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Learning Interqual

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Specializes in Telemetry, CCU.

Hi all! I just finished my first week as an inpatient case manager. In my particular position I will be managing a caseload doing discharge planning and medical necessity reviews. I started doing reviews today and I can see this being one of the more challenging parts of the job (and time consuming).

My question is: at what point does Interqual start feeling intuitive? If I have a patient who's been in the hospital for 15 days and has 8 different active problems, at what point does it feel like I'll be able to figure out the criteria fairly quickly?

Sorry if that's a vague question, I just don't want to screw up these reviews and I'll be doing them on my own (with experienced CM support) next week!

Hello! Not sure what kind of unit/floor you’ll be working, but yes eventually things do begin to feel intuitive after you’ve seen X-number of the same types of conditions/patients. It does take time, and just when you think you’ve got it all figured out and you can “IQ” someone in your head, they go and add revisions mid-year or change the format completely :banghead:.

Regarding your 15d LOS with 8 different issues, I find the Extended Stay subset easier to use than the condition-specific because there are no time limits (no actual # of days attached). If he’s still there after 2 weeks, chances are you’ll find something in the ES subset that will work. The problems I run across most frequently are:

~ Getting a pt to meet Acute when the doc changes them from Observation (unless something has happened in the past 24h that changes their story, wouldn’t they have met Acute yesterday? And if they didn’t, chances are they won’t meet today either, especially now that they’re stabilized)

~ A pt almost meets but the criteria point is just a smidge off (Creatinine isn’t >1.5x ULN but everything else matches – can’t click the box in clear conscience)

~ When a pt no longer meets any criteria but doesn’t technically meet the Discharge Screens or there’s just not a safe DC plan available for this pt (variance days can only get you so far)

Does your facility provide official IQ training? It’s a complex system, but is very doable once you get the hang of it. I prefer the actual book rather than the implanted software, it’s easier to flip pages and hunt around when you can see it all right there – especially if you’re new to the process and you’re not even sure what’s all buried in the program. It’s a learned skill that just takes a while, you’ll get it, good luck!

CABG patch kid, BSN, RN

Specializes in Telemetry, CCU.

Thank you for the advice! Since there are a few of us newbies starting, our manager is working on getting us into a class in the next month (hopefully). I should be getting a book too, I think they were waiting for the 2014 book. I am so excited to learn all this stuff, the lingo is already starting to feel like second nature!

SummerGarden, ADN, BSN, MSN, RN

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr. Has 13 years experience.

The first and most important thing to understand about Interqual is that it is NOT your job to make patients meet criteria. So DO NOT look around for the right diagnosis and treatment to make the patient meet criteria. Interqual is to be used as an evidence based medical tool, where your patients either meet the criteria listed or they do not. When he/she does not meet criteria, it is not the end of the story. Rather your facility should have a built-in system to respond...

I agree with the above poster, you need to be properly trained on Interqual because your post really sounds like you may be making some basic mistakes. Also, insurance companies will be able to figure out quickly that you are looking to make patients meet criteria even though he/she does not and you will soon be flagged as a Case Manager-to-watch (Talk to insurnce CMs about their bad UR CM list). Plus, every case should not take you long to to perform with the exceptions of cases that must be reviewed with an MD, escalated for some other reason, or you have paper charting in your facility and you have to read through chicken scratch to gather your data.

BTW, you do not need the book for 2014. Your facility is wasting money! Interqual has the book (which is updated constantly) built into the system. References, resources, ebook, help, and glossary are all located in the Interqual system. The paper book will be outdated by the time you get your hands on it... So use your Interqual software to review the book. If you have no idea what I am writing, talk to your boss or a CM that is more experienced in your facility.

Welcome and good luck! happy.png

Edited by SummerGarden

CABG patch kid, BSN, RN

Specializes in Telemetry, CCU.

Thanks for the reply. I understand my job is NOT to make patients meet and we have a physician advisor for patients that don't. Hopefully the IQ class will be soon. In the meantime I'm not doing anything that would get me "flagged" or in trouble, I've got experienced CMs looking over my work. Thanks again.

Yes, of course it is not a CM’s job to make someone meet criteria, but it is a CM/URRN’s job to identify when they do - which can, at times, be a difficult process. I respectfully disagree that one should “NOT look around”. If someone is new to the IQ concept, how else will they know what subsets and tiny little details in each should be looked through and ruled in or out? And what data they even need to gather? Not all patients fit like a puzzle piece in a condition-specific subset, especially in this day and age when everyone has comorbidities that can factor into their need for hospitalization.

I certainly hope my post did not imply that anyone should ever, ever “make” someone meet IQ, assuming “making someone meet” implies documenting untruths about a patient’s presentation. The PP is correct, they either do or they do not, hence my comment about not being able to click a box in clear conscience. I do stand by my sentiment that it is the CM’s responsibility to absolutely rule in/out the fact that they do/do not meet IP, (another hence), why I do “look around”.

Regarding the book, perhaps I’m old-school, but I want to be able to see everything right now. I find the keyword search to be less than helpful at times (hardcopy index in alphabetical order is much more efficient). I find it a waste of precious time clicking into a subset, clicking open every level of care, clicking open every + tree, and if I can’t find something or I was in the wrong place, starting all over somewhere else. With the book, I can eyeball straight down the page in 2 seconds and move on. I also like being able to flip directly to the Review Process tipsheets in the front while I’m in the middle of a review, otherwise I’d have to back out of my review and open another screen. To each his own, I just thought it was a worthy tip for someone just learning the process.

CABG patch kid, BSN, RN

Specializes in Telemetry, CCU.

Thank you Freefalling, I think you got the gist of my original question with your responses. This is exactly what I was looking for. And everything you're saying makes complete sense!

SummerGarden, ADN, BSN, MSN, RN

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr. Has 13 years experience.

No Freefalling, I was not implying false documentation. Actually a newbie mistake is the mindset (not implying stupidly either) that he/she has to make a person meet criteria or he/she is a bad nurse or he/she is missing something. I have trained a great deal of new nurses to this field and I tell them the same thing; do not look around to make your patients meet criteria. This usually gives him/her permission to accept the fact that he/she is SMART enough to do this job and that if he/she finds that a patient does not meet interqual criteria, then he/she is doing the right thing by escalating the case. Besides, time is a concern the OP mentioned was a problem in his/her original post and that is why I addressed that point.

Also, Interqual is straight forward as far as DX and treatments go... They are listed literally on the first screen. There are references to look up particular Diagnoses as well within the software so no; you do not have to look around to find what you are looking for no matter how new you are to Interqual... On the other hand, again, I was meaning by the "do not look around" comment to mean that it is not necessary to spend too much time trying to make the patient meet criteria. In fact, too much time looking around is a good indication that the patient likely does not meet criteria. Again, I was not implying stupidity or anything else.

As far as the book comment was concerned.... I was pointing out the fact that the book is outdated. The Interqual book gets updated almost every other month or so along with the software updates, and I doubt that the OP will get a new paper update to go with his/her copy of the book as often as the software updates and ebook updates because it is too costly to his/her employer. In fact, the ebook reference allows for searching through the software when trying to find information, making the ebook a much more useful and efficient tool for the masses. Of course, you are correct.... if one prefers paper copies no matter how outdated, then to each his/her own.

Edited by SummerGarden
rushed spelling and grammar

I truly believe that learning the nuts and bolts of Utilization Review is easy...but learning how the real person (patient AND family) fits into a computer program is something that takes more time and experience. I have used both Interqual and Milliman (MCG) - I find Milliman to be more "holistic". Don't expect yourself to be an instant expert. And, don't forget that doing a comprehensive review take time...be committed to doing a complete review rather than trying to rush through...everyone will benefit.

CABG patch kid, BSN, RN

Specializes in Telemetry, CCU.

Thanks for all the replies. I'm finding the reviews are getting easier as time goes by; some of the cases are truly challenging though and I'm finding discharge planning takes more of my time than anything else.