INTERQUAL IMAGING CRITERIA REVIEW PROCESS RP-1
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INTERQUAL IMAGING CRITERIA REVIEW PROCESS ORGANIZATION InterQual Imaging criteria are organized according to body system categories. These categories provide the criteria for adult patients, which are defined as patients 18 years of age, with the exception of the Pediatric category. The Pediatric category covers patients < 18 years of age. Each category contains imaging studies, also referred to as criteria subsets, pertaining to that general anatomic region. CARE PLANNING COMPONENTS Categories organize imaging studies that are related to a specific body system (e.g., Chest & Heart). In the Imaging criteria there are 7 categories. The criteria subset is the imaging study that is being reviewed (e.g., Computed Tomography (CT), Chest). Indications are the reasons why an intervention is requested. For example, Lung abnormality by CXR is one indication, or reason for requesting chest CT. Indications cover diagnoses, symptoms, or clinical findings that constitute possible reasons for performing a particular intervention. All indications are denoted with a number that ends in 00. Criteria points are clinical statements that support indications and refer to test results, medications, symptoms, clinical findings, or medical management. A unique number identifies each criteria point and they are organized in a nested decision tree. Criteria points address elements related to the evaluation and management of the patient. They serve to validate the problem identified in the indication or confirm that appropriate diagnostic or therapeutic interventions have been attempted prior to obtaining approval for the requested intervention. The criteria rules show you how many (One, Both, All, etc.) of the next level criteria a reviewer must select to fulfill the rule. To meet the criteria and determine that an intervention is appropriate, the reviewer must select criteria points as the rules specify. Rules are presented in brackets and bold print. In some cases the criteria point at the same level as the rule, in addition to the underlying criteria, must be applicable for the criteria to be met. This is called a selectable rule (or checkable rule) and occurs when both the criteria point at the same level as the rule and the underlying criteria are clinically true. Selectable rules are often designated by after preceding the rule. RP-3
InterQual Imaging Criteria: REVIEW PROCESS Notes provide reminders of best clinical practice, new clinical knowledge, explanations of criteria rationale, definitions of medical terminology, and current literature references. Except for notes that appear on the criteria subset cover page, notes are numbered to correspond with specific indications or criteria points. PRIMARY REVIEW This first level review usually involves a non-physician reviewer who uses the criteria to determine if the request is appropriate or if the case requires secondary review. Primary Review Steps: Choose the category Identify the requested criteria subset (imaging study) Choose the appropriate indication Select the criteria points that reflect the patient s condition based on available information. Apply the rules, begin at the indication and follow through all the associated criteria. Read the notes to obtain additional information pertinent to the review. The action that follows depends on whether the review criteria were met, as shown in this table. RP-4
InterQual Imaging Criteria: REVIEW PROCESS For these review findings Primary review: Criteria Met Primary review: Criteria NOT Met Do this Approve the request. Obtain additional information from the requesting physician to complete the review. - If the additional information satisfies the primary review, the request may be approved - If the additional information does not satisfy the review, refer for secondary review and select a reason code for the review. (NOTE: Secondary medical review is required for Secondary Medical Review Mandatory procedures, or when the patient presents with the clinical scenario identified in the Medical Review Note (MDR). Refer to RP-6 - RP-7.) If no further information is available, refer the case for secondary review and select a reason code. Reason Codes Reason Codes identify why the proposed request does not meet appropriateness criteria. Reason Codes vary from product to product. Documentation of reason codes over time can lead to quality improvement initiatives and assist in business decisions. Record this information during your review: Patient demographics. Actual clinical findings. Avoid writing terms such as normal or elevated or low. Planned therapies and the patient s response, or lack of response, to those services. Discussions with caregivers and physicians. Questions or concerns for follow-up review. Practical Tips If you have trouble finding an imaging study in a body system category, utilize the keyword or medical code search in CareEnhance Review Manager. Mandatory notes provide information you must read while performing a review. The criteria have two types of mandatory review notes: o Medical Review (MDR) Notes-clinical circumstances where secondary medical review is required. o Reviewer Instruction Notes (RIN)-special instructions to the reviewer regarding criteria application. Alternate procedure names are notes located on the criteria subset cover page. They provide a listing of additional names by which the requested intervention may be referred. RP-5
InterQual Imaging Criteria: REVIEW PROCESS For example, Virtual Colonoscopy and CT Colonography are alternate procedure names for CT of the colon, and are found on the subset cover page of the Computed Tomography (CT), Colon criteria subset. Urgent conditions are noted in the criteria with a 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. Secondary Medical Review Mandatory imaging studies (e.g., Discography, Lumbar; Computed Tomography (CT), Coronaries) are studies that require mandatory secondary medical review. Imaging studies are designated as Secondary Medical Review Mandatory when the interventions: o are not standard of medical care, o require further research (to examine long-term outcomes across varied patient populations), o require further comparison studies (the new intervention compared to traditional or less invasive treatment of the condition), o are infrequently performed (replaced by a newer procedure or technology), o have the potential for serious complications or side effects, or o have equivocal or limited benefit. SECONDARY REVIEW A secondary review is indicated when a case does not meet criteria. A supervisor, specialist, or physician may conduct secondary review. It is a matter for organizational policy to determine the qualifications of the reviewers as well as the extent to which secondary review is performed in order to render a review outcome. The secondary reviewer determines the medical necessity of the request based on review of the medical record, discussions with the provider or referring physician, and by applying clinical experience. When is a Secondary Review Appropriate? Criteria subset/procedure not listed Only the more common procedures or interventions are included in the criteria. This does not mean that the request is inappropriate, but that the request is rare and requires secondary review. Indications not listed An indication for performing a procedure or intervention is not listed. Only the more common and most straightforward indications are listed. Medical Review (MDR) note indicates the need for secondary review Some indications or the criteria contain Medical Review (MDR) Notes that require, in the presence of certain circumstances, that the request be sent for secondary medical review. Criteria not met When the given indication is listed, but the required criteria are not fulfilled, the case requires secondary review. Patient has comorbid conditions The general state of a patient s health may influence both the provider and the reviewer regarding the wisdom of performing a procedure or intervention. If there is any question regarding the appropriateness of an intervention because of comorbid conditions, a secondary review is required. RP-6
InterQual Imaging Criteria: REVIEW PROCESS Patient choice and preference The criteria delineate reasonable therapy for the majority of patients. Some patients refuse certain prerequisite therapies or testing; these cases require secondary review. Secondary Medical Review Mandatory imaging study or indication These imaging studies (or indications within imaging studies) 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. Secondary Review Process Secondary Review Steps: If the secondary reviewer agrees with the requested imaging study, approve the request If the secondary reviewer does not agree with the request, he or she discusses the optimal alternate management for this patient 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 Secondary Reviewer Decision Codes Secondary Reviewer Decision Codes represent the decisions of the secondary 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 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. RP-7
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