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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 2014, these Committees approved the change to the most recent InterQual 2014 for Utilization Management and policy decisions.

InterQual 2014 Summary of Clinical Revisions 

The summary outlines the revisions from McKesson of the InterQual 2014 criteria.  These revisions are based upon the latest changes in clinical evidence. The list below is not meant to represent all inclusive changes. The 2014 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
  • Home Care
  • Rehabilitation (Inpatient) 
  • Subacute/Skilled Nursing Facility (SNF)
  • Outpatient Rehabilitation and Chiropractice Care
  • Procedures/Durable Medical Equipment (DME)
  • Behavior Health
    • Adults Psychiatric
    • Child Psychiatry
    • Adolescent Psychiatric
    • Residential & Community-Based Treatment
    • Substance Use Disorders & Dual Diagnosis
    • Geriatric Psychiatric

For 2014, the following subsets were reorganized and consolidated:

  • Antepartum/Postpartum to include 4 separate subsets:
    • Antepartum
    • Labor and Delivery
    • Postpartum Complication after Discharge
    • Hypertensive disorder of pregnancy
  • Nursey: Added Neonatal Intensive Care Level IV nursery
  • Hyperbilirubinemia: Added Neonatal Intensive Care Level IV for patients requiring a double volume exchange transfusion
  • General Surgical subset: Contains all surgical criteria. The GI Surgery criteria were integrated within the subset. A note has been added to direct the reviewer to the procedure as estimated as Short, Moderate and Long Stay.
  • General Transplant moved to surgical category
  • Anemia/Bleeding:
    • Extended LOS for Hemoptysis to Episode Day 4
    • Extended the LOS for Variceal bleed to Episode Day 5 monitoring
  • Epilepsy:
    • Added criteria for planned Video EEG Monitoring
  • Sickle Cell Crisis:
    • Changed IV fluid criteria to allow for PO intake and adjusted the rates to better align with the guidelines
  • General Medical Criteria:
    • Updated electrolyte criteria-allowing for those patients with hospital acquired electrolyte imbalance
    • Updated criteria for feeding disorders requiring medical stabilizations
    • Updated TB criteria to allow for oral anti-infective treatment
    • Intermediate & Critical: updated the sepsis criteria based on new guidelines
    • Updated hypothermia criteria
    • Pleural effusion: added criteria for Chest tube to Water seal criteria
    • Changed Blood Sugar values
      • Responder= 70-250
      • Partial responder= >250
  • Home Care:
    • Care required in home setting:
      • Homebound:
        • Requires the use assistive device or special transportation (ambulance or chair car)
        • Require assistance of another person
        • Medical contraindications to leaving home
        • Requiring a considerable & taxing effort to leave the home
      • Skilled Nursing Wound Care (Adult & Pediatric) added:
        • Biologic dressings < 2 visits < wks.
        • Skin flap or graft < 1 visit <2 wks.
      • Skilled Nursing High Risk OB: Changed PIH & preeclampsia changed to pregnancy induced HTN
  • Outpatient Rehabilitation & Chiropractice (ORC):
    • New subsets: Cardiac Rehabilitation: Rehabilitation & Maintenance Therapy
    • Rehab & Chiropractic: Changed SD goals met to symptoms or findings no longer present or baseline
    • Spinal Disorders/Cervical Rehabilitation: Under severe limitations changed to <12 visits <4 wks.
  • Care Planning: Procedures:
    • New procedures: Bariatric Surgery, Adolescent & Skin Substitute Graft
      • Guidelines for Surgery & Procedures in the inpatient setting:
        • Bariatric Surgery (Revisional)
        • Skin Substitute Graft
        • Uterine Artery Embolizations (UAE) - Postpartum uterine bleeding <24 hours post-delivery/post hysterectomy bleed
        • Radiofrequency Ablation (RFA), liver: open
  • Behavior Health:
    • For consistency across the IQ products the age for which to apply the criteria has changed:
      • Adolescent changed from 13 to 17 to ages 13 through 17 yo
      • Adult subsets changed from 17 to 65 to 18 years through 64 yo
      • Child age changed from 4 to 12 to ages 4 through 12 yo
    • Updated notes to reflect changes from DSM-5 (Diagnostic and Statistical Manual of Mental Disorders Implementation)
    • Adult, Child, Adolescents: Changed name of subset Disruptive Behavior/Reckless Impulsive (Adult) to Behavioral Disturbance
    • Adult & Geriatric Symptoms to Mania listed: Changed excessive involvement in pleasurable activities with potential of painful consequences to excessive involvement in activities with potential for painful consequences
    •  Preoccupation with getting high/past drug experiences changed to preoccupation with using substances/past substance abuse and associated experiences 





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