[lawrence1.rice]

I've never been concerned about having to answer to lawyers, as my answer will always go something like:

#1 I do not admit or discharge patients. Their care is directed by the attending physician, as is medically and ethically appropriate.
#2 My employer uses the InterQual criteria as a guideline for non-medical staff to assess our utilization of resources, not to "force" an early discharge.
#3 If at anytime a concurrent stay does not meet the InterQual criteria as I understand it, it is the policy of my employer for the case to be presented to the Physician Advisor (MD) for review. All decision making in this process is directed by the MEDICAL STAFF. Period.

Interqual is intended to be a guideline, not a absolute end authority. I have discussed numerous cases with the McKesson folks, who are most helpful and reasonable. In my experience, if their guidelines are followed about 90% or more of all cases that I see in acute care can be directed to the an appropriate level of care be it acute, SNF, LTAC, HH, etc.

I grant you, it can be difficult at times to meet InterQual but constantly reminding myself that the final determination is Medical not Nursing has helped me.

[CaseManager1947]

I really liked lawrence1rice's succint reply to the question posed. It's so good I'm gonna steal it. (thanks in advance). Interqual is an evidence-based methodology of determination of medical necessity. McKesson uses these tools to determine severity of illness(how sick are they???) and intensity of service (what are we doing for them here that can't be done at another level of care???). The problem in getting folks to meet, is that they may have only one of 2 required issues met. The key thing to remember is that medical care is a physician-driven issue. I have many times told reviewers that we disagree with their determination, and they are free to send it on up for medical review. I work trauma case management, so my people usually meet it coming in the door, but it can be a struggle for the "on the fence" type of case, or with docs who admit without medical necessity. I take Remicaid for my RA, and developed a severe Pyelo. I had >18,000 wbc, fever >105 (Mckesson rounds up 1 degree for core body temp), hematuria and pyuria, and I'm immunocompromised, and I still didn't get admitted, cuz I could still take po (barely), wasn't vomiting, and succeeded at OP tx! I missed 10 days of work, but by God I didn't need to be in the hospital!!!

[Havin' A Party!]

Can anyone suggest an informative site to learn more about the InterQual / McKesson criteria?

Thanks!

[CaseManager1947]

Havn' A Party--They have a web site for folks who have shelled out the big bucks for a contract w/them. I have some old books (i can't seem to throw anything away). PM me if you want last years... it'd be better than nothing.

[rwag63]

I was wondering if anyone has the 2008 Acute care guidelines? Is kyphoplasty still listed as appropriate for the inpatient setting?

[CaseManager1947]

I can't find my 2008 book, but in 2007, under CNS/musculoskeletal, imaging findings say " Compression fx and ileus. So to meet IP criteria, pt. would need another clinical severity of illness indicator... eg. cardiac problem (dysrhythmia) or perhaps withdrawal syndrome. PO meds are excluded on nearly all the screens for these Now, do we see little old ladies/men with compression fx needing kyphoplasty as an IP? Sure, all the time.
The book is helpful, but lots of times in order to meet, ya gotta be darn near dead.

[edgwow]

Interqual on a medical floor is like fitting a square peg in a round hole, especially a transplant workup patient. You can not control when it "just doesn't meet". I gaurentee you that it is always more difficult to make them fit inpt. criteria after 3 PM.You will talk to yourself, nod your head and this will continue to happen. Do not worry, it is normal. I guess that's because you've probably done 15 other reviews and are still trudging on. Long live the NIghtmare of Interqual!!!!!!!!!!

[edgwow]

Hey, Thanks
I am going to print this up and post it on my bulletin board in front of my workstation. I didn't admit them, and I just go by the criteria. If you read my post further down, I am disillusioned by the interqual and the criteria. I hate having to task 5-8 cases a day to the physician advisor, and I especially hate when the insurance company calls more than twice for additional information.

[cap45]

Where can you get this book or software?

[ksilty]

I worked for a MCO that managed Medicaid patients. We were trained in Interqual, but I rarely used it in my job. THe UM people used it more than Case Management, but the company didn't demand usage. I found that the software was not totally user-friendly(for the application we used) and I often found it was difficult to apply the criteria to my patients - too many variables with my folks. I think the only thing I found it useful for was evaluating need for DME.