InterQual Level of Care Criteria Outpatient Rehabilitation & Chiropractic Criteria

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1 InterQual Level of Care Criteria Outpatient Rehabilitation & Chiropractic Criteria Review Process Introduction InterQual Outpatient Rehabilitation & Chiropractic Criteria support decisions about the appropriateness of therapy services and chiropractic care in the outpatient setting. Outpatient Rehabilitation & Chiropractic criteria subsets have been validated for use with adult, adolescent, or pediatric patients. (Outpatient Rehabilitation is for adult, adolescent, and school age patients. The Pediatric Rehabilitation subset is for medically complex pediatric patients. Chiropractic is for adult patients and adolescent patients.) Adult criteria are for review of patients 18 years of age or older; adolescent criteria are for review of patients 13 to < 18 years of age; school age criteria are for review of patients 5 to < 13 years of age; and the pediatric criteria are for patients < 18 years of age. Outpatient Rehabilitation & Chiropractic criteria subsets are organized by diagnosis (e.g., Carpal Tunnel Syndrome and Osteoarthritis, Shoulder). Outpatient treatment for both non-operative and postoperative conditions is addressed. Each subset includes review criteria for initial, ongoing, and discharge reviews. 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. Reference Materials Reference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria. Abbreviations and Symbols List: Defines acronyms, abbreviations, and symbols used in the criteria. Bibliography: References cited in the clinical content. Clinical Revisions: Provide details of changes to InterQual Clinical Criteria. Drug List: Categorizes drug names and classes mentioned within the criteria. Additionally, MHS Customer Hub ( provides interactive support, answers to commonly asked questions, and links to other resources McKesson Corporation and/or one of its subsidiaries. All right reserved. 1

2 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. A note icon indicates one or more notes are associated with a criteria point. To view notes, click a note icon. How to conduct a review Outpatient Rehabilitation & Chiropractic Criteria include initial, ongoing, and discharge reviews. Initial Review and Ongoing Review criteria consist of objective clinical indicators and address therapeutic services delivered in the outpatient setting. The Initial and Ongoing rule requires All criteria to be met. The clinical indicators and services components include: Clinical presentation Rehabilitation potential For patients with a functional impairment who have a chronic or progressive illness without the expectation for improvement, refer to the Maintenance Therapy subset. Criteria in this subset can be used to validate the need for therapeutic services to maintain current functional status or prevent or slow further decline. Progressive therapy program (program components, treatment goals, and progress) Functional status (e.g., mild, moderate, or severe limitation) and related visits within a designated time frame (e.g., 4 weeks). Discharge review is used to determine if the patient has reached a level of independence appropriate for safe discharge from outpatient treatment or that services may no longer be appropriate (e.g., worsening symptoms, poor rehabilitation potential). The Discharge Review rule requires One discharge criteria be met. The discharge criteria include: New onset / worsening of symptoms Patient is appropriate for an independent home exercise program Treatment goals met Functional plateau reached Poor rehabilitation potential How to conduct an initial review After the initial evaluation, to determine the appropriateness of services at the outpatient level, conduct an initial review: 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. 2

3 Obtain and review the initial evaluation Select a subset Select Initial Review criteria that apply to the case Take action based on review findings 1. Obtain and review the initial evaluation from the therapist or chiropractor. 2. Select the most appropriate criteria subset based on the patient s diagnosis. 3. Select Initial Review criteria based on the patient's clinical presentation, the documented treatment program, and functional status and determine if All criteria are met. Note the number of visits associated with the patient s functional status. 4. Take the appropriate action based on the review findings: Finding Initial Review rule met Initial Review rule not met Action Approve the initial visits. Schedule the ongoing review, if appropriate. Obtain additional information from the therapist, chiropractor, or referring physician. If additional information does not meet the corresponding Initial Review components, determine if the patient meets discharge criteria. If Discharge Review criteria are met, discuss patient self-management plan with therapist, chiropractor or physician. If there is no agreement regarding self-management, refer for secondary review. (For information about the secondary review process, refer to Secondary review on page 5.) If Discharge Review criteria are not met, refer for secondary review. (For information about the secondary review process, refer to Secondary review on page 5.) Review tips The initial review period includes the first 4 weeks of treatment. A week is defined as any 7-day period. Knowing which visit pattern to approve: The number of visits is based on the relevant functional status. More than one service requested: When more than one service is requested and will be provided by different disciplines (e.g., OT, PT, Chiro), the reviewer needs to review all services requested individually to avoid duplication of services. More than one clinical problem: When more than one clinical problem is present and will be treated by one provider, it is important to determine if the problems are related or isolated. Isolated problems should be reviewed separately and the appropriate number of visits should not exceed the maximum number of visits allowed for the more severe clinical problem. Related clinical problems may require treatment to multiple areas, but the underlying clinical problem and treatment approach are essentially the same McKesson Corporation and/or one of its subsidiaries. All rights reserved. 3

4 Example 1: Patient presents to physical therapy with low back pain (LBP) and an ankle sprain after sustaining a fall. The LBP is mild with few functional limitations and 4 visits indicated, yet the ankle sprain is severe, indicating 12 visits would be appropriate. The visits should address both complaints with the expectation that more treatment is required for the more severe condition. This is an example of two diagnoses presenting as isolated complaints, with both resulting from a single accident. Example 2: Patient presents to physical therapy with right and left hip pain due to osteoarthritis. Both hips should be treated and the visits should address both complaints with the expectations that more treatment is required for the more severe condition. This is an example of one diagnosis related to two areas of the body. New clinical problem(s): If a new injury or exacerbation occurs as a result of a diagnosis not related to the current treatment, conduct an initial review of the new diagnosis to determine if additional outpatient services are appropriate. Example 1: An initial review was conducted for Carpal Tunnel Syndrome and 4 visits were given for a mild limitation in function. The patient falls and injures his knee and is diagnosed with a ligamentous injury with a moderate limitation. The reviewer obtains evaluation information on the knee and conducts another initial review to determine the appropriate number of visits. In many cases, another discipline or therapist may provide services to the patient, necessitating separate reviews; however, if the same provider delivers the care for both clinical problems, the appropriate number of visits should not exceed the maximum number of visits allowed for the more severe clinical problem. Example 2: A patient is receiving physical therapy for a rotator cuff injury. The patient is having continued symptoms and undergoes a surgical rotator cuff repair. Postoperatively, the patient is referred for physical therapy. The reviewer obtains the initial postoperative physical therapy evaluation information and conducts another initial review to determine the appropriate number of visits. The post surgical shoulder is considered a new clinical problem. Discharge review is provided to validate that the patient can be discharged from outpatient services when Initial Review criteria are not met. How to conduct an ongoing review Beyond the initial approved visits or after the last review period is completed, to validate the need for ongoing services at the outpatient level, conduct an ongoing review: Obtain and review clinical information Select the same criteria subset used during the initial review Select Ongoing Review criteria that apply to the case Take action based on review findings 1. Obtain and review the clinical information, including progress notes, treatment notes, physician notes or orders, imaging or x-ray reports, and other information, as needed. 2. Select the same criteria subset used during the initial review or the last review period McKesson Corporation and/or one of its subsidiaries. All rights reserved. 4

5 3. Select Ongoing Review criteria and determine if All criteria are met (Clinical presentation, Rehabilitation potential, Progressive therapy program including progress toward meeting treatment goals, and Functional status). It is not necessary to meet the symptoms and findings subcriteria under clinical presentation if the diagnosis was confirmed during the initial review. Document the Ongoing Review criteria met. Note the number of visits associated with the patient s functional status. When reviewing for Ongoing treatment, there should be documented progress toward meeting goals since the initial review. In many cases, the patient s overall functional status may improve one level (e.g., evaluation revealed moderate limitation and at ongoing review, the patient has a mild limitation). If the functional level does not change, a closer review of the individual physical impairments may be needed. 4. Take the appropriate action based on the review findings: Finding Ongoing Review rule met Ongoing Review rule not met Action Approve the ongoing visits. Schedule next/final ongoing review, if appropriate. Review Discharge Review criteria to determine if discharge is appropriate. Obtain additional information from the therapist, chiropractor, or referring physician. If additional information does not meet the corresponding ongoing review, determine if the patient meets discharge criteria. If Discharge Review criteria are met, discuss patient self-management plan with the therapist, chiropractor or physician. If there is no agreement regarding self-management, refer for secondary review. (For information about the secondary review process, refer to Secondary review on page 5.) If Discharge Review criteria are not met, refer for secondary review. (For information about the secondary review process, refer to Secondary review on page 5.) Review tips For Outpatient Rehabilitation, the ongoing review period (except pediatric rehabilitation) specifies 12 weeks (initial 4 weeks of treatment and up to 8 additional weeks ongoing) of treatment. Ongoing review for Pediatric Rehabilitation can be used more than once. The total duration of treatment is determined by local medical policies or benefits. For Chiropractic, the ongoing review period limits treatment to a total of 8 weeks (initial 4 weeks of treatment and up to 4 additional weeks ongoing). Ongoing review for day rehabilitation specifies weekly review for a total of 3 weeks (initial week of treatment and up to 2 additional weeks ongoing). If the reviewing organization begins to review for continuation of services after a predetermined number of visits have been used and the associated time period has lapsed, follow the Ongoing 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. 5

6 Review criteria. If the predetermined number of visits has been used prior to the recommended time period and additional visits are requested, secondary review is appropriate. A week is defined as any 7-day period. Knowing which visit pattern to approve: The number of visits is based on the functional status selected in the ongoing review. In most cases, the functional status should reflect progress and a decrease in the severity of functional limitation. New clinical problem(s): If a new injury or exacerbation occurs as a result of a diagnosis not related to the current treatment, conduct an initial review of the new diagnosis to determine if additional outpatient services are appropriate. Example: An initial review was conducted for Carpal Tunnel Syndrome and 4 visits were given for a mild limitation in function. The patient falls and injures his knee and is diagnosed with a ligamentous injury with a moderate limitation. The reviewer obtains evaluation information on the knee and conducts another initial review to determine the appropriate number of visits. In many cases, another discipline or therapist may provide services to the patient, necessitating separate reviews; however, if the same provider delivers the care for both clinical problems, the appropriate number of visits should not exceed the maximum number of visits allowed for the more severe clinical problem. Discharge review is provided to validate that the patient is appropriate to be discharged from outpatient services when Initial or Ongoing Review criteria are not met. If the discharge occurs prior to the completion of the authorized treatment period, the discharge review is optional and can be used to determine the appropriateness of discharge. Secondary review When a case does not meet criteria, it is referred for a secondary review. A supervisor, a specialist (e.g., therapist, chiropractor), or a physician may conduct a secondary review. It is a matter of organizational policy to determine the qualifications of the reviewers as well as the extent to which secondary review(s) is performed to render a review outcome. The secondary reviewer determines the medical necessity of initial or ongoing care based on review of the medical record, discussions with the provider and referring physician, and by applying clinical experience. When is a secondary review appropriate? Review rules 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 this case by evaluated by a specialist? 2017 McKesson Corporation and/or one of its subsidiaries. All rights reserved. 6

7 Secondary review steps 1. If the secondary reviewer agrees with the existing care plan, approve the visits and schedule the next review. 2. If the secondary reviewer does not agree with the requested visits or care plan, he or she discusses the self-management options for this patient with the provider or referring physician. If the provider agrees with the secondary reviewer, the provider continues care within the authorized or revised visit structure, facilitating discharge when indicated. If the provider or ordering physician does not agree with the secondary reviewer, initiate action as directed by organizational policy. 3. Document the review outcome McKesson Corporation and/or one of its subsidiaries. All rights reserved. 7