INTERQUAL ACUTE CRITERIA REVIEW PROCESS

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1 REVIEW RP-1

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3 REVIEW The InterQual Acute Criteria provide support for determining the appropriateness of admission, continued stay and discharge. The Acute Criteria address the observation, critical, intermediate, and acute levels of care and 4 levels of nursery care in pediatrics that include: NICU, Special Care, Newborn, and Transitional Care. Adult criteria are for review of patients 18 years of age and pediatric criteria are for review of patients < 18 years of age. REVIEW The InterQual Acute Criteria are moving towards a condition-specific focus and have begun a transition away from body-system subsets organized by level of care, to subsets that are condition-specific and comprise multiple levels of care. These new subsets guide reviewers through a condition-specific, evidence-based, clinical course that effectively supports both utilization and case management. During this transition, two types of subsets will be available. The reviewer should refer to the appropriate section for review details: Condition-Specific Subset Review Process Traditional Subset Review Process If a condition-specific subset isn t available for a patient s condition, then the reviewer should select one of the traditional subsets. For additional information that applies to all InterQual Acute Adult or Pediatric Criteria, including secondary reviews, variances, transition plan, practical tips, and supporting materials, refer to the Additional Information section. CONDITION SPECIFIC SUBSET REVIEW The 2011 InterQual Acute Criteria provide condition-specific subsets for the following adult and pediatric conditions: Acute Adult Acute Pediatric Acute Coronary Syndrome (ACS) Asthma Asthma Croup Epilepsy Epilepsy Heart Failure (HF) Pneumonia Pneumonia Stroke / TIA Reviewers should use condition-specific subsets when the patient s primary condition or diagnosis matches one of the subsets above. There are two types of reviews that can be conducted using the condition-specific subsets: Admission Determines the appropriateness of admission to a level of care. Reviews are conducted using only the Severity of Illness (SI) component which consists of objective, clinical findings and treatments appropriate for the condition or diagnosis. The SI component is considered episode day 1, the first day in the episode of care for that condition. This component includes all of the appropriate levels of care for the condition and is organized from the least to the most intensive level. Continued Stay Determines if the level of care is still appropriate. Reviews are conducted using the Intensity of Service (IS) component which consist of clinical findings, monitoring, therapeutic services, or expected guideline treatments for the given episode day. The IS component includes episode days 2 and beyond. This component includes all of the appropriate levels of care for the condition and is organized from the least to the most intensive level. Within the levels of care, there are three types of responder criteria: Responder Criteria that indicate the patient is clinically stable (last 12h 24h); discharge is expected on the day responder criteria is selected. Selection of these criteria does not meet for continued stay and are denoted by the ς symbol. Partial-responder Criteria that indicate the patient is clinically appropriate for continued stay, at that level of care, for the designated episode day and condition. RP-3

4 REVIEW Non-responder Criteria that indicate the patient requires continued stay, however, the episode days within the current condition-specific subset and level of care have been exhausted. The reviewer needs to select alternative criteria in the most appropriate subset based on current clinical findings and conduct a review. (See the Traditional Subset Review Process ). Selection of these criteria does not meet for continued stay and are denoted by the ς symbol. NOTE: On some of the early days within the episode, criteria may not contain any responder type components. Responder criteria are introduced on the first episode day that a patient (who was appropriately admitted) would likely be clinically ready for discharge. Once responder criteria are introduced, from that day on there will always be responder criteria and either a partial or non-responder criteria component. CONDUCTING A CONDITION-SPECIFIC ADMISSION REVIEW An admission review is conducted on the day of admission for the condition or the day that the condition first presents itself. If the review is conducted retrospectively, data from the day of admission for the condition or the day that the condition first presented itself should be used. For example: A patient presents to the emergency room with chest pain radiating to the left arm. Reviewer should conduct the review using episode Day 1 criteria in the Acute Coronary Syndrome (ACS) subset If a patient is admitted for heart failure and rules in for an NSTEMI on episode day 2, the reviewer should conduct the review using the episode day 1 criteria in the Acute Coronary Syndrome (ACS) subset. ACS is now the driving condition and it would be the first day in the episode of care for the NSTEMI. The SI rule requires one level of care to be met The SI time requirement is Symptom or finding within last 24h Admission Review Steps 1. Select the most appropriate condition-specific subset based on the primary condition or working diagnosis. NOTE: if there is no condition-specific subset for the primary condition or diagnosis, select the most appropriate traditional level of care subset based on the patient s clinical symptoms and findings. Follow the directions under Traditional Subset Review Process 2. Identify the level of care based on the patient s current or proposed level. 3. Review patient-specific clinical information available at the time of admission (or time of transfer to a higher level of care). Emergency room data can be used to complete the admission review (e.g., imaging studies, EEG findings, history and physical, MD orders). NOTE: The SI time requirement Symptom or finding within 24h should be considered when conducting the admission review. Although SI must be met within the designated time, a review is often performed within hours of, or a day after, a patient s admission. 4. Select the SI criteria based on the patient's clinical findings, treatment, or service, making sure to meet all the rules for duration, time frames, and number of criteria. 5. Continue according to the following recommended actions: RP-4

5 Finding SI met SI not met REVIEW Action Approve admission to level of care Schedule Continued Stay review Obtain additional information from the attending medical practitioner or other caregivers If additional information does not meet SI, discuss the condition with attending medical practitioner (a traditional level of care subset or an alternative setting may be more appropriate for the patient s diagnosis) Conduct review using the appropriate subset or facilitate transfer if the attending medical practitioner is agreeable to an alternate setting Refer for Secondary Review if the attending medical practitioner does not agree (See Secondary Review Process ) REVIEW NOTE: When a patient is transferred to a new facility for a service that is unavailable at the current facility, to be closer to family, or at the request of the payer, the review should be conducted using the appropriate episode day. For example: If it is the second day in the episode of care, then a continued stay review using episode Day 2 criteria would be appropriate. When a hospital unit s name (e.g., Progressive Care Unit) does not match the InterQual levels of care, refer to the level of care definition notes. In the software, these notes display as ToolTips in the left navigation pane; in the books, they are available in the glossary. CONDUCTING A CONDITION-SPECIFIC CONTINUED STAY REVIEW A continued stay review is conducted to determine the appropriateness of continued stay. Continued Stay comprises multiple episode days, beginning on episode Day 2, the second day within the episode of care. The number of episode days varies based on the condition and includes common comorbidities and complicating factors associated with the primary condition. Each episode day includes criteria only for the levels of care that are clinically appropriate for the condition on that day. NOTE: The reviewer must apply criteria for the appropriate episode day. For example, on the third day of an episode, the reviewer applies episode Day 3 criteria. A patient may meet criteria for a specific episode day only once; criteria cannot be met for the same episode day on multiple reviews. The frequency of reviews should be conducted according to organizational policy and are not required to be conducted on every episode day. To conduct a continued stay review, apply the Intensity of Service criteria (IS) component. The IS rules require that one episode day and one level of care be met When a level of care includes more than one responder type, only one responder type can be met Continued Stay Review Steps 1. Begin with the same condition subset used during the admission review. NOTE: If the condition has changed, then the reviewer may use a subset that is more appropriate (either another condition-specific subset or a traditional subset). 2. Review patient-specific clinical information. 3. Select the appropriate day within the episode of care and select the current level of care. NOTE: If the patient has moved or needs to move to a higher level of care, it is not necessary to conduct an admission review. RP-5

6 REVIEW 4. Apply IS based on findings, treatments, medications, or interventions, making sure to meet all the rules for duration, time frames, and number of criteria. NOTE: Responder criteria will only be present if discharge is clinically expected or reasonable on that episode day (not every day will have responder criteria). If a patient meets Non-responder criteria, the reviewer must conduct a continued stay review using the subset that is most appropriate based on clinical findings (either another condition-specific subset or a traditional subset). Software Redirection In some instances, when a patient s condition changes (and it is clinically appropriate) the user may be redirected from the condition subset they are currently using to a condition subset that is now more appropriate. For example: A patient admitted with heart failure has positive cardiac biomarkers on episode day 2. Heart failure would no longer be the most appropriate condition subset; the reviewer would be redirected to the Acute Coronary Syndrome subset. Continue according to the following recommended actions: Finding Action IS Criteria or Partial responder met Level of care met: Approve level of care for that episode day Schedule next Continued Stay review IS Responder met Level of care not met: Prepare for discharge. Review discharge screens to determine most appropriate post acute level of care IS Non-responder met Level of care not met: Select most appropriate subset based on the patients current condition and clinical findings Conduct review IS Criteria, Responder, Partial responder, and Non-responder not met Level of care not met: Obtain additional information from attending medical practitioner or other caregivers If additional information does not meet criteria, discuss condition with attending medical practitioner (the traditional subsets or an alternative setting may be more appropriate for the patient s diagnosis) Facilitate transfer if attending medical practitioner is agreeable to alternate setting or level of care Refer for Secondary review if attending medical practitioner does not agree (see Secondary Review Process ) When Responder criteria are met, the reviewer may use the Discharge Screens (DS) to assist in determining the most appropriate post acute level of care. DS consist of ongoing service needs for alternate levels of care and are organized by level of care. The DS are organized by the least to most intensive alternate levels of care. There is no time requirement for DS RP-6

7 REVIEW TRADITIONAL SUBSET REVIEW Reviewers should use the Traditional Level of Care subsets when there is no appropriate condition-specific subset. There are four types of reviews that can be conducted using the Traditional Level of Care subsets: Preadmission Determines the appropriateness of an admission prior to a planned procedure being performed. Reviews are conducted using the Severity of Illness (SI) Criteria component only. Admission Determines the appropriateness of admission to a level of care. Reviews are conducted for an admission and when a patient is transferred to a higher level of care. Reviews are completed using the Severity of Illness (SI) and Intensity of Service (IS) Criteria components. Continued Stay Determines if the level of care is still appropriate. Reviews are conducted using the Intensity of Service (IS) Criteria component only. Discharge Determines the safety of discharge or transfer from one level of care to another. Reviews are completed using the Discharge Screen (DS) criteria component. REVIEW SI component: SI criteria consist of objective, clinical indicators of illness, which focus on an individual patient's clinical presentation and/or diagnosis. SI criteria are grouped by reason for admission and alphabetized for ease of use and quick reference. The SI rule requires One SI criteria to be met The time requirements vary based on the level of care Onset within 24h (e.g., Observation) Onset within 1 wk (e.g., Acute Care) Most criteria subsets are organized into the following categories: Clinical findings, Imaging findings, ECG findings, and Laboratory findings Observation, Infectious Disease, and Obstetrics/Gynecology/Genitourinary criteria subsets are organized by body system OB-Antepartum criteria subset is organized by: High risk obstetrics, Laboratory findings, and Medical comorbid conditions IS component: IS criteria consist of monitoring and therapeutic services, singularly or in combination, that can only be administered at a specific level of care. The IS rule requires that One IS or Three *IS criteria be met The time requirement requires that IS must be At Least Daily Some IS criteria specify other time designations. For example, the criterion Corticosteroids 3x/24h specifies that corticosteroids should be administered at least three times within a 24-hour period and overrides the At Least Daily designation Some post operative IS are associated with a duration of time, which are intended to allow the reviewer to approve up to the number of days indicated. The days are based on a calendar day, which start at 12:01 a.m. regardless of the time of admission. However, the exception to this would be admissions in the evening (e.g., after 6 p.m.); in which case, day one would not begin until the next day. NOTE: Regulatory or contractual agreements may dictate other specifics concerning when the "new day" begins. Other IS criteria are associated with an endpoint. For example, in the criterion Cardiac monitoring, continuous (excludes Holter) 2d, One, the endpoint 2d indicates that the criterion may be used for no more than 2 days within the episode. RP-7

8 REVIEW Care facilitation criteria suggest alternate levels of care that may be appropriate for patients who are approaching discharge readiness. These criteria are denoted by a Ø symbol and have Discharge review or and discharge review with suggested levels of care attached to the criterion. For example: Chest tube, One: Suction, continuous Ø 200mL/d and discharge review (HC / SAC) *IS criteria are standardized within each level of care for ease of use and to cover treatments and medications specific to common complications and comorbid conditions *IS are important case management flags that prompt the reviewer to perform a discharge review. Patients who meet three *IS are approaching discharge readiness and will most likely transition quickly from the current level to an alternate level of care. DS component: DS criteria consist of objective clinical indicators to determine if the patient has reached the level of clinical stability appropriate for safe transfer to a specific level of care and assist the reviewer in determining whether an alternate level of care is appropriate based on ongoing service needs. The DS rule requires One ALOC to be met The time requirement for adult criteria is At Least Last 12h and for the pediatric criteria it is At Least Last 24h Some DS criteria specify a different time designation, as some criteria require more or less time to ensure safe discharge or transfer. The time associated with a specific DS criterion overrides the general time requirement. For example: In adult, Pre-op transplant stabilized last 24h (Adult Critical Care Surgical Trauma) overrides the At Least Last 12h In pediatric, Airway / Tracheostomy stable last 7d (Pediatric Intensive Care) overrides the At Least Last 24h The Acute level DS are organized by the least to most intensive alternate levels of care, while the Critical, Intermediate, and Nursery levels, are organized by most intensive to least intensive alternate levels of care CONDUCTING A TRADITIONAL PREADMISSION REVIEW A preadmission review may be conducted when a patient is being admitted to the hospital prior to an elective surgery or procedure. Criteria are found in the following subsets: Surgery / Trauma for surgery or procedures Transplant for pre-op transplant or donor OB / GYN /GU for C-section or induction Preadmission Review Steps 1. Select the appropriate subset and apply the Severity of Illness (SI) criteria. 2. Continue according to the following recommended actions: RP-8

9 Finding Preadmission met Preadmission not met REVIEW Action Approve planned admission Contact the attending medical practitioner for additional information to verify the need for admission to the inpatient setting If the additional information satisfies the preadmission rule, the planned admission may be approved If the additional information does not satisfy the preadmission rule, refer for Secondary Review (See Secondary Review Process ) REVIEW CONDUCTING A TRADITIONAL ADMISSION REVIEW An admission review is performed when the patient is admitted to a level of care to determine if that level of care is appropriate. If the patient is transferred from a lower level of care to a higher level care, an admission review is also required. Both the Severity of Illness (SI) criteria and the Intensity of Services (IS) criteria rules from the same criteria subset must be met on admission. Admission Review Steps 1. Identify the level of care based on the patient s current or proposed level. 2. Select the most appropriate criteria subset based on the patient s predominant presenting clinical findings. 3. Obtain and review patient specific clinical information derived at the time of admission. Emergency room data such as imaging studies, EEG findings, history and physical, and medical practitioner orders can be used to complete the admission review. NOTE: Once the decision is made to admit the patient, the SI and IS rules should be reviewed. Although SI and IS must be met within the designated time, in reality, a review is often performed within hours of, or a day after, a patient s admission. 4. Apply the SI rule by selecting the SI criteria based on the patient's clinical findings, making sure to meet all the rules for time of onset and number of criteria. 5. Apply IS by selecting the IS criteria based on prescribed treatments, medications, or interventions from the same criteria subset used to select SI, making sure to meet all the rules for duration and number of criteria. NOTE: Some SI criteria points have a corresponding IS. For an admission review, if the chosen SI criterion has a corresponding IS criterion, the reviewer should select this specific criterion point. For example, when a patient presents on admission with a DVT and the reviewer determines the criteria DVT in the CV/PV subset is appropriate, the reviewer would then select the corresponding IS for the condition: DVT treatment, One. 6. Continue according to the following recommended actions: Finding SI and IS met SI or IS not met Action Approve admission to level of care Schedule Continued Stay review Obtain additional information from the attending medical practitioner or other caregivers If additional information does not meet the corresponding SI or IS/*IS, discuss alternate levels of care with attending medical practitioner Facilitate transfer if the attending medical practitioner is agreeable to an alternate level of care Refer for Secondary Review if the attending medical practitioner does not agree with alternate level of care (See Secondary Review Process ) RP-9

10 REVIEW NOTE: When a patient is transferred to a new facility, for a service that is unavailable at the current facility, to be closer to family, or at the request of the payer, an admission review is not necessary if criteria were met at the transferring facility. An admission review would be required for an increase in level of care (e.g., from acute to intermediate care). When a hospital unit s name (e.g., Progressive Care Unit) does not match the InterQual Criteria subset titles, refer to the Subset Level note located on the title page of a specific criteria subset. The minimum requirements for monitoring and interventions generally provided at the specific level of care will be noted. Ø IS selected on admission review will not meet criteria. The reviewer should use the Discharge Screens to determine an alternate level of care that can provide the necessary services to meet the patient s clinical needs. CONDUCTING A TRADITIONAL CONTINUED STAY REVIEW A continued stay review is performed to determine the appropriateness of continued stay at a level of care. Apply the Intensity of Service (IS) criteria (One IS or Three *IS). IS has to be met daily. Continued Stay Review Steps 1. Begin at the same criteria subset used during the admission review, unless: The patient has been transferred to a lower level of care. In this case, select the appropriate criteria subset, based on the patient s clinical information. The patient has been transferred to a higher level of care, then conduct an admission review. The patient remains at the current level of care, but the medical condition has changed, then the reviewer may use a different subset within that level of care and would only need to apply IS criteria. 2. Obtain and review patient specific clinical information (e.g., progress notes, medical practitioner orders, medication, and treatment records). 3. Apply IS by selecting the IS criteria based on prescribed treatments, medications, or interventions making sure to meet all the rules for duration, time frames and number of criteria. 4. Continue according to the following recommended actions: Finding Action IS met Approve level of care for that day Schedule next Continued Stay review Three *IS met Approve level of care for that day Review the discharge screens and document the discharge plan Schedule next Continued Stay review IS or three *IS not met Obtain additional information from the attending or medical practitioner or other caregivers IS and discharge review If IS or three *IS still not met, perform discharge criteria are selected review (See Discharge Review ) NOTE: If allowed by your organization s policy, a 24 hour grace period can be given, one time only, when DS are not met and the IS rule (One IS or three *IS) is not met. For example: RP-10

11 REVIEW A therapeutic pause is needed. This could be due to planned intermittent therapy or side effects that need to clear before initiating a new regimen. For example: High-dose steroids in a cardiovascular patient are scheduled for two days on and one day off. A renal patient's IV therapy has been discontinued due to adverse effects and time is needed to allow the medication to clear the patient's system before instituting a new medication. A patient is meeting only two *IS but does not meet DS and it is anticipated that they will be ready for discharge within 24 hours. Patients who meet three *IS are approaching discharge readiness. *IS are important case management flags to prompt the reviewer to review the DS screens to assist in determining the next appropriate level of care. When there is an endpoint associated with an IS criterion (e.g., 2d), the criterion may be used up to the amount of days specified. For example: Cardiac monitoring, continuous (excludes Holter) 2d, One. The endpoint 2d indicates that the criterion can only be used for up to 2 days if appropriate. NOTE: The exception to this rule occurs when reviewing continued stay for a surgical patient in the Critical Surgery/Trauma, Acute Surgery / Trauma, and Transplant subsets. For example: Routine review 2d. The endpoint for this criterion indicates that the reviewer may approve up to the timeframe, eliminating the need for daily review. REVIEW CONDUCTING A TRADITIONAL DISCHARGE REVIEW Discharge reviews are performed when criteria for continued stay are not met, an IS criterion is selected that states and discharge review, or to assist in determining the next appropriate level of care within the facility (a transfer to another unit) or discharge from the facility. Discharge Review Steps 1. Select the same criteria subset used for the admission or continued stay review and apply the DS rule for the appropriate level of care. 2. Continue according to the following recommended actions: Review reason Finding Action IS or three *IS not met or IS and discharge review selected DS met DS not met If discharge is scheduled, no action required If discharge is not scheduled: Contact the attending medical practitioner to discuss the discharge plan and alternate level of care options Facilitate discharge or transfer if the attending medical practitioner agrees Refer for Secondary Review if the attending medical practitioner does not agree with the alternate level of care (See Secondary Review Process ) Approve the day and schedule the next review within 24 hours On next review, if DS still not met, refer for Secondary Review (See Secondary Review Process ) RP-11

12 REVIEW ADDITIONAL INFORMATION SUPPORTING MATERIAL Supporting materials are provided with the criteria and should be used to assist in correct interpretation of the criteria. In software they can be found in CareEnhance Review Manager Clinical Reference Help, as well as in book format and include: Transition Plan: serves as a tool to assist the reviewer in planning for a safe transition to the most appropriate post-acute level of care. Quality Indicator Checklist: contains National Quality Forum s standard set of hospital quality measures. Alternate Level of Care (ALOC) Guidelines: helps identify appropriate level of care options. Glossary: contains general notes that provide definitions, detail related to specific criteria points and care management notes. Abbreviations and Symbols List: defines acronyms, abbreviations, and symbols used in the criteria. Inpatient List: identifies procedures that are appropriate for the inpatient setting. Index: lists diagnoses and symptoms with associated criteria subsets to help identify the appropriate criteria subset. Additionally, the MHS Customer Hub ( provides interactive support, answers to commonly asked questions, and links to other resources (e.g., Drug list, Bibliography). SECONDARY REVIEW The secondary review process determines the appropriateness of the current or alternate level of care. A supervisor, specialist (e.g., therapist, wound ostomy nurse), or medical practitioner may conduct a secondary review. Organizational policy should determine the qualifications of the reviewers as well as the extent to which secondary review(s) is performed in order to render a review outcome. The secondary reviewer determines the medical necessity of admission or continued stay based on review of the medical record, discussions with nursing, discharge planner, and attending medical practitioner, and by applying clinical knowledge. When is a Secondary Review Appropriate? Review criteria are not met You have questions about the quality of care What Questions Does a Secondary Review Address? Does the patient require this level of care? What are the treatment options? Is there a quality of care question? Should a specialist evaluate this case? Secondary Review Steps 1. If the secondary reviewer agrees with the existing level of care, approve the level of care and schedule the next review. RP-12

13 REVIEW 2. If the secondary reviewer does not agree with the existing level of care, he or she discusses the alternate level of care options for this patient with the attending medical practitioner. If the attending medical practitioner agrees with the secondary reviewer, facilitate the transfer to the alternate setting or level of care, if available. If the attending medical practitioner does not agree with the secondary reviewer, initiate action as approved by organizational policy. 3. If the alternate level of care is unavailable, record the number of variance days and the reason for the variance. 4. Document the review outcome. REVIEW IMPORTANT: The Criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. DOCUMENTING VARIANCES When Discharge Screens are met and an alternate level of care is appropriate, but unavailable, the reviewer should: 1. Indicate the reason the patient has not been transferred. 2. Assign a level of care that represents the alternate level of care, which would be appropriate for the patient had it been available. 3. Document the number of days (referred to as variance days) used at a specific level of care when a less intensive, less costly level is appropriate. 4. Discuss the case with a secondary reviewer and document the review decision. TRANSITION PLAN This guideline is intended to serve as a tool to assist the reviewer in planning for a safe transition to the most appropriate post-acute level of care. Reviewers are encouraged to begin using the Transition Plan tool at the time of admission. The Transition Plan: Is NOT a required part of the Review Process Outlines interventions necessary to ensure continuity of quality care Identifies patients who are at high risk of readmission Provides a framework for identifying discharge needs PRACTICAL TIPS Process Review all notes, rules, and criteria points. The reviewer may select as many criteria as the rule(s) allows, or as specified by organizational policy for documentation purposes, as long as the minimum number of criteria has been met. For example, for a rule of " One," the reviewer can select one or more than one underlying criteria point(s). For a rule of "One," the reviewer should select only one criteria point. RP-13

14 REVIEW PRN medication can be used to meet criteria during an admission review when actual administration is documented for the required frequency (e.g., 3x/24h). Oxygen saturation (O 2 sat) measurements are based on room air readings, unless the criterion states otherwise. Sustained refers to a prolonged finding, such as a heart rate or respiratory rate and excludes an isolated reading or transient abnormal vital sign measurement. Vital sign measurements should be repeated at regular intervals to confirm sustained abnormal or normal values. When a slash ( / ) occurs in the criteria, it represents the term or. For example, in the criterion for CNS infection / Meningitis 3d," this should be interpreted as "CNS infection 3d" or "Meningitis 3d. When criteria points are more complex, the case type (e.g., capital or lower case letters) assists the reviewer in interpreting the criteria. For example: Hyperbaric oxygen and gangrene / osteomyelitis / necrotizing soft tissue infection. Because the first letters after the slash are in lower case, the correct interpretation of this criterion is Hyperbaric oxygen and gangrene, or Hyperbaric oxygen and osteomyelitis, or Hyperbaric oxygen and necrotizing soft tissue infection Fracture / Dislocation, cervical / thoracic / lumbar vertebrae should be interpreted as Fracture, cervical vertebrae, or Fracture, thoracic vertebrae, or Fracture, lumbar vertebrae, or Dislocation, cervical vertebrae, or Dislocation, thoracic vertebrae, or Dislocation, lumbar vertebrae Disorientation / Agitation / Increasing irritability / lethargy should be interpreted as Disorientation, or Agitation, or Increasing irritability, or Increasing lethargy Emergency department data can be used to meet SI. For example: A patient presents to the emergency department with an O 2 sat level of 88% (0.88). Oxygen therapy is initiated at 40% (0.40) and the patient is scheduled for admission. On admission, the patient has an O 2 sat of 91% (0.91) and 40% (0.40) oxygen is ordered to be continued. Selection of SI would be appropriate based on the O 2 sat level documented in the emergency department and the ongoing need for oxygen supplementation. Medical practitioner orders that were initiated in the emergency room or during Observation Status that are ordered to be continued after admission may be used to meet the SI criteria. NOTE: Treatments or services that are only given once while in the ED cannot be used to meet for admission. General exceptions to this include: cardioversion, thrombolytics, and emergency pericardiocentesis When criteria states within normal limits (WNL), within acceptable range, or at baseline, it refers to when a patient returns to his or her personal baseline. Software functionality tip: All rules When a reviewer selects a criterion that has a rule of All, in some instances, the underlying criteria points will automatically be selected. This feature is intended to enhance usability; however, it is essential that All be selected when all of the underlying criteria points are met and notes are reviewed. Level of Care Higher level of care criteria may be used when the setting has the capability to provide the higher level services. For example, an acute care unit has the capability to provide intermediate level of care, e.g., telemetry. Intermediate Care criteria can be used to approve admission to acute care. Lower level of care criteria may be used to review at a higher level of care, when the facility does not have the lower level of care. For example, if the facility does not have an RP-14

15 REVIEW intermediate care unit, and cardiac monitoring cannot be provided on an acute care unit, then the Intermediate criteria may be used to approve an admission or continued stay in a Critical Care Unit. Note: This is an exception to the general rule that lower level of care criteria cannot be used to approve an admission or continued stay to a higher level of care. On occasion, patients who are appropriate at the Acute, Intermediate, or Critical levels of care may also meet criteria at a lower level of care. In this situation, application of the higher level of care is appropriate when clinical documentation supports the need for higher level of care services. When a patient is located at a level of care that is different from the assigned level of care, the reviewer should use the criteria set aligned with the level of care assignment. For example, if the patient is in an acute care bed, but is assigned observation status, the Observation criteria are used for review. When an infant 31 days old is admitted to an acute care facility, the reviewer should use the appropriate Nursery Level subset that corresponds to the severity and intensity of services the infant is receiving, regardless of location. REVIEW RP-15

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