Viewing InterQual® Criteria in Book View

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

Depending on the product you select, the medical review is available in either decision-tree format or question-and-answer (Q&A) format.

View decision tree criteria

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

  • Select 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, select Open or Download PDF.

  • Use the controls in the PDF to save and/or print the PDF.

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 de-identified claims data, representing 7 billion patient encounters. Benchmarks are not intended to serve as treatment limits or substitute for clinical judgment. They are for informational use only.

Benchmark length of stay values are available in the following decision-tree 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 (inpatient only), and Substance Use Disorders (Inpatient and Inpatient Detoxification)

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 and CP: Procedures Criteria.

View a benchmark:

  • Select BENCHMARKS.

    The Utilization Benchmarks dialog 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, select CARE MANAGEMENT to slide out the pane, or select the arrow to open a larger pane that displays 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, select 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 or slide it back to the side of the screen.

Note: Decision-tree criteria applies to InterQual® LOC: Acute Adult and Acute Pediatric, LOC: Long Term Acute Care, LOC Inpatient Rehabilitation, LOC: Subacute and Skilled Nursing Criteria; BH: Adult and Geriatric Psychiatry, BH: Child and Adolescent Psychiatry, BH: Substance Use Disorders Criteria; and CP: Retrospective Monitoring and Specialty Referral Criteria.

  • Select a subset and then select Book View.
  • Depending on the subset you selected, do the following:
  • LOC: Acute Adult and Pediatric — select an Episode Day or Initial review.
  • LOC: Long-Term Acute Care and Inpatient Rehabilitation — select Admission, Continued Stay, or Discharge..
  • LOC: Subacute & Skilled Nursing — select Preadmission or the appropriate episode week.
  • BH Adult and Geriatric Psychiatry, BH Child and Adolescent Psychiatry, and Substance Use Disorders — select a level of care and then choose the appropriate episode day or episode week.
  • CP: Specialty Referral and CP: Retrospective Monitoring — select an indication.
  • Expand the decision tree as follows:
  • Select a plus sign Plus sign icon to expand a section of the decision tree and select a minus sign Minus sign icon to collapse it.
  • Select Expand All to expand all criteria in the decision tree and select 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 selecting the appropriate note icon:
  • Informational note Informational note — provides reminders of best medical practice, new clinical knowledge,
  • Transition Plan note 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.
  • Mandatory note Red Mandatory note — associated with an indication or criteria point, mandatory notes provide important information that you must read while conducting a review.
  • Care Management note Care Management note — provides information that helps drive quality care and ensure that the patient is progressing along the continuum of care.
  • CMS Two-midnight rule note Two midnight rule note — provides instructions for the Two-midnight rule.
  • When you finish viewing criteria, do any of the following:

View Q&A criteria

Note: Applies to InterQual® LOC: Home Care Q & A and LOC and Outpatient Rehabilitation & Chiropractic; InterQual® BH: Behavioral Health Services; InterQual® CP: Durable Medical Equipment, CP: Imaging, CP: Molecular Diagnostics, CP: Procedures, CP: Specialty Rx Non-Oncology, and CP: Specialty Rx Oncology; The ASAM Criteria®1 Navigator; Concert Genetics Navigator; and Medicare Content Navigator products.

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 InterQual® CriteriaView.

There are two steps to evaluating criteria in a medical review

Answer questions

(Optional) See the following review-related task you might perform as you answer the questions

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

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

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

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

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

  • select Select All button 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 answer choice;, as appropriate.
  • Follow 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, select 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 selecting the note Information note iconicon.
  • 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, select CriteriaView to display the pane.
  • Select View All to see all recommendations or select Selected to see only tracked recommendations. Tracked recommendations that become unavailable, based on your answers, are crossed off; for example, Image of crossed off recommendation.

  • View the question that caused a recommendation to become unavailable by selecting the question mark (Image of crossed off question) next to the recommendation.

    The Recommendation Availability dialog appears and shows the question. From here, you can view additional criteria and answer questions that lead to the recommendation or you can return to the medical review.

    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 by continuing with step 5 below.
  • Return to the medical review and answer the remaining questions. Select the X to close the Recommendations Availability dialog, answer the remaining medical review questions, and then continue with step 6 below.
  • In the Recommendation Availability dialog, select VIEW ADDITIONAL CRITERIA.

  • 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, select ADDITIONAL CRITERIA COMPLETED or select the continue to recommendations link.

    Note: Selecting Cancel returns you to the medical review without saving your additional criteria responses.

    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 selecting the edit icon next to the recommendation.
  • View additional criteria for another unavailable recommendation by selecting the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Select Yes or No in the warning message that appears.
  • Return to Book View by selecting Previous and answering the remaining questions. Answering the remaining questions will erase your additional criteria responses. Select Yes or No in the warning message that appears.
  • If you continued with the medical review, when you reach the end of the questions, select View Recommendations.

View recommendations and additional criteria

When you complete the questions, the results display on 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 the CriteriaView feature is available, you may see recommendations that are no longer available. Image of Recommendations

  • View the recommendation details:
  • Read any notes by selecting the note icon.
  • View the ICD, CPT®,and HCPCS codes that apply by selecting Show Codes. Hide the codes by selecting 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 selecting 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.
  • Includes the number of visits and, if appropriate, the duration; for example, Physical Therapy – 6 Visits within 2 weeks.
  • Private Duty Nursing (PDN) Assessment recommendations include a suggested maximum number of private duty nursing hours per day and per week. Recommendations also have a total sum of points based on the selected answer choices. The sum of points falls within a predetermined range of points with the recommendation. The recommendation note provides information about the range of points.
  • If benchmark information is available for an inpatient procedure, optionally, view the values:

  • Select Benchmarks.

    The Utilization Benchmarks dialog appears

  • If appropriate, find a procedure by entering a partial or complete description in the Indications box.

  • Select the Close (X) button when you finish viewing the results.

  • When you have finished viewing recommendations, do one of the following:
  • Optionally, view additional criteria for any unavailable recommendations.
  • Select Change Subset to view criteria for a different subset.
  • Select Previous to return to a previous screen.
  • Select Menu to exit the workflow and then, optionally, select an option from the navigation pane.

If the CriteriaView feature is available and a recommendation(s) is no longer available, you can view additional criteria and answer questions to see the clinical scenarios that lead to a recommendation.

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

    The Recommendation Availability dialog appears.

  • If more than one recommendation is available, select one from the list.
  • Review the question that caused the recommendation to become unavailable and then select VIEW ADDITIONAL CRITERIA.

  • 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, select ADDITIONAL CRITERIA COMPLETED.

    Note: Selecting Cancel erases your additional criteria responses.

    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 check mark (Check mark image) indicates the answer you selected leads to the recommendation.
  • An X (X mark image) indicates the answer you selected does not lead to the recommendation.
  • Optionally, continue with the following options:
  • If appropriate, edit your selections for the same recommendation by selecting the pencil icon (pencil icon) next to the recommendation.
  • View additional criteria for another unavailable recommendation by selecting the Additional Criteria link and selecting a recommendation. Answering questions for a different recommendation will erase your current additional criteria responses. Select Yes or No in the warning message that appears.