InterQual Procedures Criteria Review Process Introduction As part of the InterQual Care Planning family of products, InterQual Procedures Criteria provide healthcare organizations with evidence-based clinical decision support for procedures. Healthcare providers and reviewers use the criteria to make effective utilization decisions at the point of care or during the preauthorization process. Criteria are presented in an interactive question-and-answer (Q&A) format. As you conduct a review, your answers to questions about the patient s clinical presentation will lead you to the recommended procedure(s). 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 health care 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. When conducting reviews, the issue of gender may be relevant. InterQual content contains numerous references to gender. Depending on the context, these references may refer to either genotypic or phenotypic gender. At the individual patient level, a variety of factors, including but not limited to gender identity and gender reassignment via surgery or hormonal manipulation, may affect the applicability of some InterQual criteria. This is most often the case with genetic testing and procedures that assume the presence of gender-specific anatomy. With these considerations in mind, all references to gender in InterQual have been reviewed and modified when appropriate. InterQual users should carefully consider issues related to patient genotype and anatomy, especially for transgender individuals, when appropriate. Reference materials Reference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria. For example: Bibliographies Clinical revisions Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 1
Abbreviations and symbols list Drug list They are available within the software, for example, on the InterQual Review Manager Help menu in the InterQual Clinical Reference. Additionally, Change Healthcare Customer Hub https://customerhub.changehealthcare.com provides: Interactive support Answers to commonly asked questions Bibliographies Clinical revision documents Links to other resources Informational notes Informational notes provide information regarding best clinical practice, new clinical knowledge, explanations of criteria rationale, definitions of medical terminology, and current literature references. The notes in the criteria are specific to each question, answer, and/or recommendation. How to conduct a medical review During a medical review, you use the criteria as a decision support tool to assess the medical appropriateness of a given procedure. Although labeled as a Medical Review in the software, this type of review is also known as a primary review. This first-level review typically involves a non-physician reviewer who uses the criteria to determine if the request is appropriate or if the review requires secondary review. Conduct a medical review as follows: Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 2
Step 1: Select a category Select a category. If you are uncertain about which category to select, select All Categories. Categories organize specific, logical clinical groupings of procedures. Procedures Criteria are organized according to the following medical specialty categories: Cardiology Cardiothoracic General Surgery Hand, Plastic & Reconstructive Neurosurgery Obstetrics & Gynecology Ophthalmology Oro-Maxillo-Facial, Dental & Otolaryngology Orthopedic - Lower Extremity Orthopedic - Upper Extremity Podiatry Specialized Procedures Urology Vascular Each medical specialty category contains surgical and invasive procedures generally performed by physicians in that surgical specialty. The Specialized Procedures category contains procedures performed by a variety of surgical and behavioral health specialists. There are also two age-related categories: Adult - patients 18 years of age Pediatric - patients < 18 years of age In some subsets, the content in the Pediatric category is appropriate for adolescents only, which are defined as 13 and < 18 years of age. Step 2: Select a subset Select a subset. You can search for a subset using one or more of the following methods: By category By keyword(s) By medical code(s) Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 3
A subset is the procedure that is being reviewed (e.g., appendectomy, colonoscopy, craniotomy). The adult and pediatric content are in separate subsets. Pediatric content includes (Pediatric) in the subset description, e.g., Appendectomy (Pediatric). The subset overview notes include notes regarding alternate procedure names. These notes provide a list of additional names by which the requested intervention may be referred or the names of different procedures that produce the same result. For example, Roux-en-Y Gastric Bypass (RYGB) and Laparoscopic Adjustable Gastric Banding (LAGB) are alternate procedure names found in the Bariatric Surgery criteria subset. They are two different weight loss surgery procedures for patients with obesity. The subset overview notes also include Inpatient/Outpatient designations. These designations may be included with the recommendation to provide an Inpatient or Outpatient setting recommendation. The recommended settings are determined by literature, data, and InterQual consultant consensus and are based on best medical practices. The recommendation of Inpatient refers to those procedures most commonly performed in the acute care setting and for which admission to the hospital is indicated (typically a stay of 24 hours or more). The Outpatient recommendation refers to those procedures performed in the physician s office, in an ambulatory care setting, or procedures that do not require an acute hospital admission (typically a stay of less than 24 hours). Step 3: Complete the review detail information This step applies to InterQual Review Manager users only. Complete the review detail information. Review detail includes information pertinent to the review, for example, requested services, requesting provider(s), facility, service start and end dates, and comments. Step 4: Answer medical review questions Answer the medical review questions based on the clinical scenario. The medical review is a sophisticated, branching-logic algorithm for evidence-based procedures; a series of questions directs you to the most appropriate pathway based on the clinical need for the procedure. For example, in the Bronchoscopy subset, you are presented with a list of medical conditions that may require the procedure (e.g., hemoptysis, tumor resection, pneumonia). Your answers lead to the most appropriate recommendation(s). Urgent conditions are noted in the criteria with (urgent) to the right of the criteria text. Urgent conditions do not require preauthorization. A review to determine the appropriateness of the intervention is generally performed following the intervention. If there is adequate time to complete a review before performing the intervention, the urgent criteria may also be used for a prospective review. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 4
Review Questions Questions regarding symptoms and findings, prior imaging or diagnostic testing results, or conservative treatment are in a Yes/No, Choose one, or multiple choice (Choose all that apply) format. The rules displayed in the multiple choice questions indicate how many items must be selected to fulfill the rule. When answering questions, keep the following guidelines in mind: For questions that enable you to select more than one answer choice, you must click Next to advance to the next question. In many questions, the last answer choice is Other clinical information (add comment). If the clinical scenario does not satisfy the other answer choices, select this answer. The following recommendation displays: Current evidence does not support procedure in this clinical scenario. Selecting None of the above also displays the recommendation: Current evidence does not support procedure in this clinical scenario. Selecting More choices leads to another question with more medical conditions that may require a procedure or intervention. Selecting None of the above, more choices leads to additional questions or a recommendation. This option is used when there is a list of criteria (e.g., symptoms, findings, diagnoses, medical conditions) that must be reviewed prior to moving to the next question (e.g., risk factors for cancer, involuntary weight loss, dysphagia, odynophagia). If any of the listed criteria are present, it must be selected. If none of the listed criteria are present, select None of the above, more choices to advance to the next question or directly to a recommendation. When criteria are not available for a specific age group, the recommendation Current evidence does not support testing in this clinical scenario displays (e.g., bronchoscopy content is available for the adult patient only; strabismus repair is available for the pediatric patient only). Reviewer comments can be added at any time during the review. Step 5: Select recommendation(s) Review and select recommendation(s) to authorize the appropriate procedure(s). Based on your organizational policies, you can also select the appropriate ICD-10, CPT, and/or HCPCS codes. Recommendations The recommendations that display after you answer the questions in a particular pathway are based on the best available medical evidence and current practice. Once the medical review is completed, depending on the pathway taken, you will be led to any of the following recommendations: One procedure is recommended More than one procedure is recommended and one or more procedure can be selected, but not all the procedures need to be selected. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 5
More than one procedure is recommended and all procedures in a group should be selected (i.e., two or more procedures are mutually recommended). Messaging indicates which procedures must be selected together. More than one procedure is recommended but only one procedure should be selected (i.e., the procedures are mutually exclusive). Messaging indicates which procedures cannot be selected together. No procedure is recommended: Current evidence does not support testing in this clinical scenario. This occurs when all of the required criteria have not been fulfilled, the requested reason for the procedure is not included, or the content does not cover the procedure for the age group selected. No procedure is recommended: Current evidence does not support testing in this clinical scenario. This can occur when all of the required criteria have been fulfilled but the procedure is considered cosmetic based on the pathway taken. A note will display Current evidence-based literature and input from our independent panel of clinical experts does not support this procedure as medically necessary based upon the criteria selected. It may be performed, in some instances, for cosmetic reasons. Whether to perform this procedure for cosmetic purposes is a matter of local organizational policy. A procedure is recommended and flagged as This recommendation is designated as Limited Evidence in this clinical scenario. Criteria cannot be met. These procedure recommendations are also designated Secondary review required. Criteria cannot be met. A note will display Recommendations are designated as Limited Evidence based on one or more of the following: Research to date has not demonstrated this intervention s equivalence or superiority to the current standard of care. The balance of benefits and harms does not clearly favor this intervention. The clinical utility of this intervention has not been clearly established. The evidence is mixed, unclear, or of low quality. This intervention is not standard of care New technology is still being investigated. Next action(s) Your next action(s) depends on the medical review results as shown in the following table: Medical review results Select recommendation(s) Action(s) According to current evidence, one or more of the recommendations or recommendation combinations is appropriate in this clinical scenario. (View notes, if any, for details.) According to current evidence, one or more recommendations Recommended (one is selected) Recommended (two or more are selected) Mutually Exclusive (only one can be selected) Mutually Recommended (two or more must be selected) Limited Evidence Approve the recommended procedure Approve the recommended procedures Approve the recommended procedure Approve the recommended procedures Refer for secondary review or secondary medical review as Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 6
Medical review results Select recommendation(s) Action(s) or combinations of recommendations is based on limited evidence (LE). If LE recommendations are selected, medical review is suggested based on payer policy. (View notes for details.) The criteria enable reviewers to proactively gather and document patientspecific clinical information for medical review. Mutually Exclusive Limited Evidence OR Recommended dictated by your organizational policies Limited Evidence: Refer for secondary review or secondary medical review as dictated by your organizational policies Recommended: Approve the recommended procedure(s) Current evidence does not support procedure in this clinical scenario Current evidence does not support procedure in this clinical scenario Cancel current review No recommendations were made based on the answers to the Medical Review questions. Please answer all questions. Medical review incomplete Obtain additional information from the requesting physician if needed. If the additional information satisfies the medical review, approve the recommended procedure If the additional information does not satisfy the medical review, or if no further information is available, refer for secondary review or secondary medical review as dictated by your organizational policies Procedure is considered cosmetic. Refer for secondary review or secondary medical review as dictated by your organizational policies Cancel the review Answer all questions Benchmark Length of Stay (LOS) Powered by RelayHealth Financial Benchmark length of stay (LOS) information is included in the Procedures criteria subsets that are recommended for the inpatient setting. The LOS values are derived from a select set of claims data from RelayHealth Financial and have been statistically validated. They represent geometric mean length of stay based on DRG claims data. Additionally, in the Adult content, the Centers for Medicare & Medicaid Services Medicare Severity Diagnosis Related Groups Geometric Mean Length of Stay (CMS MS-DRG GMLOS) is provided. These values create guidance designed to facilitate efficient management of a patient to a target length of stay. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 7
Step 6: Approve the recommended procedure(s) or refer for secondary review This step applies to InterQual Review Manager users only. If you use Review Manager, complete the primary outcome information, including the outcome date and time, next review date, priority, outcome (e.g., Approved, Referred for Secondary, Referred for Secondary Medical, or Request Canceled), and outcome comments. Outcome referral reasons Referral reasons identify reasons why the proposed request does or does not meet medical necessity or medical appropriateness. Examples include criteria issues, such as no criteria to cover indication/diagnosis/procedure, and provider issues, such as test results incomplete. Referral reasons vary from product to product and display based on the selected outcome. An organization can add specific referral reasons and create unique outcome groups to delete or hide existing referral reasons. Secondary Review Secondary review is indicated when a primary review results in any of these outcomes: Criteria subset/procedure not listed. Only the more common procedures are included in the criteria. This does not mean that the request is inappropriate, but that the request is less common, not often preauthorized, or emerging and requires secondary review. Indication not listed. The condition or symptom for performing a procedure is not listed. Only the most common conditions are listed. Criteria not available for the age group. The criteria do not cover the procedure for the age group requested. Criteria not met. When the given reason for the procedure is listed, but the required criteria are not fulfilled, the case requires secondary review and results in a recommendation of Current evidence does not support procedure in this clinical scenario. Recommendation with Limited Evidence. These procedures within a subset require secondary medical review. These criteria have been developed to provide reviewers with a basis for proactively gathering and documenting patient-specific clinical information that will facilitate secondary medical review. Recommendation with secondary review required. These procedures within a subset require secondary medical review. These criteria have been developed to provide reviewers with a basis for proactively gathering and documenting patient-specific clinical information that will facilitate secondary medical review. Patient choice and preference. The criteria delineate reasonable courses for the majority of patients. Some patients refuse certain prerequisite therapies or testing; these cases require secondary review. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 8
Secondary Review Process A supervisor, specialist, or physician may conduct a secondary review. The organization s policies determine the qualifications of the reviewers, as well as the extent to which secondary review is conducted to render a review outcome. The secondary reviewer determines the medical necessity of the request based on a review of the medical record, discussions with the provider or referring physician, and by applying clinical experience. When conducting a secondary review: If the secondary reviewer agrees with the requested procedure, approve the request and select the approved procedure. If the secondary reviewer does not agree with the request, the optimal alternate treatment for this patient may be discussed with the requesting provider. If the requesting provider does not agree with the secondary reviewer s determination, a specialist may become involved in the review process. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 9