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InterQual Clinical Revisions

2016

Commercially developed clinical review criteria utilized by JHHC (Johns Hopkins HealthCare) 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. In May and June 2016, these Committees review the changes to the most recent InterQual 2016 Criteria for appropriateness of use in Utilization Management and policy decisions.


Child & Adolescent Psychiatry Criteria - Behavioral Health

  • The Child Psychiatry and Adolescent Psychiatry products have been combined into one product, Child and Adolescent Psychiatry.
  • Dual diagnosis criteria related to having a co-occurring substance use disorder are included in Child and Adolescent Psychiatry.
  • Levels of care previously identified in the Residential and Community-Based Treatment product are now included in the Child and Adolescent Psychiatry and the Residential and Community-Based Treatment product has been discontinued.
  • Procedures subsets have been removed from the Child and Adolescent Psychiatry criteria and a new Behavioral Health Procedures product has been created.
  • Inpatient and Observation levels of care have been separated and criteria have been added specific to Observation level of care.
  • Extensive content changes were made throughout Child and Adolescent Psychiatry including changes to terminology and criteria specific changes to improve consistency across products and to enhance usability by moving criteria formerly found in notes, into the criteria itself.
  • The format of the review has changed from Initial Review and Concurrent Review to review based on Episode Day to enhance usability by providing both initial and continued stay review in one workflow.
  • The Review Process has been updated to reflect the new format.

Adult & Geriatric Psychiatry Criteria - Behavioral Health

In response to the evolving needs of the behavioral market, McKesson has re-designed the Behavioral Health suite of criteria to help better manage the entire continuum of care within one workflow and provide better transparency of the criteria. The criteria now meet the patient where they are in a particular level of care. Below are the highlights:

  • The Adult Psychiatry and Geriatric Psychiatry products have been combined into one product, Adult and Geriatric Psychiatry.
  • Dual diagnosis criteria related to having a co-occurring substance use disorder are included in Adult and Geriatric Psychiatry.
  • Levels of care previously identified in the Residential and Community-Based Treatment product are now included in the Adult and Geriatric Psychiatry criteria and the Residential and Community-Based Treatment product has been discontinued.
  • Procedures subsets have been removed from the Adult and Geriatric Psychiatry criteria and a new Behavioral Health Procedures product has been created.
  • Inpatient and Observation levels of care have been separated and criteria have been added specific to Observation level of care.
  • The Homecare criteria has been expanded to the adult population and has been significantly updated to better represent an individual requiring psychiatric homecare including individuals who are not homebound but may need homecare to prevent residential placement.
  • Extensive content changes were made throughout Adult and Geriatric Psychiatry including changes to terminology and criteria specific changes to improve consistency across products and to enhance usability by moving criteria formerly found in notes, into the criteria itself.
  • The format of the review has changed from Initial Review and Concurrent Review to review based on Episode Day to enhance usability by providing both initial and continued stay review in one workflow.
  • The Review Process has been updated to reflect the new format.

Procedures - Behavioral Health

Procedure subsets have been removed from the Adult and Geriatric Psychiatry and the Child and Adolescent Psychiatry products and a new Behavioral Health Procedures product has been created.  Subsets created for Adolescent Electroconvulsive Therapy (ECT) Acute/Short Term, Adult Electroconvulsive Therapy (ECT) Acute/Short Term, and Geriatric Electroconvulsive Therapy (ECT) Acute/Short Term.


Substance Use Disorders - Behavioral Health

  • The Substance Use Disorders and Dual Diagnosis product has been renamed Substance Use Disorders.
  • Dual diagnosis criteria related to having a co-occurring substance use disorder have been incorporated, where applicable, into levels of care within the Substance Use Disorders, the Adult and Geriatric Psychiatry, and the Child and Adolescent Psychiatry products.
  • Levels of care previously identified in the Residential and Community-Based Treatment product are now included in the Substance Use Disorders criteria and the Residential and Community-Based Treatment product has been discontinued.
  • Inpatient and Observation levels of care are separated and criteria have been added specific to Observation level of care.
  • The format of the review has changed from Initial Review and Concurrent Review to review based on Episode Day to enhance usability by providing both initial and continued stay review in one workflow.
  • Inpatient Rehabilitation has been removed as a level of care and the appropriate criteria incorporated into Inpatient and Residential Treatment Center levels of care to better represent current practice.
  • Ambulatory Detoxification has been removed as a distinct level of care and detoxification criteria has been added to most levels of care to better represent current practice in allowing treatment for detoxification to occur in many levels of care.
  • Intensive Community-Based Treatment has been removed as a level of care within the Substance Use Disorder as the research does not support the effectiveness of these programs for a person with substance use disorders unless there is a co-occurring psychiatric disorder. The Child and Adolescent Psychiatry and the Adult and Geriatric Psychiatry products provide criteria for this level of care for adolescents with serious emotional disturbance or adults with severe and persistent mental illness and a co-occurring substance use disorder.
  • The Residential Treatment Center criteria have been extensively updated to better reflect the intent of the criteria in identifying an individual who requires 24-hour supervision without intensive medical monitoring and medical services.
  • The Supervised Living criteria has been extensively updated to better reflect the intent of the criteria in identifying an individual who is unable to reside within the community without intensive monitoring, supervision, and support.
  • The Partial Hospital criteria has been extensively updated to include individuals who are at risk for acute hospitalization, inpatient detoxification, or require step-down from a more intensive level of care and have the support and skills necessary to reside within the community.
  • The Intensive Outpatient Program criteria has been extensively updated to better reflect intent of criteria in identifying individuals who require treatment and clinical supervision at least 3 days per week to achieve or maintain abstinence.
  • The Outpatient criteria has been updated to better reflect individuals at risk for relapse, those with a history of substance use who require continued monitoring, and those individuals unable to achieve or maintain abstinence without treatment.
  • The Review Process has been updated to reflect the new format.

InterQual® Durable Medical Equipment (DME) – Care Planning

The following new subsets have been added:

  • Home International Normalized Ratio (INR) Monitoring Device
  • Home International Normalized Ratio (INR) Monitoring Device – Senior

Revisions have been made to the following subsets:

  • Prosthetics, Myoelectric, Upper Extremity
  • Transcutaneous Electrical Nerve Stimulation (TENS) - Senior
  • Transcutaneous Electrical Nerve Stimulation (TENS)

Revisions have been made to update the HCPCS codes for the following DME:

  • Prosthetics, Lower Extremity
  • Prosthetics, Lower Extremity - Senior
  • Prosthetics, Myoelectric Upper Extremity
  • Transcutaneous Electrical Nerve Stimulation (TENS)

InterQual® Procedures Criteria

The following new criteria have been added:

  • Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
  • Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent)
  • Arthroscopy, Surgical, Hip (Pediatric)
  • Electroconvulsive Therapy (ECT), Acute or Short-term
  • Electroconvulsive Therapy (ECT), Acute or Short-term (Adolescent)
  • Electroconvulsive Therapy (ECT), Continuation or Maintenance
  • Neuropsychological Testing
  • Neuropsychological Testing (Pediatric)
  • Transcranial Magnetic Stimulation (TMS)

Revisions have been made to the following criteria:

Cardiology
  • Angiogram, Coronary +/- Left Heart Catheterization (Procedure)
  • Cardiac Catheterization, Right Heart with Coronary Angiogram (Procedure)
  • Percutaneous Coronary Intervention (PCI)
Cardiothoracic
  • Antireflux Procedures, Endoscopic
  • Antireflux Surgery or Hiatal Hernia Repair
  • Coronary Artery Bypass Graft (CABG)
  • Left Ventricular Assist Device (LVAD) Insertion
General Surgery
  • Bariatric Surgery
  • Thyroidectomy, Partial or Total
Hand, Plastic & Reconstructive
  • Arthroplasty, Carpometacarpal (CMC) Joint, Thumb
  • Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers
  • Breast Implant Removal
  • Ganglion Cyst Excision
  • Nerve Repair, Wrist or Hand or Digit
  • Tendon Sheath Incision or Excision, Hand, Flexor
  • Tendon Transfer, Hand or Forearm
Neurosurgery
  • Artificial Disc Replacement, Cervical
  • Artificial Disc Replacement, Lumbar
  • Craniotomy
  • Decompression +/- Fusion, Cervical
  • Decompression +/- Fusion, Lumbar
  • Decompression +/- Fusion, Thoracic
  • Endovascular Intervention (Intracranial)
  • Fusion, Cervical
  • Fusion, Lumbar
  • Fusion, Thoracic
  • Interspinous Process Decompression
  • Scoliosis Surgery
  • Stereotactic Introduction, Subcortical Electrodes
  • Stereotactic Radiosurgery, Brain or Skull Base
  • Vertebroplasty or Kyphoplasty
Obstetrics & Gynecology
  • Ablation or Excision, Endometriosis, Laparoscopic
  • Hysterectomy, +/- Bilateral Salpingo- Oophorectomy (BSO) or +/- Bilateral Salpingectomy
  • Hysteroscopy + Dilatation and Curettage (D&C), Diagnostic
  • Hysteroscopy, Operative
  • Laparoscopy, Diagnostic (Pelvic)
  • Myomectomy
  • Uterine Artery Embolization (UAE)
Orthopedic - Lower Extremity
  • Amputation of Digit or Extremity
  • Arthrodesis, Ankle (Talotibial Joint)
  • Arthrodesis, Hip
  • Arthrodesis, Knee
  • Arthroscopy or Arthroscopically Assisted Surgery, Knee
  • Arthroscopy, Diagnostic. +/- Synovial Biopsy, Hip
  • Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee
  • Arthroscopy, Surgical, Ankle
  • Arthroscopy, Surgical, Hip
  • Arthrotomy, Ankle
  • Arthrotomy, Hip
  • Arthrotomy, Knee
  • Osteotomy, High Tibial
  • Osteotomy, Pelvic or Proximal Femur
  • Osteotomy, Supracondylar Femur
  • Prosthetic Replacement, Fracture, Hip (Proximal Femur)
  • Removal and Replacement, Total Joint Replacement (TJR), Hip
  • Removal and Replacement, Total Joint Replacement (TJR), Knee
  • Total Joint Replacement (TJR), Ankle
  • Total Joint Replacement (TJR), Hip
  • Total Joint Replacement (TJR), Knee
  • Unicondylar Knee Replacement
Orthopedic - Upper Extremity
  • Arthroscopy, Diagnostic +/- Synovial Biopsy, Shoulder
  • Amputation of Digit or Extremity
  • Arthroscopy or Arthroscopically Assisted Surgery, Shoulder
  • Arthroscopy or Arthroscopically Assisted Surgery, Wrist
  • Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist
  • Arthroscopy, Surgical, Elbow
  • Arthrotomy, Elbow
  • Arthrotomy, Shoulder
  • Arthrotomy, Wrist
  • Epicondyloplasty, Lateral, Elbow
  • Epicondyloplasty, Medial, Elbow
  • Joint Replacement, Elbow
  • Joint Replacement, Shoulder
  • Joint Replacement Wrist
  • Manipulation Under Anesthesia, Shoulder
  • Median Nerve Decompression, +/- Neurolysis, Wrist
  • Reduction and Fixation, Distal Radius +/- Ulna
  • Reduction and Fixation, Radius +/- Ulna Shaft
  • Removal and Replacement, Total Joint Replacement (TJR), Shoulder
  • Ulnar Nerve Decompression or Transposition, Elbow
  • Ulnar Nerve Decompression, Wrist
Pediatric
  • Bariatric Surgery (Adolescent)
  • Endoscopy, Upper Gastrointestinal (Pediatric)
  • Scoliosis Surgery (Pediatric)
  • Sleep Studies (Pediatric)
  • Thyroidectomy, Partial or Total (Pediatric)
  • Video Electroencephalographic (EEG) Monitoring (Pediatric)
  • Video Electroencephalographic (VEEG) Monitoring (Pediatric)
Podiatry
  • Tibial Nerve Decompression
Specialized Procedures
  • Colonoscopy
  • Discography, Spine Lumbar
  • Electromyography (EMG) and Nerve Conduction Studies (NCS)
  • Electromyelogram (EMG) and Nerve Conduction Studies (NCS)
  • Endoscopic Ultrasound (EUS)
  • Endoscopy, Upper Gastrointestinal
  • Epidural or Intrathecal Catheter Placement
  • Epidural Steroid Injection
  • Facet joint injection
  • Neuroablation, Percutaneous
  • Sacroiliac Joint injection
  • Sigmoidoscopy
  • Sleep Studies
  • Spinal Cord Stimulator (SCS) Insertion
  • Sympathetic Blockade
  • Sympathectomy
  • Transplantation, Autologous Stem Cell
  • Transplantation, Allogeneic Stem Cell
  • Transplantation, Cardiac
  • Transplantation, Renal
  • Transplantation, Liver
  • Vagus Nerve Stimulation
  • Video Electroencephalographic (EEG) Monitoring
  • Video Electroencephalographic (VEEG) Monitoring

Revisions have been made to update the CPT codes for the procedures documented above.


InterQual® SIM plus Criteria - Care Planning

SIM plus™ is the InterQual Surgical and Invasive Monitoring (SIM) tool. It is a valuable component of a comprehensive surgical case review program, providing an objective demonstration that surgery and/or invasive procedures were performed for clinically sound, properly documented indications.
SIM plus™ references patient-specific characteristics and tissue analysis to retrospectively evaluate the appropriateness of surgical and invasive procedures.

SIM plus™ helps answer these questions:

  • Was the surgery or invasive procedure clinically or medically appropriate?
  • Were appropriate medical or therapy interventions provided prior to the surgery or procedure?
  • Is there pathologic evidence that the procedure was performed adequately?
  • Is there tissue evidence of the procedure performed?

The following new subset has been added:

  • Artificial Disc Replacement, Cervical

Changes have been made to the following criteria:

Cardiology
  • Angiogram, Coronary +/- Left Heart Catheterization
  • Percutaneous Coronary Intervention (PCI)
Cardiothoracic
  • Antireflux Surgery/Hiatal Hernia Repair
  • Aortic Valve Replacement (AVR)
  • Coronary Artery Bypass Graft (CABG)
General Surgery
  • Bariatric Surgery
  • Thyroidectomy, Partial/Total
Hand, Plastic & Reconstructive
  • Ganglion Cyst Excision
  • Nerve Repair, Wrist/Hand/Digit
  • Tendon Sheath Incision/Excision, Hand, Flexor
Neurosurgery
  • Changed subset name "Discectomy, Lumbar" to "Discectomy, Percutaneous, Lumbar"
  • Craniotomy
  • Discectomy and Fusion, Anterior Cervical
  • Discectomy, Percutaneous, Lumbar
  • Fusion, Cervical Spine
  • Fusion, Lumbar Spine
  • Fusion, Thoracic Spine
  • Hemi-laminectomy, Cervical
  • Hemi-laminectomy, Lumbar
  • Laminectomy, Cervical, +/- Fusion
  • Laminectomy, Lumbar, +/- Fusion
  • Laminectomy, Thoracic, +/- Fusion
  • Scoliosis Surgery
  • Stereotactic Radiosurgery, Brain/Skull Base
  • Vertebroplasty or Kyphoplasty
Obstetrics & Gynecology
  • Hysterectomy and BSO, Abdominal
  • Hysterectomy and BSO, Laparoscopically Assisted Vaginal (LAVH)
  • Hysterectomy and BSO, Open/Laparoscopic Supracervical (LSH)
  • Hysterectomy and BSO, Total Laparoscopic (TLH)
  • Hysterectomy and BSO, Vaginal
  • Hysterectomy, Abdominal +/- Bilateral Salpingectomy
  • Hysterectomy, Laparoscopically Assisted Vaginal (LAVH) +/- Bilateral Salpingectomy
  • Hysterectomy, Open/Laparoscopic Supracervical (LSH) +/- Bilateral Salpingectomy
  • Hysterectomy, Total Laparoscopic (TLH) +/- Bilateral Salpingectomy
  • Hysterectomy, Vaginal +/- Bilateral Salpingectomy
  • Hysteroscopy, Operative
  • Myomectomy
Orthopedic
  • Retired subset “Arthrocentesis”
  • Retired subset “Arthroscopy, Diagnostic +/-Synovial Biopsy, Shoulder”
  • Retired subset “Biopsy/Excision, Muscle/Bone/Cartilage/Synovium Tumor”
  • Retired subset “Reduction, Closed Fracture/Dislocation”

Revisions have been made to the following subsets:

  • Amputation of Digit/Extremity
  • Arthrodesis, Ankle (Talotibial Joint)
  • Arthrodesis, Hip
  • Arthrodesis, Knee
  • Arthroscopically Assisted Surgery, Knee
  • Arthroscopically Assisted Surgery, Shoulder
  • Arthroscopically Assisted Surgery, Wrist
  • Arthroscopy, Surgical, Ankle
  • Arthroscopy, Surgical, Hip
  • Arthroscopy, Surgical, Knee
  • Arthroscopy, Surgical, Shoulder
  • Arthroscopy, Surgical, Wrist
  • Arthrotomy, Ankle
  • Arthrotomy, Elbow
  • Arthrotomy, Hip
  • Arthrotomy, Knee
  • Arthrotomy, Shoulder
  • Arthrotomy, Wrist
  • Joint Replacement, Shoulder
  • Median Nerve Decompression, +/- Neurolysis, Wrist
  • Osteotomy, High Tibial
  • Osteotomy, Pelvic/Proximal Femur
  • Osteotomy, Supracondylar Femur
  • Prosthetic Replacement, Fracture, Hip (Proximal Femur)
  • Reduction and Fixation, Radius, +/- Ulnar Shaft
  • Total Joint Replacement (TJR), Hip
  • Total Joint Replacement (TJR), Knee
  • Ulnar Nerve Decompression, Wrist
  • Ulnar Nerve Decompression/Transposition, Elbow
  • Unicondylar Knee Replacement
Pediatric
  • Bariatric Surgery (Pediatric)
  • Endoscopy, Upper Gastrointestinal (Pediatric)
Podiatry
  • Tibial Nerve Decompression
Specialized Procedures
  • Changed subset title “Epidural Catheter Placement” to “Epidural or Intrathecal Catheter Placement”
  • Changed subset title "Epidural Injection" to "Epidural Steroid injection"

Revisions have been made to the following subsets:

  • Colonoscopy
  • Endoscopy, Upper Gastrointestinal
  • Epidural or Intrathecal Catheter Placement
  • Epidural Steroid Injection
  • Paracentesis
  • Sigmoidoscopy

InterQual® Guidelines for Surgery and Procedures Performed in the Inpatient Setting

The following new procedures are appropriate for the inpatient setting based on InterQual® Procedures Criteria:

General - Thyroidectomy, Partial or Total

  • Radical Neck Dissection
  • Sternal Split
  • Transthoracic

Neurologic & Spine - Decompression +/- Fusion, Cervical

  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Vertebral Corpectomy and Fusion, Cervical
  • Multiple-level Laminectomy +/- Fusion, Cervical
  • Single-level Laminectomy with Fusion, Cervical
  • Laminoplasty, Cervical

Decompression +/- Fusion, Lumbar

  • Multiple-level Laminectomy +/- Fusion, Lumbar
  • Single-level Laminectomy with Fusion, Lumbar

Decompression +/- Fusion, Thoracic

  • Laminectomy +/- Fusion, Thoracic

 Orthopedic - Arthroscopy or Arthroscopically Assisted Surgery, Shoulder

  • Lavage of joint with joint aspirate diagnostic for infection

Arthroscopy or Arthroscopically Assisted Surgery, Wrist

  • Lavage of joint with joint aspirate diagnostic for infection

Arthroscopy or Arthroscopically Assisted Surgery, Knee

  • Lavage of joint with joint aspirate diagnostic for infection

Pediatric - Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)

  • Joint exploration post penetrating joint injury
  • Lavage of joint with joint aspirate diagnostic for infection
  • Reconstruction or repair of multiligamentous injury
  • Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent): Lavage of joint with joint aspirate diagnostic for infection
  • Arthroscopy Surgical, Hip (Pediatric): Lavage of joint with joint aspirate diagnostic for infection

Criteria - Specific Changes

  • Neurologic & Spine
  • Obstetric/Gynecologic
  • Orthopedic/Upper Extremity
  • Orthopedic/Lower Extremity
  • Specialized Procedures

InterQual® Level of Care: Acute Adult Criteria

Review Process Updates

  • Benchmark length of stay was added to software in order to facilitate management of a patient to a specific length of stay target.
  • Care management information was added to assist in tracking patient progress toward expected goals, while addressing barriers to clinical progression as they arise.

Global Revisions at the ACUTE Level of Care

  • Blood Sugar - range documented and frequency clarified
  • COPD - added to Findings - arterial Pco2
  • Ileus - removed requirement for imaging
  • Orthostatic hypotension - added definition
  • Bleeding - added platelet count and definition of orthostatic hypotension to Findings
  • Heart Failure - added worsening edema and daily med adjustment for diuresis
  • Hyponatremia or SIADH - added Sodium chloride 0.9%
  • Acute Kidney Injury - added clinical value for creatinine to Findings; added dialysis to Interventions
  • Medications - added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Global Revisions at the INTERMEDIATE Level of Care

  • Medications - added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Global Revisions at the CRITICAL Level of Care

  • Acute Kidney Injury - added clinical indications for potassium and sodium monitoring; added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Criteria - Specific Changes

  • Acute Coronary Syndrome (ACS)
  • Anemia-Bleeding
  • Antepartum
  • Arrhythmia
  • Extended Stay N/A – not clinically stable for discharge, but exhaust the episode days for the primary condition-specific or general subset
  • Heart Failure
  • Hypertensive Disorders of Pregnancy
  • Pneumonia
  • Postpartum Complication after Discharge
  • Sickle Cell Crisis
  • General Trauma
  • General Medical
  • General Surgical

InterQual® Level of Care: Acute Pediatric Criteria

Review Process Updates

  • Benchmark length of stay was added to software in order to facilitate management of a patient to a specific length of stay target
  • Care management information was added to assist in tracking patient progress toward expected goals, while addressing barriers to clinical progression as they arise

Global Revisions at the ACUTE Level of Care

  • Blood Sugar – range documented, frequency clarified, and use of oral hypoglycemic agent added
  • Orthostatic hypotension – added definition
  • Bleeding – added platelet count, heart rate by age range, and definition of orthostatic hypotension to Findings
  • Hyponatremia or SIADH – added Sodium chloride 0.9%
  • Ileus – removed requirement for imaging
  • Acute Kidney Injury – added clinical value for creatinine to Findings; added dialysis to Interventions
  • Medications – added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Global Revisions at the INTERMEDIATE Level of Care

  • Medications – added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Global Revisions at the CRITICAL Level of Care

  • Acute Kidney Injury – added clinical indications for potassium monitoring; added clinical ranges for hemodynamic instability
  • Medications - added Branched-chain amino acids (BCAA) (includes PO) and L-ornithine L-aspartate (LOLA) to meds

Criteria - Specific Changes

  • Anemia-Bleeding
  • Antepartum
  • Asthma
  • Bronchiolitis
  • Carbon Monoxide Poisoning
  • Croup
  • Extended Stay N/A – not clinically stable for discharge, but exhaust the episode days for the primary condition-specific or general subset
  • Hyperbilirubinemia
  • Hypertensive Disorders of Pregnancy
  • Pneumonia
  • Postpartum Complication after Discharge
  • Sickle Cell Crisis
  • General Trauma
  • General Medical
  • Nursery
  • General Surgical

InterQual® Home Care Criteria

There are no significant changes to the 2016 criteria. Citations have been added to support criteria


InterQual® Level of Care: Outpatient Rehabilitation & Chiropractic Criteria

Criteria - Specific Changes

  • Lymphedema

Global Revisions

  • Intensity of Service – added definition of Orthostatic hypotension: The American Autonomic Society and the American Academy of Neurology use the terminology “orthostatic hypotension” and define it as and a drop in SBP of at least 20 mm or DBP drop at least 10 mm

Criteria - Specific Changes

  • CNS/TBI
  • Medically Intensive Severity of Illness
  • Medically Intensive Intensity of Service
  • Medically Intensive Discharge Screens
  • Subacute Rehabilitation Severity of Illness
  • Subacute Rehabilitation Intensity of Service
  • Subacute Rehabilitation Discharge Screens

InterQual® Level of Care: Subacute & SNF Criteria

Global Revisions

 Severity of Illness
  • changed “inability to ingest food” to “nutritional route not established”
  • changed “CVA” to “stroke”
  • changed, in all Adult subsets: “Impairment (new) with functional activity limitation requiring at least minimum assistance, ≥ One” to “Impairment (new) with functional limitation requiring at least minimum assistance, ≥ One”

Intensity of Service

  • changed, in all Adult subsets: “Mental status assessment ≥ 1x/24h, ≥ One” to “Neurological assessment ≥ 1X/24h, ≥One”
  • added, in all Adult subsets: “Branched-chain amino acids (BCAA) (includes PO)” and “L-ornithine L-aspartate (LOLA)”
  • changed, in all Adult subsets: “Administration, One: Symptoms unresponsive, Increased side effects, Initiation ≤ 2d” to “Administration, One: Adjustment, ≥ One: Adverse side effects, Symptoms unresponsive, Initiation ≤ 2d”
  • added to ALL subsets: “Medical instability (new onset) and decreased participation in therapy < 2h/d for ≤ 3d (excludes admission review), ≥ One
    • Chest pain (excludes suspected or known cardiac etiology)
    • COPD exacerbation and increase in baseline treatment
    • Drug induced fever suspected, Both: T > 99.4°F (37.4°C) PO, new onset, Precipitating drug discontinued ≤ 3d
    • DVT
    • Dyspnea at rest
    • Exercise or activity program induced instability, ≥ One: Hypoglycemic symptoms requiring adjustment, ≥One; Insulin; Diet, parenteral, or enteral feedings; O2 sat < 90% (0.90) with minimal exertion requiring
    • Infection, actual or suspected, Both: Finding, ≥ One: T > 99.4°F (37.4°C) PO; WBC > 13,000/cu.mm (13x109/L); Bands > 10% (0.10) Intervention,≥ One; Intervention Anti-infective (includes PO), Culture pending ≤ 2d, Imaging study ≤ 24h
    • Mental status change and neurological assessment ≥ 4x/24h
    • Neurological deficit and neurological assessment ≥ 4x/24h
    • Oxygenation < baseline and requiring supplemental oxygen, ≥One: O2 sat 89-91% (0.89-0.91), Arterial Po2 56-60 mmHg (7.5-8.0 kPa)
    • Uncontrolled pain requiring new pain management regimen
    • R/O fracture after fall and imaging studies scheduled or pending ≤ 1d
    • Vomiting or diarrhea and IV fluids ≥ 50 mL/h
    • Orthostatic hypotension, Both: Sustained drop in blood pressure within 3 min of sitting or standing, Blood pressure, ≥One,  Systolic BP drop 20mmHg, Diastolic BP drop, 10 mmHg
    • Wound dehiscence
  • changed “TPN or PPN” to “Parenteral nutrition”

Discharge Screens - Changed in All Adult Subsets

  • changed in all Adult subsets: “O2 sat within acceptable limits or baseline” to “O2 sat ≥ 92% (0.92) or within acceptable limits”
  • changed “labs within acceptable limits or baseline” to “labs within acceptable limits”
  • changed “hemodynamic and neurological stability ≥ 24h” to “hemodynamic stability ≥ 24h, neurological stability ≥ 24h
  • changed in all Adult subsets “drug levels within therapeutic range or baseline” to “drug levels within therapeutic range”
  • changed “tolerating PO fluids or nutritional route established” to “tolerating PO or nutritional route established”

Criteria - Specific Changes

  • Level I (SNF) – SI
  • Level I (SNF) – IS
  • Level II (SAC) – SI
  • Level II (SAC) – IS
  • Level II (SAC) – DS
  • Level III (Complex Care) – SI
  • Level III (Complex Care) – IS
  • Level III (Complex Care) – DS
  • Pediatric Subacute – SI
  • Pediatric Subacute – IS
  • Pediatric Subacute – DS