Meniscal  Injury, Knee Rehabilitation

 

o  

Added to criteria: neuromuscular education to improve proprioception and balance

 

Added: Improved hamstring muscle strength and Improved proprioception and balance

 

Osteoarthritis, Knee Rehabilitation

 

o  

Confirmed by imaging

 

o  

Added neuromuscular education for proprioception and balance to initial and ongoing review

 

o  

Soft Tissue Disorders, Knee Rehabilitation

 

o  

Added patellar instability, iliotibial band syndrome and  patellar tendinopathy

 

o  

Changes were related to improving balance as a component of therapy

 

o  

Added improved hamstring muscle strength with a goal of 4/5 to 5/5 upon discharge

 

 

Surgery and Procedures

 

New Procedures

 

o  

Capsule Endoscopy (Pediatric)

 

o  

Cryoablation, Prostate

 

o  

Cystolithotomy (Pediatric) Endovascular Repair, Thoracic Aortic Aneurysm

 

o  

Transcatheter Aortic Valve Replacement (TAVR)

 

o  

Thoracic Aortic Aneurysm Endovascular Repair + Stenting

 

o  

Thoracic Endovascular Aneurysm Repair (TEVAR)

 

o  

Thyroidectomy, Partial or Total (Pediatric)

 

o  

Endovascular Repair, Thoracic Aortic Aneurysm

 

o  

Segmentectomy, Lung

 

o  

Cystostomy, Open (Pediatric)

 

Procedures Requiring Secondary Reviews

 

o  

Antireflux Procedures, Endoscopic

 

o  

Lung Volume Reduction Surgery (LVRS)

 

o  

Transcatheter Aortic Valve Replacement (TAVR)

 

o  

Artificial Disc Replacement

 

o  

Cervical Artificial Disc Replacement Lumbar

 

o  

Interspinous Process Decompression

 

o  

Oro-Maxillo-Facial, Dental & Otolaryngology

 

o  

Uvulopalatopharyngoplasty (UPPP)

 

o  

Total Joint Replacement (TJR), Ankle

 

o  

Discography, Spine, Lumbar

 

o  

Gastric Stimulation

 

o  

Penile Implant Insertion

 

 

Behavior Health

 

Adolescent, Adult, and Residential & Community-Based Treatment Criteria

 

o  

Added subset for psychological testing

 

o  

Changed “self-mutilation” to “Non-suicidal self-injury”

 

o  

Time requirements removed in concurrent review  and added to specific criteria

 

o  

For all subsets except Eating Disorder Program recommendations updated to include medication management

 

Child Psychiatry

 

o  

Updated outpatient program recommendations to include medication management

 

o  

Time requirements removed in concurrent review  and added to specific criteria

 

Substance Use Disorders & Dual Diagnosis

 

o  

Changed “Manic/Hypomanic” to “Mania/Hypomania”

 

o  

Time requirements removed in concurrent review  and added to specific criteria

 

o  

Changed “homeless” to “homeless and temporary housing unavailable” for  a Levels of Care recommendation of Inpatient Rehabilitation

 

o  

Updated treatment plan from goal directed to recovery-oriented treatment plan

 

o  

Changed “self-mutilation” to “non-suicidal self-injury”

 

 

 

Geriatric Psychiatry

 

o  

Changed “self-mutilation” to “non-suicidal self-injury”

 

o  

Time requirements removed in concurrent review  and added to specific criteria

 

o  

Removed “Severe psychiatric medication reaction” from Clinical Findings, Immediate Safety Risk in all Continued Stay Alternate Levels of Care