InterQual Behavioral Health Criteria Substance Use Disorders Review Process Introduction InterQual Behavioral Health Substance Use Disorders Criteria provide support for determining the clinical appropriateness of the current or proposed level of care including: Inpatient Inpatient Detoxification Inpatient Rehabilitation Observation Residential Treatment Center Supervised Living Partial Hospital Program Intensive Outpatient Outpatient The Substance Use Disorders Criteria are designed for review of patients 13 years of age and older. 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. Note: When evidence in the medical literature to support the efficacy and effectiveness of the intervention or service is absent, mixed, or unclear, criteria reflect the opinion of McKesson s expert clinical consultants. It is based upon current best practice and is the product of an iterative process involving multiple clinicians with diverse expertise in varied practice and geographic settings. Reference Materials Reference materials are provided with the criteria and should be used to assist in correct interpretation of the criteria. Clinical Revisions: provide details of changes to InterQual Clinical Criteria. Bibliography Abbreviations and Symbols List: defines acronyms, abbreviations, and symbols used in the criteria. Drug List: categorizes drug names and classes mentioned within the criteria. 2017 McKesson Corporation and/or one of its subsidiaries. All right reserved. Produced in Cork, Ireland. 1
Assessment tool: for Alcohol Withdrawal Additionally, MHS Customer Hub (http://mhscustomerhub.mckesson.com) provides interactive support, answers to commonly asked questions, and links to other resources. When to Conduct a Review: 1. Conduct a review on any day during the episode of care. 2. If conducting a review at the time of admission, users can only apply data that are available at the time the decision to treat the patient was made. 3. 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 treat was made. How to Conduct a Review Select a subset Select a level of care Select an episode day Select criteria that apply to the case Take action based on review findings Conduct a Behavioral Health Review as follows: 1. Select a subset (e.g., Substance Use Disorders). 2. Select a level of care based on the patient s current or proposed level of care. 3. Select the appropriate episode day. Episode Day 1 represents the first day in the episode of care for the patient s symptom. Episode Day 2 represents the second day in the episode of care, and so on. 4. Select criteria based on the patient s clinical finding and when required, intervention. Read all notes and any organizational policies. 5. Take the appropriate action based on the review findings. Important: The actual number of hours, days, or visits authorized is determined by organizational policy. Levels of care Levels of care in the criteria are listed in descending order of intensity of services. The level of care names used in InterQual Behavioral Health criteria are the most nationally recognized. However, when the program or unit s name does not match the InterQual levels of care, refer to the Informational note attached to each level of care, which defines the services recommended for that level of care. This may include alternate level of care names. Episode day An episode day is a calendar day, which normally begins at 12:00 a.m. The number of episode days varies 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 2
by level of care. Episode Day 1 is the day of admission or initiation of treatment for the symptom the patient presents with. Episode Day 2 represents the second day in the episode of care and so on. When applying criteria to visits rather than days, the same logic applies. The first visit would be Episode Day 1. In some instances the criteria are intended to be used for a range of days as opposed to a single day, for example, Episode Day 2 6. When there is a range of days, reviews are done using the same criteria for the range of days specified. Some levels of care include episode days 2-x. In these instances, x represents an unspecified number of days. Criteria points Criteria points are the clinical statements the reviewer should consider when conducting reviews. Criteria comprise evidence-based clinical statements and rules for their application. Select as many criteria as the rule(s) allows within an episode day, 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," select one or more than one underlying criteria point(s). For a rule of "One," select only one criteria point. Note: Nested decision tree logic requires that the reviewer ensure that each criteria point selected is appropriate. Criteria located below a rule should only be selected when information supporting the upper criteria point is documented in the medical record. For example: Correct application of the following nested criteria is appropriate only when there is documentation in the patient s medical record that the patient presents with fire setting within last 24 hours with risk of harm to self or others with documented high risk of potential for harm due to location or intensity or size of fire; history of previous fire setting; or had intent to harm. Notes Fire setting within last 24 hours with risk of harm to self or others, > ONE: High risk of potential for harm due to location or intensity or size of fire History of previous fire setting Intent to harm Notes provide important information that assists the reviewer by providing reminders of best medical practice, new clinical knowledge, explanations of criteria rationale, definitions of medical terminology, and current literature references. A note icon indicates one or more notes are associated with a criteria point. To view notes click a note icon Rules and the corresponding note(s) display in a separate window. Rules (e.g., One, Both, and All) specify how many of the next-level criteria are required. Software Note: When you select 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 of the underlying criteria points are met and notes are reviewed before selecting the parent criteria point. This functionality is enabled based on organizational preference. 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 3
Time requirements When conducting a review, observe the time requirements, where applicable. The time requirement specifies a time frame over which clinical findings develop, worsen, or improve. For example, the criteria Finding within last 24 hours requires the listed clinical finding be present within the last 24 hours. If a specific time is not identified, the time frame would be based on current clinical findings. Symptom Type On the appropriate episode day, criteria may include one or more of the following Symptom Type criteria: Symptom improved - Criteria that indicate the patient is clinically stable. Discharge is expected on the day this criteria is selected. The met for the current level of care. symbol indicates that the criteria are not Symptom improving or expected to improve - Criteria that indicate the patient is clinically appropriate at that level of care, for the designated episode day and symptom. Symptom worsening Criteria that indicate that the patient s symptom is worsening and may require a more intensive level of care. The reviewer may select the recommended alternate level of care and continue the review. The symbol indicates that the criteria are not met for the current level of care. NOTE: When an episode day includes more than one Symptom Type, only one Symptom Type can be met. 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 4
For these review findings Episode day criteria met or Symptom improving or expected to improve criteria met Symptom improved criteria met Symptom worsening criteria met Episode day criteria, Symptom improved, Symptom improving or expected to improve, or Symptom worsening Do this Level of care met: Approve level of care for that episode day. Schedule next review. Level of care not met: Prepare for discharge. Apply the attached recommended level of care criteria, Episode day 1, to assist in determining the most appropriate alternate level of care (ALOC). Level of care not met: Apply the identified recommended level of care criteria to assist in determining the most appropriate alternate level of care (ALOC). Level of care not met: Obtain additional information from attending behavioral health clinician or other caregivers, if organizational policy allows. If additional information does not support criteria, discuss condition with behavioral health clinician (an alternative setting may be more appropriate for managing the patient s condition). Facilitate transfer if behavioral health clinician is agreeable to alternate setting or level of care. Refer for secondary review if behavioral health clinician does not agree. Redirection As you evaluate criteria, there are certain situations where you may be directed to a different Behavioral Health product and subset. For example, in the clinical scenario of a patient in a Substance Use Disorder Supervised Living level of care who has worsening symptoms and presents as an acute danger to self or others, the reviewer would see this redirection within the criteria: (see InterQual Adult and Geriatric Psychiatry Inpatient criteria) Additional Review Tips: When conducting an episode day 1 review, Emergency department data may be used (e.g., imaging studies, evaluation finding, lab, history and physical, medical practitioner orders). Level of Care versus Place of Care When a patient is located at a level of care that is different from the criteria assigned level of care, use the criteria set aligned with the level of care assignment. For example, if the patient is on an inpatient unit, but is assigned observation status, the Observation level of care criteria is used for the review. When the program or unit s name does not match the InterQual levels of care, refer to the note attached to each level of care, which defines the services recommended for that level of care. When a patient is transferred to the same level of care at a new facility, an episode day 1 review is not necessary if criteria were met at the transferring facility. The accepting facility should conduct the next review on the appropriate episode day. For example, a patient is admitted to Inpatient level of care on Wednesday and is transferred to Inpatient at another facility on Thursday. The reviewer would conduct a review for episode day 2. 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 5
Important: When a level of care is not available in your area (e.g., Intensive Outpatient Program), we recommend that you refer the patient to the next higher level of care (e.g., Partial Hospital Program). Note: You should document the number of these cases to determine if development of an additional level of care would be beneficial for your organization. When a patient is admitted on an involuntary hold or commitment, apply the criteria based on the symptom the patient is presenting with. Secondary Review When a case does not meet criteria, it is referred for secondary review, which can be conducted by a supervisor, physician, or designated clinician. It is a matter for organizational policy to determine the qualifications of the reviewers as well as the extent to which secondary review(s) is conducted to render a review outcome. The secondary reviewer determines the medical necessity of admission, continued stay, or a procedure. Important: A Secondary Reviewer is essential for reviewing the more difficult cases. It is helpful to have a Secondary Reviewer who can represent and support the review staff in discussions with the medical staff and/or behavioral health clinicians. If your organization does not have a Secondary Reviewer, it would be beneficial to have a discussion with senior management about obtaining a Secondary Reviewer as either a staff member or a consultant. When is a Secondary Review Appropriate? Criteria rules are not met. You have questions about the quality of care. The behavioral health clinician, patient, or patient s family, or patient s guardian disagrees with the level of care assignment or procedure recommendation and an agreement cannot be attained. What Questions Does a Secondary Review Address? Does the patient require this level of care or procedure? What are the treatment options? Is there a quality of care question? Should a specialist evaluate this case? Secondary Review Process The secondary review process determines the appropriateness of the requested level of care or procedure. Follow these steps when you conduct a secondary review: If the Secondary Reviewer agrees with the requested level of care or procedure, authorize the level of care or procedure and schedule the next review. 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 6
If the Secondary Reviewer disagrees with the requested level of care or procedure, he/she discusses the options for this patient with the attending physician or behavioral health clinician. If the attending physician or behavioral health clinician: Agrees with the Secondary Reviewer, authorize the procedure or agreed-upon level of care, if available. Disagrees with the Secondary Reviewer, initiate action as approved by organizational policy. If an alternate level of care is recommended but unavailable, finalize the Variance Code. Document the review outcome. 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 7