Viewing Criteria in Book View

Book View enables you to quickly view criteria when saving the results of a medical review isn't necessary.

  • Click Clinical Reference button to see a list of resources (for example, clinical revisions, criteria bibliographies, review process, and other supporting materials).
  • Click a resource to view it.
  • For PDFs, depending on the options available, click Open or click Download PDF button and use the controls in the PDF to save and/or print it.

InterQual® content includes benchmarks for length of stay, percent paid as observation, and Urine Drug Testing. The InterQual benchmark values are derived from a select set of claims data from Change Healthcare, one of the industry’s largest claims clearinghouses, representing millions of patient encounters. InterQual benchmarks create guidance designed to facilitate efficient management of the patient to that target. Benchmarks are not intended to serve as treatment limits or substitute for clinical judgement.

Benchmark length of stay values are available in the following products:

  • LOC: Acute Adult and Pediatric Criteria
  • LOC: Inpatient Rehabilitation Criteria
  • LOC: Subacute and Skilled Nursing Criteria
  • BH: Adult and Geriatric Psychiatry, Child and Adolescent Psychiatry, and Substance Use Disorders

Percent paid as Observation values are available in the LOC: Acute Adult and Pediatric Criteria.

Urine drug testing average annual volumes are available in BH: Behavioral Health Services Criteria.

View a benchmark as follows:

  • Click BENCHMARKS.

    The Utilization Benchmarks dialog box appears.

  • For Behavioral Health Criteria, if available, select a level of care tab.
  • If appropriate, find a condition or procedure in the list by entering a partial or complete description.

Available for select subsets, care management information is associated with a specific episode day.

To view care management information:

  • If closed, open the CARE MANAGEMENT pane by clicking CARE MANAGEMENT to slide out the pane, or click the arrow Criteria Management icon to open a larger pane that appears in the center of the screen.

    Depending on the episode day, the following information appears:

  • Admission Considerations—Identifies the types of clinical findings that should be considered as part of an admission review.
  • Expected Progress—Provides an overall picture of what a care manager should expect in response to treatment, potential barriers to care, and suggested interventions.
  • Care Facilitation—Identifies when a plateau has been reached and provides direction to appropriate post acute levels of care.

  • When you are done viewing the information, click CLOSE, if you are viewing the information in the large pane. If you are viewing the information in the slide out pane, optionally leave it open as you evaluate criteria.

  • Click Print and then depending on the options available, select one of the following:
  • Current Selection—Creates a printable version of the criteria you are currently viewing.
  • Full Subset—Creates a printable version of the entire subset.
  • Depending on the options available, click Open or click Download PDF.
  • Use the controls in the PDF to save and/or print the PDF.

ⓘ  Note: Applies to InterQual® LOC products (except Home Care Q & A and Outpatient Rehabilitation & Chiropractic); InterQual® BH products, except Behavioral Health Services; InterQual® CP: Retrospective Monitoring and CP: Specialty Referral products.

  • Select a subset and then click Book View button.
  • Depending on the subset you selected, do the following:
  • Acute Adult and Pediatric—Select an Episode Day (or Initial Review) from the list.
  • Long Term Acute Care and Inpatient Rehabilitation—Select a review type (that is, Preadmission, Admission, Continued Stay, or Discharge).
  • Subacute and Skilled Nursing—Select Preadmission or the appropriate episode week.
  • BH: Adult and Geriatric Psychiatry, BH: Child and Adolescent Psychiatry, and BH: Substance Use Disorders— Select a level of care and then choose the appropriate Episode Day.
  • CP: Specialty Referral and CP: Retrospective Monitoring—Select an indication from the list.
  • Expand the decision tree as follows:
  • Click a plus sign Plus sign icon to expand a section of the decision tree and click a minus sign Minus sign icon to collapse it.
  • Click Expand All to expand all criteria in the decision tree and click Collapse All to collapse it.
  • For criteria points that include abbreviations, symbols, or terms with a dotted underline, move the pointer over the underlined item to display the definition of the abbreviation or symbol, or full description of the term. For example, the abbreviation NIPPV is underlined in this criteria point
  • Use the vertical scroll bar to see all the criteria.
  • View any notes associated with the criteria by clicking the appropriate note icon:
  • Informational Note Note icon—Provides reminders of the best medical practice, new clinical knowledge, procedural information, explanations of criteria rationale, and current literature references.
  • Quality Indicator Note Quality Indicator note—Indicates that quality indicator data exists for this condition.
  • Transition Plan Note —Indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning. If you select a criteria point that has a Transition Plan note, Change Healthcare recommends that you complete a transition plan.
  • Note (Red) Mandatory note—Mandatory notes are associated with an indication or criteria point and provide important information that you must read while conducting a review.

  • Care Management Note —Provides information that helps to drive quality care and ensure that the patient is progressing along the continuum of care.

  • CMS Two-Midnight Rule Note —Provides instructions for the Two-Midnight rule.

    ⓘ  Note: At any time, if you want to select a different subset, click Change Subset.

  • When you finish viewing criteria, do any of the following:
  • Click Decision Reasons icon to view InterQual® Decision Reasons.
  • Click Change Subset button to view criteria for a different subset.
  • Click Previous button to return to the Subset Overview screen.
  • Click Menu to exit the workflow and then, optionally, select an option from the navigation pane.

ⓘ  Note: Applies to InterQual® LOC: Home Care Q & A and Outpatient Rehabilitation & Chiropractic; InterQual®; BH: Behavioral Health Services; InterQual® CP: Procedures, CP: Imaging, CP: Specialty Rx Oncology, CP: Specialty Rx Non-Oncology, CP: Molecular Diagnostics, CP: Durable Medical Equipment; all Medicare Content Navigator products; Concert Genetics Navigator; and The ASAM Criteria®Navigator1.

1The ASAM Criteria is a registered trademark of the American Society of Addiction Medicine.

If the InterQual® CriteriaView feature is available, you can track availability of recommendations as you answer questions and view additional criteria for recommendations that do not meet criteria. For additional overview information, see About CriteriaView.

There are two steps to viewing criteria.

ⓘ  Note: If the CriteriaView feature is not available, skip steps 2, 4, and 5 in the directions below.

  • Select a subset and then click Book View button.
  • Optionally, select recommendations you want to track:

  • Click CriteriaView™ on the right side of the screen to display the CriteriaView pane. Hide the pane at any time by clicking CriteriaView again or, optionally, leave it open as you answer the questions.

    The CriteriaView pane displays a list of recommendations for the subset.

  • Click Select All to track all recommendations or select the check box(es) to track specific recommendation(s).

  • Answer the questions by reviewing each one as it appears and providing answers by selecting one or more options, as appropriate.

  • Follow any rules associated with the questions. Rules display in brackets next to the question (for example, [ ≥ One, except Other clinical information (add comment)] is a rule).
  • If necessary, click Next button to continue to the next question. Single answer questions automatically display the next question, while multi-answer questions display the Next button.
  • View any notes associated with the questions by clicking the Note icon icon.
  • Required questions appear with the word Required in red text next to a question.
  • Optionally, view availability of the recommendations in the CriteriaView pane:
  • If closed, click CriteriaView to display the pane.
  • Click View All to see all recommendations or click Selected to see only tracked recommendations. Tracked recommendations that become unavailable, based on your answers, are crossed off; for example, .
  • View the question that caused the recommendation to become unavailable by clicking the question mark () next to the recommendation.

  • The Recommendation Availability dialog box appears and shows the question. From here, you can view additional criteria and answer questions that lead to the recommendation or you can continue with the questions.

    ⓘ  Note: If you choose not to view additional criteria at this point in the workflow, you can do so later in the Recommendations screen for any unavailable recommendations.

  • Continue with one of the following options:

  • View additional criteria and answer questions that lead to the recommendation by continuing with step 5 below.

  • Return to answer the remaining questions. Click the X to close the Recommendations Availability dialog box, answer the remaining questions, and then continue with step 6 below.
  • In the Recommendation Availability dialog box, click .

  • Review the question that caused the recommendation to become unavailable, then using the rules that display in the highlighted box below each question as a guide, answer the questions.

    ⓘ  Note: If you do not have all the required information, you may skip a question. Additionally, you are not required to answer the questions in any specific order; however, the rules may guide you to follow a certain path.

  • When you finish answering the questions, click Additional Criteria Completed or click the continue to recommendations link.

    The Recommendations screen appears. It shows why criteria for the recommendation were not met and, beginning with the question that caused the recommendation to become unavailable, lists each clinical scenario that would lead to the recommendation.

  • A checkmark () indicates the answer you selected leads to the recommendation.
  • An X () indicates the answer you selected does not lead to the recommendation.
  • After you view the results, continue with any of the following options:
  • If appropriate, edit your selections for the same recommendation by clicking the pencil icon next to the recommendation .
  • View additional criteria for another unavailable recommendation by clicking the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Click Yes or No in the warning message that appears.
  • Return to Book View by clicking Previous button and answer the remaining questions. Answering the remaining questions will erase your additional criteria responses. Click Yes or No in the warning message that appears.
  • If you continued with answering questions, when you reach the end of the questions, click .

When you complete the questions, the results display in the Recommendations screen.

The results vary depending on the product (for example, not recommended, one recommendation, more than one recommendation, mutually exclusive recommendations and so on). Additionally, if CriteriaView is available, you might see recommendations that became unavailable.

Recommendations screen

  • View the details of any recommendations as follows:
  • Read any notes by clicking the note icon.
  • View the ICD, CPT®,and HCPCS codes that apply by clicking Show Codes, and then clicking the appropriate tab. Hide the codes by clicking Hide Codes.
  • View any values associated with the recommendation, such as hour(s) per day, time(s) per year, or visit(s). For example, a Home Physical Therapy recommendation might indicate a number visits within a given time frame, such as 6 visits within 2 weeks.
  • For Specialty Rx Oncology:
  • View the NCCN Drugs & Biologics Compendium (NCCN Compendium®) rating for an off-label drug recommendation.
  • Optionally, view the NCCN Compendium® rating description by moving the pointer over the rating number.
  • Optionally, access the National Comprehensive Cancer Network® (NCCN®) website by clicking the link within the red note.
  • For Level of Care: Home Care Q & A, the results might show both Recommended Services and Not Recommended Services. This occurs when you select two or more services and at least one service is recommended and at least one service is not recommended.
  • If benchmark information is available for a procedure, optionally, view the values:

  • Click Benchmarks.

    The Utilization Benchmarks dialog box appears.

  • If appropriate, find a procedure by entering a partial or complete description in the Indications box.
  • Click the Close button (X) when you have finished viewing the results.
  • When you finish viewing recommendations, do one of the following:
  • View additional criteria for recommendations no longer available
  • Click Change Subset button to view criteria for a different subset
  • Click Previous button to return to a previous screen
  • Click Menu to exit the workflow and then, optionally, select an option from the navigation pane

If the CriteriaView feature is available and there are unavailable recommendations, you can view additional criteria and answer questions to see the clinical scenarios that lead to a recommendation.

  • Click the Why didn't a requested intervention meet criteria? link.

    The Recommendation Availability dialog box appears.

  • If there is more than one recommendation, select a recommendation from the list.

  • Review the question that caused the recommendation to become unavailable, then click .

  • Answer the questions using the rules that display below each question as a guide.

    ⓘ  Note: If you do not have all the required information, you may skip a question. Additionally, you are not required to answer the questions in any specific order; however, the rules may guide you to follow a certain path.

  • When you finish answering the questions, click Additional Criteria Completed.

    The Recommendations screen results show why criteria for the recommendation were not met and, beginning with the question that caused the recommendation to become unavailable, lists each clinical scenario that would lead to the recommendation.

  • A checkmark () indicates the answer you selected leads to the recommendation.
  • An X () indicates the answer you selected does not lead to the recommendation.

  • Optionally, continue with any of the following options:

  • If appropriate, edit your selections for the same recommendation by clicking the pencil icon next to the recommendation .
  • View additional criteria for another unavailable recommendation by clicking the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Click Yes or No in the warning message that appears.