InterQual® Site of Service

Overview

As you conduct a review for a procedure, you follow your organizational policies to select the appropriate CPT®, ICD-10, and/or HCPCS codes. Selecting the requested CPT codes helps determine the supported setting for a procedure.

Criteria include InterQual and the Centers for Medicare and Medicaid Services (CMS) supported settings based on CPT codes. InterQual settings are determined using aggregate claims data at a 75% threshold:

  • Inpatient: Procedures most commonly performed in an acute care setting, requiring hospital admission (usually 24 hours or more).
  • Outpatient: Procedures performed in a physician’s office, an ambulatory care setting, or a hospital outpatient setting, not requiring hospital admission (usually less than 24 hours).

If claims data for a given code do not meet the 75% threshold for either inpatient or outpatient, "No setting determined" is displayed. In cases where data meet the threshold, but the volume of data is not statistically significant, a limited data (LTD) flag is displayed. CMS settings are based on publicly available data from CMS.

Selecting codes

As you conduct a review, you select the source of the setting data (InterQual or CMS) based on the review being conducted.

The InterQual or CMS-supported setting is determined as follows:

  • If the setting for all CPT codes associated with a recommendation is the same, the setting is displayed under the Recommendation header. You do not need to select CPT codes to determine the setting.
  • If the setting varies by CPT code, you must select all CPT codes associated with the medical review to determine the setting.
  • If more than one recommendation is available, you should select all appropriate recommendations and CPT codes to determine the setting.

When you select multiple CPT codes, the setting is based on the following criteria:

InterQual CMS
If any code has a value of Inpatient, the setting is Inpatient. If any code has a value of CMS Inpatient Only, the setting is CMS Inpatient Only.
If all codes have a value of Outpatient, the setting is Outpatient. If any code has a value of CMS ASC excluded and no code has a value of CMS Inpatient Only, the setting is CMS ASC excluded.
If all codes have a value of No Setting Determined, the setting is No Setting Determined. If codes include a mix of only CMS ASC eligible and No CMS Setting Available, the setting is CMS ASC eligible.
If codes include a mix of only Outpatient and No Setting Determined, the setting is No Setting Determined. When there is no information available from CMS for a selected code, No CMS Setting Available is displayed.

The determination of the appropriate setting (Inpatient versus Outpatient) is a clinical decision that should consider multiple factors. These include the procedure being performed, the surgical approach, variations in practice, geographic differences, available resources, social determinants of health (SDOH), patient age, clinical findings of increased risk or active comorbidity, and the specific indications and urgency of the procedure.

(Optional) InterQual® Site of Service add-on feature

InterQual Site of Service includes additional data and functionality available through a separately licensed feature that supports setting determinations. When this feature is enabled, you have access to:

  • Setting lookup functionality for an expanded code library that can be used independently of a medical review. This code lookup allows you to determine the setting for a procedure when a medical review is not required by the organization, but a setting determination is needed. The code library includes both CPT codes addressed in the InterQual Procedures content as well as those not addressed in the criteria.
  • Data insights for inpatient and outpatient setting designations and ambulatory site-of-service benchmarks. Visualization of supporting data can help inform a setting designation that falls below the threshold of 75% and help guide organizations to direct procedures to the safest care setting.
  • An evidence-based alternate setting review that captures additional clinical factors that may support a change in setting based on a unique patient scenario. You have the option of completing a setting review to gather more information to inform a secondary review determination when a requested setting does not align with an InterQual or CMS setting.