Qualis Health News:McKesson releases Interqual Criteria 2003 Version

FOR IMMEDIATE RELEASE
Contact: Lauri Hennessey
(206) 463-1388
lauri@pyramidcommunications.com

McKesson releases Interqual Criteria 2003 Version

Questions?

If you have questions not covered here, or to find out more about McKesson's Interqual Criteria, contact McKesson at 800.522.6780, or via e-mail at InterQual@mckesson.com,
or you can visit the Interqual website at www.interqual.com.

Worksheets:

Qualis Health has developed some helpful tools you can use to apply the Interqual Criteria from McKesson. You can download them here.

What are the Changes in the 2003 Version of the InterQual Criteria?

Qualis Health issued a bulletin in April 2003 to all facilities in the states of Alaska, Idaho and Washington to inform them that we were implementing the 2003 version of the InterQual Criteria sets on Monday, April 28, 2003. At that time, we stated we would send a subsequent provider bulletin in May 2003 detailing the major changes to this latest version of the InterQual Criteria sets.

The following information is a summary of those InterQual criteria changes relevant to Qualis Health review in the 2003 version.

In addition, Qualis Health is including information on how we will be applying the 2003 updated InterQual Discharge Screens.

Finally, we are providing you with a utilization review tool titled, Inpatient Review Concept Template, to help you identify the necessary clinical information we need to document as a result of these changes with the InterQual Criteria sets.

Introducing a "Care Facilitation" Approach: The Next Step in the Case Management Paradigm

The 2003 InterQual version presents a new acute level of care content in the Adult Acute Criteria that can assist nurse reviewers in managing the timely identification of discharge planning opportunities and appropriate alternate levels of care. InterQual will be extending care facilitation features to other inpatient level of care criteria over the next several annual releases.

This change in the application of InterQual criteria results in a major shift from Qualis Health utilizing physician advisors strictly to determine if a case should be non-certified to using physician advisors as consultants in a patient’s discharge plan.

Due to this change, listed below are three key Qualis Health decisions on the application of 2003 Updated InterQual Discharge Screens:

When a review is not meeting the Intensity of Service (*IS), Qualis Health nurse reviewers will refer the review to a Qualis Health Medical Director. This is a change. Previously if a review did not meet IS, the nurse reviewer went to the discharge screens and if it did not meet the discharge screens the nurse reviewer could grant a grace day.
For the new care facilitation IS requirements that require a review to meet one IS criteria and discharge review, Qualis Health nurse reviewers will refer the review to a Qualis Health Medical Director. The discharge review is new with the 2003 InterQual criteria.
When using the > Three (3) *IS indicators Qualis Health nurse reviewers will continue to give up to 3 grace days for this. The 2003 InterQual Criteria change is to > Three (3) *IS indicators and Discharge Review.

Cases taken to Medical Director Review for any reason rely upon the physician’s professional judgement, not on InterQual. InterQual criteria are only used for non-physician review.

Major InterQual Criteria Updates and Changes per McKesson

Acute Criteria

With the development of an expanded Behavioral Health Criteria suite in 2003, InterQual is removing Chemical Dependency and Mental Health criteria from the Acute Criteria set. InterQual will continue to include criteria for medically related conditions that require observation, acute care or critical care (e.g., detox/DTs, withdrawal syndromes, seizures, eating disorders with abnormal lab values and weight loss) in the Acute Criteria.

Procedures Criteria

Based on client feedback and market research, we have streamlined the book format of the Procedures Criteria for adults: InterQual has provided the 100 most widely used adult procedures in two volumes, plus a CD-ROM that contains the full complement of procedures criteria. The ability to select and print procedures from the CD ensures you can include any procedure relevant to your organization in your binder. Pediatric Procedures will continue to be published as a separate book.
InterQual has introduced prompts for "controversial" procedures (e.g., Virtual Colonoscopy) to encourage a primary reviewer to gather and document patient-specific clinical information that will speed the secondary medical review process.
New criteria have been added: Lung Volume Reduction Surgery (Cardiothoracic), Supracervical Hysterectomy (OB/GYN), and Weight Loss Surgery (General).
In light of recent clinical research, notes to Hormone Replacement Therapy have been updated.

Behavioral Health Criteria

The 2003 criteria release will include a Residential psychiatric criteria set for adolescents—a first in the industry—as well as Chemical Dependency and Dual Diagnosis criteria for this age group. Managed care clients licensing the Behavioral Health Level of Care Continuum will receive this as part of their current license.
This release introduces a behavioral health procedure supplement—Acute Electroconvulsive Therapy (ECT)—to the Adult, Adolescent and Geriatric Psychiatry products.

Rehabilitation Criteria

InterQual has added Pediatric Rehabilitation to the Rehabilitation Criteria product.

Durable Medical Equipment Criteria

New DME subsets include Below Knee Prosthetics in a new category, Prosthetics; Continuous Passive Motion, Knee, and Seat Lift Mechanisms (Standard Equipment); and Secretion Clearance Devices (Pulmonary Devices).

For other changes please go to the website, www.InterQual.com.

These include changes to Imaging Criteria and the Outpatient Rehabilitation & Chiropractic Criteria.

Qualis Health Utilization Review Tool

Qualis Health has developed this concept template to help us obtain the relevant information needed for initial and concurrent reviews. Please consider using it when providing information for review - either by fax, telephone, voicemail, or in person. Our RN review staff will also be using this template during telephonic UR contact. If we do not obtain the information necessary to conduct the review Qualis Health will contact the utilization review department to obtain additional information. (See Attachment 1-Inpatient Review Concept Template)

This is provided as a tool to help organize information that will help patients get medically necessary services at the right level of care and at the right time while meeting Qualis Health’s need for appropriate InterQual documentation. Please consider the following as a ‘guide’, not a requirement or guarantee of payment for admission or for continued stay review.

Demographics:

Patient name, ID number
Attending name, pager number and best time for a Qualis Health Medical Director to call if needed
The day or dates under review

SI [Symptom Intensity]- How sick is the patient? This places the patient’s services in context with their clinical condition and is needed both for initial review and for concurrent review

What is the main clinical issue?
Abnormal vital signs?
Pain present- where, what is cause?
Neurological Status: alert to obtunded
Brief description of diagnostic tests [especially if lab or x-rays are abnormal]
Any consultations and evaluations or procedures?

IS [Intensity of Services]- What care is the patient receiving?

IV medications and frequency
Any IV PRN meds given for nausea, pain? How often each day?
IV fluids/ TPN
Blood or blood products [should have a HCT as a reason]
Oxygen needed? FiO2 and route? ABGs done or O2 sats?
Diet/ Tube feeds/ gavage [what is infant’s weight]
If patient is on a sliding scale, what were high/low glucose values? How many coverage units were given on each day [not the routine doses]?
Wound management: describe wound and dressing/ debridement/ special issues
Any other treatments or therapies?

DS [Discharge Screens]- What is the long-term plan?

What is the expected destination after the hospitalization?
What discharge planning activities are being done
What care needs are there post-discharge? Educational needs?
Are there significant psycho-social issues?

	Contact Number	Fax Number
Alaska Medicaid Pre-Admission	800-783-9207	800-826-3630
Idaho Medicaid Pre-Admission	800-783-9207	800-826-3836
L & I Pre-Admission	800-541-2894	877-665-0383 206-366-3378
WA Teamsters Pre-Admission	877-372-7861	206-368-2765
Private Insurance Pre-Admission	800-783-8606	206-368-2765
L&I Physician Hotline	877-665-0382
Medicaid / Private Physician Hotline	877-292-2615

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Qualis Health
Qualis Health (www.qualishealth.org) is dedicated to improving the quality of healthcare delivery and health outcomes for individuals and populations across the nation. In operation since 1974, the nonprofit, healthcare quality improvement organization (QIO) is headquartered in Seattle, Washington and has offices in Alaska, Idaho, California, South Carolina and Nebraska. Qualis Health holds QIO contracts with the Centers for Medicare & Medicaid Services in Idaho and Washington.