Table of Contents Document Revision History... 4 Annual Criteria Release... 5

Transcription

1 Page 1 InterQual FAQ

2 Table of Contents Document Revision History... 4 Annual Criteria Release... 5 When is the annual criteria release?... 5 When will the new criteria be available to my organization?... 5 Why are the criteria revised each year?... 5 What steps should my organization take to transition to the revised criteria?... 6 Release Resources... 6 What resources are available for staff to become familiar with the revised criteria prior to its release?... 6 How can I access the Clinical Revisions documents?... 6 What other resources are available on MHS Customer Hub?... 6 How can I arrange for training from McKesson?... 7 How can I find out who my Account Manager is?... 7 How can I access the CMS Inpatient Only List (Addendum E)?... 7 How can I get answers to additional questions?... 7 Review Process... 7 Page 2

3 With the new condition-specific criteria, my organization has seen an increase in the number of second-level reviews. What can be done to minimize this? 7 What is the definition of an episode day?... 8 What data can be used when conducting a review?... 8 How do I apply criteria for Medicare beneficiaries who are impacted by the CMS 2-midnight rule?... 9 Clinical Criteria Content How is the InterQual Guidelines for Surgery and Procedures Performed in the Inpatient Setting (Inpatient List) different from the CMS Inpatient Only List? 11 Does the diagnosis need to be documented in the patient's chart in order to apply diagnosis specific criteria? Do the chest x-ray results have to specify pneumonia in order to apply the Pneumonia confirmed by imaging criteria point? Is a written order necessary for neurologic checks or other nursing interventions? What steps will InterQual be taking to address the CMS Jimmo v. Sebelius settlement agreement in the InterQual Post Acute products? How do I apply the criteria point "Comorbid pneumonia in a hospitalized patient"? Why is carotid sinus massage (CSM) a requirement for the evaluation of a patient with syncope, it is rarely used at my organization? Why doesn t the criteria for DVT or PE include medications like rivoroxaban or dabigatran in criteria for the treatment of DVT or PE? Review Manager Software Why do the surgical subsets in 2013 differ from book to software; e.g. laparoscopic cholecystectomy (software) and GI Surgery (book)? Where are the GI surgical subsets and General Transplant subset located for 2014? Where do I find the 2013 version of the Procedures Criteria in Review Manager? Known Issues: Please review this document periodically. These FAQs will be updated as questions regarding the InterQual Criteria are submitted to McKesson Product Support. The date of the most recent revision, along with a brief description, can be found in the table below. Page 3

4 Document Revision History Date Revision Description 3/1/ Creation of FAQ Document 4/3/ FAQ s added/modified 4/4/ Additional FAQ s added 4/10/ Additional FAQ s added 4/11/ Modifications 4/29/ Additional FAQ added 5/30/ Addition FAQ added, Known Issues List added 6/13/ Additional Known Issues added 6/27/ Known Issue added 7/18/ Additional Known Issues added 12/2/ Removed N/A FAQ, Additional Known Issues added 1/24/ Added an FAQ 2/21/ Revised an FAQ 8/22/ Known Issues Added, Added FAQs Page 4

5 Date Revision Description 9/3/ Behavioral Health Known Issue added 11/14/ Acute Adult Known Issue added 11/24/ Acute Adult and Behavioral Health Known Issues added 02/09/ SIM plus, Imaging, and Procedures Known Issues added 4/1/ Known Issues added 05/29/ Known Issues removed, see new document Annual Criteria Release When is the annual criteria release? o InterQual Criteria are generally available during the month of April of each year. When will the new criteria be available to my organization? o McKesson ships InterQual products (software and books) during the months of April, May, and June. Contact your McKesson Account Manager for specific information regarding the shipment of revised criteria to your organization. o The timing for when an organization should switch over to the new release version of InterQual has been an issue between payors and providers for quite some time. To avoid confusion and administrative burden, we recommend that organizations consider implementing a standard switch over date. McKesson suggests switching over by July 1st, 3 months from the date that the new release is issued (most organizations require approximately 3 months to integrate and roll out the new content). Having a formal cut-over date help streamline criteria for payors and providers so that the same criteria can be applied and they can migrate to the new version in the same timeframe. Ultimately the decision for when to switch over is up to the licensing organization. Transparency between both parties regarding the preferred implementation date will assist in the transition to the new criteria. Why are the criteria revised each year? Page 5

6 o Each year, our development team improves the criteria to better address clinical presentations and treatment plans. McKesson wants the InterQual products to be the best tool possible for screening for medical appropriateness, and we hope that each year s revisions move us closer to that goal. What steps should my organization take to transition to the revised criteria? o Each year, your organization should have an implementation plan for transitioning to the revised criteria. Many organizations choose to document their implementation plan in their Utilization Review committee or other committee minutes. This documentation might include the date you receive the criteria, your plan for training staff in its use, and the date you plan to switch to the revised criteria. Release Resources What resources are available for staff to become familiar with the revised criteria prior to its release? o The following resources are available from the MHS Customer Hub ( o Clinical Revisions documents for all InterQual Criteria o A demonstration of the use of InterQual Acute Adult Criteria (requires Adobe Reader 9 or later) How can I access the Clinical Revisions documents? o From MHS Customer Hub ( click Documents on the left menu, select the Clinical Revision Docs document type, and then click Search. They are also available from the Top Documents portal on the right side of the Home page. What other resources are available on MHS Customer Hub? o The following resources are also available from the MHS Customer Hub ( Case Review worksheets Transition Plan worksheets Drug List Bibliographies Page 6

7 o Webinars will also be recorded and posted to the Customer Hub. To access Webinars, click Documents on the left menu, select the Webinar document type, and then click Search How can I arrange for training from McKesson? o Your Account Manager can help you to plan for and arrange McKesson InterQual training, which includes both selfpaced, Web-based training and instructor-led training. How can I find out who my Account Manager is? o From MHS Customer Hub ( click My Company s Info at the top of any page. Your company information includes your McKesson Account Manager(s) s name and contact information. How can I access the CMS Inpatient Only List (Addendum E)? o From MHS Customer Hub ( click Knowledge Items on the left menu, search for keyword CMS, and then click Search. This document is often also available from the Top Knowledge Items portal on the right side of the Home page. How can I get answers to additional questions? o From MHS Customer Hub ( click Knowledge Items on the left menu, search for the appropriate keyword(s), and then click Search. o o If you re unable to find an answer to your question you can submit a question to McKesson Clinical Support. From MHS Customer Hub ( click Create New Case on the left menu (if available). You can also contact MHS Customer Support at cesupport@mckesson.com or by calling and following the prompts for either clinical support (to speak to an RN about medical criteria issues) or technical support (to speak to a technical support representative about software or other computer issues). Review Process With the new condition-specific criteria, my organization has seen an increase in the number of second-level reviews. What can be done to minimize this? Page 7

8 o As with any change, there is a learning curve. Not only has the structure of the content changed, but so have the workflow, concepts, and the data required for conducting a review. Strategies for effectively implementing this new model and reducing the need for second-level review include: Improve MD documentation in the medical record, for example: Post signage at dictation stations (e.g., When dictating on patients with heart failure, please remember to document XYZ ). Use standardized order sheets or templates for subsets where medications drive care (e.g., ACS, HF). Educate MDs on the importance of solid documentation so they become an ally, not an obstacle. Reinforce the purpose of the internal physician advisor role to intercede prior to needing second-level review externally or at the payer level. For many organizations, this is a missed opportunity. What is the definition of an episode day? **This is a new clarification for the 2013 criteria release o An episode day is a calendar day, which begins at 12:00 AM. However, the exception to this would be inpatient admissions in the evening (e.g., after 6 p.m.); in which case, episode day one may be used for admission day and the next hospital day. For patients in Observation, the expectation is that within hours a decision will be made to determine whether admission or discharge is appropriate. What data can be used when conducting a review? **This is a new clarification for the 2013 criteria release o If conducting a review at the time of admission or condition change (referred to as a concurrent review in the Review Process), reviewers can only use data that are available at the time the decision was made to admit. Page 8

9 o If conducting a retrospective review, use data from the episode for the day that the review is being conducted. This includes information that may have been pending or incomplete at the time the decision to admit was made. How do I apply criteria for Medicare beneficiaries who are impacted by the CMS 2-midnight rule? o The CMS 2-midnight rule provides guidance to providers in determining the appropriate status for a patient based on a specific time determination. In addition to medical necessity, there must be an expectation that the patient will require care greater than two midnights in order to be considered inpatient status. When there is uncertainty that the care will span 2 midnights or there is the expectation that care will require less than 2 midnights, the patient should be designated as Observation status. Exceptions to this rule currently include CMS designated inpatient only surgical procedures, death, AMA, transfer to another facility, a decision to pursue hospice care following inpatient admission, new onset mechanical ventilation, or unexpected rapid recovery. InterQual Acute Level of Care criteria is objective, evidenced based medical necessity criteria. The criteria was developed based on the average length of stay for each condition and can assist the reviewer in determining if the 2 midnight requirement will be met. The following process should be followed for CMS beneficiaries who are impacted by this rule: Page 9

10 Page 10

11 As the rule may continue to evolve as CMS issues additional clarifying information, stay tuned to the MHS Customer Hub for additional information and resources Clinical Criteria Content Level of Care How is the InterQual Guidelines for Surgery and Procedures Performed in the Inpatient Setting (Inpatient List) different from the CMS Inpatient Only List? o The InterQual Inpatient List is very different than the CMS Inpatient Only List. The InterQual Inpatient List was developed to assist clients in determining when a procedure might be appropriate for the inpatient setting. It addresses medical appropriateness, not reimbursement. The CMS Inpatient Only List represents a list of procedures that Medicare will reimburse only if done in an inpatient setting. InterQual s Inpatient List is developed independently of the CMS Inpatient Only List, and is not intended to duplicate the CMS list. Does the diagnosis need to be documented in the patient's chart in order to apply diagnosis specific criteria? o In order to apply criteria related to a specific diagnosis, the diagnosis must be documented in the medical record. In the absence of documentation, the reviewer should obtain additional information from a medical practitioner. o It is up to the discretion of each organization to allow their reviewers to assume a diagnosis based on the patient's clinical presentation and treatments. Organizations that choose to do so should create an organizational policy to address this practice. Do the chest x-ray results have to specify pneumonia in order to apply the Pneumonia confirmed by imaging criteria point? o The chest x-ray results do not have to specify pneumonia. In most cases pneumonia is a clinical diagnosis and is not an imaging finding seen in isolation. It is the combination of an abnormal chest x-ray and the clinical presentation that are considered in the diagnosis. The radiologist reading the chest x-ray may not have access to the patient s Page 11

12 clinical findings and may not specify a diagnosis of pneumonia when reporting imaging results. The admitting physician should document the diagnosis of pneumonia in the patient s medical record. o It is up to the discretion of each organization to allow their reviewers to assume a diagnosis based on the patient's clinical presentation and treatments. Organizations that choose to do so should create an organizational policy to address this practice Is a written order necessary for neurologic checks or other nursing interventions? o Nursing interventions such as coughing and deep breathing, seizure precautions, strict intake and output, and neuro assessment do not require MD order, but do require documentation that they are being performed in the medical record. What steps will InterQual be taking to address the CMS Jimmo v. Sebelius settlement agreement in the InterQual Post Acute products? o The InterQual clinical development team is aware of the CMS settlement in the case of Jimmo vs Sebelius. CMS released medical policy changes to address this ruling in January. McKesson has reviewed the medical policy changes and assessed the impact across our product line. We have determined that there is no impact to our SAC/SNF product however we are addressing it in the Home Care and Outpatient Rehabilitation and Chiropractic products for 2014 with a Maintenance Therapy subset. How do I apply the criteria point "Comorbid pneumonia in a hospitalized patient"? o The criteria point Comorbid Pneumonia in a hospitalized patient can only be applied to patients who have developed pneumonia as a complication of their current inpatient stay in an acute care facility. The criteria points cannot be applied for patients who have been either discharged to home or transferred to a post-acute facility. Why is carotid sinus massage (CSM) a requirement for the evaluation of a patient with syncope, it is rarely used at my organization? o The requirement for CSM in the syncope criteria is derived from evidence based guidelines supporting its use as an essential part of the initial evaluation of a patient with syncope (Moya et al., Eur Heart J 2009; 30(21): , National Institute for Health and Care Excellence, 2010, NICE clinical guideline 109). It is an inexpensive evaluation which can rapidly determine the cause of syncope (Brignole, Heart 2007, 93: 1306). Twenty-eight to forty-five percent of patients with syncope are found to have carotid sinus hypersensitivity based on a positive CSM test Page 12

13 (Kumar et al., Age and Ageing 2003, 32: 6669). A positive CSM test obviates the need to perform unnecessary additional diagnostic tests, provides an immediate etiologic diagnosis, and leads to prompt intervention. In addition to being supported in the literature, McKesson consultants agree that CSM should be performed in patients 40 years of age or older as part of the initial evaluation of syncope, unless contraindicated. Complications of CSM testing are rare. Why doesn t the criteria for DVT or PE include medications like rivoroxaban or dabigatran in criteria for the treatment of DVT or PE? o InterQual s inpatient admission criteria for deep vein thrombosis are limited to those patients who are experiencing a complication or are at risk for a complication. The only published study of rivoroxaban for the treatment of DVT specifically excluded patients at high risk for complications, including bleeding ( December 23, 2010 The EINSTEIN Investigators N Engl J Med 2010; 363: ). The use of rivoroxaban or dabigatran in this patient population is further complicated by the risk of bleeding and the lack of any agent to reverse the anticoagulant effect. McKesson consultants do not recommend oral agents for the initial treatment of pulmonary embolism. As these medications are relatively new to the market and randomized control trials may be ongoing regarding their use in specialized populations, we will continue to evaluate them for inclusion in the criteria for future releases. Review Manager Software Why do the surgical subsets in 2013 differ from book to software; e.g. laparoscopic cholecystectomy (software) and GI Surgery (book)? Where are the GI surgical subsets and General Transplant subset located for 2014? Page 13

14 o o Actually, the subsets do not differ. The only difference is in how you get to them. In the software the short, moderate, and long stay subsets are used behind the scenes and the surgery/procedure is mapped to the appropriate one. This is an automation feature that can be employed in the software that cannot be in hardcopy books. It eliminates the need for the reviewer to figure out what subset is appropriate when using the software. For the 2014 release, the GI surgical subsets were consolidated in the General Surgical subset. The General Transplant subset was moved under the surgical category in Review Manager. Where do I find the 2013 version of the Procedures Criteria in Review Manager? o The InterQual Procedures products (CP: Procedures Adult and CP: Procedures Pediatric) were merged into a single product for the 2013 release, named CP: Procedures. This product will contain all the 2013 content. The CP: Procedures Adult and CP: Procedures Pediatric products will remain within InterQual software, such as Review Manager and InterQual View, if they were installed by a previous version, but it will not be updated going forward as CP: Procedures has superseded them. Known Issues: Where can I find information on the 2015 Known Issues? The Known Issues have been removed from this FAQ document. They can now be found in a Known Issues document, in the Documents / Webinars section, of the Customer Hub website. Where can I find information on Known Issues for 2014? The Known Issues for 2014 will remain on the Customer Hub website. They can be found in the 2014 FAQ document, in the documents section of Customer Hub website. Page 14