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InterQual Clinical Revisions

2017

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 the JHHC Medical Policy Advisory Committee (MPAC)  and approved by the JHHC Quality Assurance Process Improvement (QAPI) committee, prior to adoption. In August and September 2017, these Committees review the changes to the most recent InterQual® 2017 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.
  • The age range for the Eating Disorder criteria has been removed based on consultant consensus that the criteria can be used for individuals exhibiting eating disorder symptoms, who are under the age of 12.
  • For "Symptom improved and discharge expected today" and "Symptom worsening and more intensive level of care indicated" sections, under "High risk of rehospitalization (see Intensive Outpatient Program criteria)," removed "Cognitively able to participate in treatment program" to be consistent with changes made to content for Intensive Outpatient Program, and changed "Requires treatment at least 3 times a week for at least 3 hours per day" to "Requires treatment at least 3 days a week for at least 3 hours per day" to clarify intent.
  • For "Symptom improved and discharge expected today" and "Symptom worsening and more intensive level of care indicated," Eating disorder symptom severe and treatment not expected to be successful in less intensive level of care (see Residential Treatment Center criteria), removed "Medically stable", and added "Treatment not expected to be successful in less intensive level of care" to be consistent with changes made to content for Residential Treatment Center.
  • For "Symptom improved and discharge expected today" under "Patient with serious emotional disturbance", changed "Patient unable to maintain behavioral control for more than 48 hours and improvement expected within next 2 weeks (see Subacute Care criteria)" to "Inconsistent ability to maintain behavioral control and responsive to 24-hour staff interventions (see Subacute Care criteria)" to be consistent with changes made to content for Subacute Care.

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.
  • For "Symptom improved and discharge expected today" and "Symptom worsening and more intensive level of care indicated" sections, under "High risk of rehospitalization (see Intensive Outpatient Program criteria)," removed "Cognitively able to participate in treatment program" to be consistent with changes made to content for Intensive Outpatient Program and changed "Requires treatment at least 3 times a week for at least 3 hours per day" to "Requires treatment at least 3 days a week for at least 3 hours per day" to clarify intent.
  • In "Symptom improved and discharge expected today" and "Symptom worsening and more intensive level of care indicated," sections changed "Eating disorder symptom severe and treatment not expected to be successful in less intensive level of care " to "Eating Disorder symptom severe and added new subcriteria to be consistent with changes made to content for Residential Treatment Center.

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.

Revisions:

  • Adolescent Electroconvulsive Therapy (ECT) Acute/Short-Term: Removed the subcriteria under Acute Mania.
  • Adult and Geriatric Electroconvulsive Therapy (ECT) Acute/Short-Term: Removed the subcriteria under Acute Mania

The following new subsets have been added:

  • Stereotactic Introduction, SubcorticaI Electrodes subset added to Adult Procedures and Geriatric
  • Procedures
  • Vagus Nerve Stimulations added to Adult Procedures and Geriatric Procedures

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.
  • For "Symptom  worsening  and  more  intensive  level of care  indicated" sections,  under "Acute danger  to self or others or gravely  disabled"  removed  the criteria  points "Age  18 or older  (see  InterQual®  Adult and Geriatric Psychiatry  Inpatient  criteria)" and "Age  13 thru 17  so that  it now  reads as "Acute danger to self or others  or  gravely disabled
  • For "Symptom improved and discharge expected today" and "Symptom worsening and more intensive level of care indicated" sections, under "High risk of rehospitalization and "High risk of rehospitalization or readmission to residential treatment removed "Cognitively able to participate in treatment program changed to "Requires treatment at least 3 days a week for at least 3 hours per day" to clarify intent
  •  In the following levels of care: Inpatient, Inpatient Detoxification, Inpatient Rehabilitation and Observation for "Symptom improved and discharge expected today" under "Co-occurring serious emotional disturbance and age 13 thru 17", changed "Patient unable to maintain behavioral control for more than 48 hours and improvement expected within next 2 weeks to "Inconsistent ability to maintain behavioral control and responsive to 24-hour staff interventions.
  • In the following levels of care: Inpatient and Inpatient Detoxification under "Symptom improved and discharge expected today" added "Requires nursing observation and monitoring 24 hours per day of co­ occurring psychiatric or medical condition or pregnancy and minimizes or lacks understanding  of consequences of substance  use on condition.
  • In the following levels of care: Observation, Residential Treatment, Supervised Living, Partial Hospital Program, Intensive Outpatient Program and Outpatient Program, under "Symptom worsening and more intensive  level of care indicated" added "Lack of motivation  or cognitive  impairment  or lack of self­-efficacy interferes with treatment in less intensive level of care and high risk of relapse without  24  hour nursing  observation  and monitoring.
  • For "Symptom improved  and discharge expected  today" and "Symptom  worsening and more intensive
    level of care indicated," sections, removed "In lieu of residential based care or patient homebound and requires skilled  nursing care or assessment at least 1 time per  week.

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
  • Enteral and Parenteral NutritionTherapy
  • Enteral and Parenteral Nutrition Therapy - Senior

Revisions have been made to the following subsets:

  • Prosthetics, Myoelectric, Upper Extremity
  • Transcutaneous Electrical Nerve Stimulation (TENS) - Senior
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • The criteria for review and evaluation by a RESNA- certified Assistive Technology Professional are not necessary for Group 2 power wheelchairs with no power options when patients weigh more than 300 pounds.

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:

  • Ambulatory  Phlebectomy,  Varicose Vein
  • Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
  • Arthroscopy or Arthroscopically Assisted Surgery, Shoulder (Adolescent)
  • Arthroscopy, Surgical, Hip (Pediatric)
  • Cholangiogram, Intraoperative (Pediatric)
  • Cholecystectomy, Laparoscopic (Pediatric)
  • Electroconvulsive Therapy (ECT), Acute or Short-term
  • Electroconvulsive Therapy (ECT), Acute or Short-term (Adolescent)
  • Electroconvulsive Therapy (ECT), Continuation or Maintenance
  • Gender Reassignment Surgery
  • High intensity Focused Ultrasound (HlFU)
  • Hyperbaric Oxygen Therapy
  • Neuropsychological Testing
  • Neuropsychological Testing (Pediatric)
  • Transcranial Magnetic Stimulation (TMS)
  • Vaginal Delivery, Early Elective

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
  • Cesarcao Section, During Labor (Pediatric)
  • Cesarean Section, Prior to the Onset of Labor (Pediatric)
  • Cholangiogram, lntraoperative (Pediatric)
  • Cholecystectomv, Laparoscopic (Pediatric)

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) ​(AVR-Changed recommendation "Aortic Valve Replacement (AYR)" to "Current evidence doe not support procedure in this clinical scenario" under "Aortic regurgitation (AR) by imaging" when "Other clinical  information"  is selected
  • Coronary Artery Bypass Graft (CABG)
General Surgery
  • Bariatric Surgery - Changed setting for "Removal, revision, or replacement of adjustable gastric band (AGB) device  or  port" from "Inpatient" to "Outpatient"
  • 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" Neuroablation, Percutaneous-for cervical and/or lumbar facet joint pain-Changed "Repeat cervical neuroablation within 12 months of initial neuroablation" to "Repeat cervical and/or lumbar neuroablation"

Revisions have been made to the following subsets:

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

Revisions to medical codes to include the following:

  • Craniotomy
  • Decompression+/- Fusion , Cervical, Lumbar, thoracic spine
  • Electromyography (EMG)  and  NerveConduction Studies (NCS) Electromyography (EMG) and Nerve Conduction Studies (NCS)
  • Fusion, Cervical, Lumbar and Thoriatic spine
  • Gender Reassignment Surgery
  • Hysterectomy, +/- Bilateral Salpingo-OOphoectomy (BSO) or Bilateral Salpingectomy Hysterectomy for pelvic pain, endometriosis, fibroids, abnormal uterine bleeding, endometrial hyperplasia, lynch II syndrome and gene mutation

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.
  • In the HOME CARE DISCHARGE SCREEN, change OP management contraindicated or unavailable to Outpatient management

The following are new subsets for Acute Adult:

  • Hypertension
  • Electrolvte or Mineral Imbalance

  • Stroke

  • TIA

Initial Review content was added to the following subsets to help the reviewer determine whether a patient is appropriate for Observation or inpatient admission at the time a decision to admit the patient is being made.

  •  Acute Coronary Syndrome (ACS)
  • Anemia/Bleeding
  • Arrhythmia
  • Asthma
  • Cholecystitis
  • COPD
  • Diabetes Mellitus
  • Diabetic Ketoacidosis
  • Deep Vein Thrombosis
  • Electrolyte or Mineral Imbalance
  • Heart Failure
  • Hypertension
  • Hyperosmolar Hyperglycemic State
  • Hypoglycemia
  • Inflammatory Bowel Disease
  • Infection: CNS
  • Infection: Endocarditis
  • Infection: GI/GU/GYN
  • Infection: Musculoskeletal
  • Infection: Pneumonia
  • Infection: Skin
  • Pancreatitis
  • Pulmonary Embolism
  • Stroke
  • Syncope
  • TIA
  • General Trauma
  • General Medical

Responder and Non-responder days have been adjusted based on length of stay. Responder criteria appear starting on Episode Day 2 and are designated as “Early responder” in the following subsets:

  • Acute Coronary Syndrome
  •  COPD
  •  Deep Vein Thrombosis
  •  Epilepsy
  • Heart Failure
  • Hyperosmolar Hyperglycemic State
  • Infection GI/GU/GYN
  • Pancreatitis
  • Pulmonary Embolism
  • Syncope
 

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
  • Responder to Early Responder, discharge expected today if clinically stable last 12h, and added to the finding: Complication or comorbidity and clinically stable for discharge
  • Changed New onset infection, requires WBC < 13.0
  • Bleeding, actual or suspected from Hct and Hb decreased last 24 h to Hct or Hb decreased last 24h
  • COPD, in addition to arterial PCO2 ≤ 60 now requires an arterial or venous PO2 > baseline
  • Heart Failure- no longer requires continuous heart monitoring
  • Ileus unresolved added Nasogastric tube to suction and chronic heart failure under IV fluid
  • New onset infection, actual or suspected, changed WBC > 13.0
  • Pneumonia changed respiratory intervention from at least q4 to at least 6x/24hrs
  • Therapeutic anticoagulation/oral anticoagulation requires both Patient or caregiver unable to administer an Outpatient services unavailable when INR is non-therapeutic
  • To  Non-vitamin K oral anticoagulant (includes PO) planned at discharge ≥ 5 d added LMWH
  • To Heparin-induced thrombocytopenia, suspected or by history under Intervention added Fondaparinux

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
  • Hypokalemia under  Significant ventricular ectopy now includes: Atrioventricular blocks, PR interval  prolongation, T wave and U wave fusion and U wave

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
  • In the HOME CARE DISCHARGE SCREEN, changed OP management contraindicated or unavailable to outpatient management

The following are  new subsets  for Acute Pediatrics:

  • Brief Resolved Unexplained Event (formerly called Acute Life Threatening Event)
  • Hypertension
  • Electrolyte  or Mineral Imbalance

Responder and Non-responder days have been adjusted based on length of stay. Responder criteria appear starting on Episode Day 2 and are designated  as "Early  responder"  in the following subsets:

  • Epilepsy
  • Gastroenteritis
  • Infection: Pneumonia
  • Pancreatitis

The non-responder day has been updated in the following subsets to align with LOS:

  • Asthma
  • Diabetic Ketoacidosis
  • Hypoglycemia

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
  • Responder to Early Responder, discharge expected today if clinically stable last 12h, and added to the finding: Complication or comorbidity and clinically stable for discharge
  • New onset infection, actual or suspected, changed WBC < 13.0
  • Bleeding, actual or suspected from Hct and Hb decreased last 24h to Hct or Hb decreased last 24h
  • From NG tube to suction to Nasogastric tube to suction
  • Respiratory intervention at least q4h to at least 6X/24H
  • To Heparin- induced thrombocytopenia, suspected or by history under Intervention added Fondaparinux

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
  • Hypokalemia under Significant ventricular ectopy now includes: Atrioventricular blocks, PR interval prolongation, T wave and U wave fusion and U wave

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 2017 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
  • Intensity of Service and “Initial evaluation with full patient participation,” changed: Medical or psychosocial management, ≥ One:- Spasm To: Medical or psychosocial management, One: Spasticity

    Intensity of Service, “Partial responder and potential for significant improvement,” and Medical instability (new onset) and decreased participation in therapy < 3h/d for  ≥ 3d,” changed: Infection, actual or suspected, WBC > 13,000/cu.mm (13x109/L) or  > 10% (0.10) bands  To: WBC ≥ 13,000/cu.mm  (13x109/L) or  > 10% (0.10) bands

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

The following new subset has been added:

  • Medicare (SNF)

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”
  • “continued progressive therapy program with at least 1 discipline and 1-2/d of therapy ? 5/d/wk,” and “Functional status, “ Changed: Functional plateau  reached or minimal functional gains (ADLs, mobility, cognition) and discharge planning ≥ 1 wk TO: Functional plateau reached or minimal functional gains (ADLs, mobility, cognition) and discharge planning 24h.
  • 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, Therapy- Continued progressive therapy program with at least 1 discipline and 1-2h/d of therapy ≥ 5d/wk, Changed: Medical instability (new onset) and decreased participation in therapy < 2h/d for ≤ 3 d (excludes admission review), To: Medical instability (new onset) and decreased participation in therapy < 1h/d for ≤ 3d(excludes admission review)
  • 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