= = = = = = = = = = = = = INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA

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1 INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW REVIEW Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-1

2 REVIEW Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-2

3 AGE PARAMETERS INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW REVIEW Specific InterQual Outpatient Rehabilitation and Chiropractic Care criteria subsets have been validated for use with adult, adolescent, or pediatric patients. Adult criteria are for review of patients over 17 years of age; adolescent criteria for review of patients who are ages 13 to 17; and the pediatric criteria are for patients 17 years of age. The appropriate age designations are indicated in the upper right or left corner of the book pages or in the Subset description in CareEnhance Review Manager. ORGANIZATION InterQual Outpatient Rehabilitation and Chiropractic Care criteria subsets are organized by diagnosis (e.g., Carpal Tunnel Syndrome, Osteoarthritis Shoulder). Outpatient treatment for both non-operative and postoperative conditions is addressed. Each subset contains review criteria for Initial and Ongoing reviews, as well as Discharge review. OUTPATIENT REHABILITATION AND CHIROPRACTIC REVIEW COMPONENTS Initial 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 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 INITIAL REVIEW Initial Review Rule To determine the appropriateness of services at the outpatient level, all Initial review components must be met. Review Type Initial Review Time After initial evaluation Review Rule Apply Initial review Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-3

4 REVIEW INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW Initial Review Steps 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. Apply Initial review rule. 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. Document the Initial review criteria as met. Note the number of visits associated with the patient s functional status. 4. Continue according to the following recommended actions. Initial Review Actions For these review findings Initial review rule met Initial review rule not met Do this 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 selfmanagement, refer for Secondary Review. (For information about the Secondary Review process, refer to page RP-7.) If Discharge Review criteria are not met, refer for Secondary Review. (For information about the Secondary Review process, refer to page RP-7.) Practical Tips Initial review period specifies the time-frame from injury, exacerbation, or surgery. 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 is essentially the same. Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-4

5 INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW Example 1: Patient presents to physical therapy with low back pain 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 expectations 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. REVIEW New Clinical Problem(s). If a new injury or exacerbation occurs of a diagnosis not related to the current treatment, an Initial Review of the new diagnosis should be conducted to determine if additional outpatient services are appropriate. Example 1: Initial review was done 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 completes another initial review to determine 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 completes another initial review to determine 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. ONGOING REVIEW To validate the need for ongoing services at the outpatient level, the Ongoing review rule must be met. Review Type Ongoing Review Time Beyond initial approved visits or after last review period completed Review Rule Apply Ongoing review Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-5

6 REVIEW INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW Ongoing Review Steps 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 as used during the Initial Review or the last review period. 3. Apply Ongoing review rule. 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. NOTE: 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. Document the Ongoing review criteria met. Note the number of visits associated with the patient s functional status. 4. Continue according to the following recommended actions. Ongoing Review Actions For these review findings Ongoing review rule met Ongoing review rule not met Do this 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 page RP-7.) If Discharge Review criteria are not met, refer for Secondary Review. (For information about the Secondary Review process, refer to page RP-7.) Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-6

7 Practical Tips INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW Ongoing review period for outpatient rehab (except pediatric rehabilitation) specifies 12 weeks (Initial 4 weeks of treatment and 8 additional weeks Ongoing) from injury, exacerbation, or surgery. Ongoing review period for chiropractic limits treatment to a total of 8 weeks. Ongoing review for day rehabilitation specifies weekly review for a total of 3 weeks (Initial week of treatment and 2 additional weeks Ongoing). Ongoing review for pediatric rehabilitation can be used more than once. The total duration of treatment is determined by local medical policies or benefits. If the reviewing organization begins to review for continuation of services after a predetermined number of visits have been utilized, the Ongoing review criteria should be followed. 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 of a diagnosis not related to the current treatment, an Initial Review of the new diagnosis should be conducted to determine if additional outpatient services are appropriate. Example: Initial review was done 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 completes another initial review to determine 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 reviews 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 appropriateness of discharge. REVIEW 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 in order 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? Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-7

8 REVIEW INTERQUAL OUTPATIENT REHABILITATION AND CHIROPRACTIC CRITERIA REVIEW Should this case by evaluated by a specialist? Secondary Review Process The Secondary Review process determines the appropriateness of the current care plan. Follow these steps when you refer a case for Secondary Review: If the secondary reviewer agrees with the existing care plan, approve the visits and schedule the next review. 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. Document the review outcome. 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. Copyright 2010 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. RP-8