InterQual Level of Care Outpatient Rehabilitation & Chiropractic Criteria 2010 Clinical Revisions

Transcription

1 InterQual Level of Care Outpatient & Criteria 2010 Clinical Revisions Criteria Evidence Review and Update McKesson Health Solutions is committed to keeping the InterQual product suite current and accurate. Criteria are continually reviewed and updated, with new editions of every product released annually. McKesson Health Solutions staff of physicians, nurses, and other licensed healthcare professionals and its extensive array of primary care and specialty consultants participate in ongoing criteria revision as new medical information emerges. Each annual release of the criteria reflects a thorough review of the most recent evidence-based medical literature, society guidelines, current practice standards, and incorporation of consultant and user feedback. Organization and Features New Format for Clinical Revisions The Clinical Revisions have been redesigned to provide greater ease of use for criteria users. Criteria-specific changes are presented in table format, allowing the details of each change to be more easily identified. Scope of Clinical Revisions The Clinical Revisions provide details of changes to InterQual Clinical Criteria. They do not provide information on changes made to CareEnhance Review Manager software. For information on Review Manager software changes, see the Review Manager Release Notes and the What's New topic in CareEnhance Review Manager Help. InterQual Outpatient & Clinical Revisions Page 1 of 5

2 Criteria-Specific s Subset Criteria Component Revision Rationale Review Review The criteria point "Spinal cord compression excluded by Hx & PE" has been changed to "Spinal cord compression / myelopathy excluded by Hx & PE" for both Cervical Radiculopathy and Cervical Spinal Stenosis. Leg pain has been added as a symptom for lumbar spinal stenosis that may be present rather than classic neurogenic Myelopathy was added to this criteria point to better describe the clinical presentation that indicates a condition that is more appropriate for medical/surgical intervention. Although neurogenic claudication is often seen in lumbar spinal stenosis, not all patients present with classic neurogenic Review "Pain decreased with sitting" has been added as a finding seen in lumbar spinal stenosis. Some patients will report pain relief with trunk forward flexion, while others will report decreased pain with sitting. in limitations;" and the rule to meet this criteria point has been changed to at least TWO areas of improvement documented. InterQual Outpatient & Clinical Revisions Page 2 of 5

3 Thoracic Outlet Syndrome: The criteria point "Progress made towards selfmanagement" has been changed to "Independence in selfmanagement." This criteria point was changed to better define the treatment goal for the patient; to become independent in self-management. Thoracic Outlet Syndrome: The ongoing review no longer limits application of these criteria to an additional 8 weeks of treatment. The ongoing review can be used to assess progress and ongoing care as long as necessary (based on coverage and organizational policies and/or limitations). The rehabilitation for some pediatric patients may be clinically appropriate beyond 12 weeks. McKesson consultants agree that children with plagiocephaly may require outpatient rehabilitation services. Review Plagiocephaly has been added as a Musculoskeletal Impairment that may be appropriate for therapy intervention with the pediatric population. Review At the criteria for "Moderate limitations" and "Sensory processing or perceptual deficits, the criteria point "Low tone" has been changed to "Low muscle tone." "Low muscle tone" better defines the deficit that the child may present with. needed to establish that the child has reached a functional plateau. InterQual Outpatient & Clinical Revisions Page 3 of 5

4 Review The criteria point "Spinal cord compression excluded by Hx & PE" has been changed to "Spinal cord compression / myelopathy excluded by Hx & PE" for both acute and subacute cervical radiculopathy. Myelopathy was added to this criteria point to better describe the clinical presentation that indicates a condition that is more appropriate for medical/surgical intervention. Review Leg pain has been added as a symptom for lumbar spinal stenosis that may be present rather than classic neurogenic Although neurogenic claudication is often seen in lumbar spinal stenosis, not all patients present with classic neurogenic Review "Pain decreased with sitting" has been added as a finding seen in lumbar spinal stenosis. Some patients will report pain relief with trunk forward flexion, while other will report decreased pain with sitting. The rule to meet "Improvement in function and reduction in limitations" has been changed to at least TWO areas of improvement documented. A reduction in pain alone is not adequate to justify ongoing treatment although it is an area frequently addressed and The criteria point "Decreased low back pain" has been changed to "Decreased pain." A decrease in pain may be reported in an area other than the low back, e.g. gluteal pain, leg pain. InterQual Outpatient & Clinical Revisions Page 4 of 5

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