Evaluating Q&A criteria

After you select a subset, you evaluate criteria in a medical review to determine the medical necessity of the proposed services.

Note: Q&A criteria 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. For steps on how to use CriteriaView in a review, see Evaluating Q&A criteria using CriteriaView.

There are two steps to evaluating criteria in a Q&A medical review:

Answering questions

  • 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.

Add reviewer comments

As you evaluate criteria, you can add comments to the review or to specific criteria points. Comments have a 4,000 character limit.

  • Select Comments to add a comment to the review or select the appropriate comments icon for a criteria point.

    The Reviewer Comments dialog appears.

  • Enter your comment in the text box.
  • Select Add Comment.

  • Select the X to close the dialog.

    When you add a comment to a criteria point, the appearance of the comment icon changes, indicating reviewer comments are associated with the criteria point.

  • You can view the details of all added comments by selecting Comments. If you added a comment to a criteria point, select Tree Location to view the location of the criteria point within the decision tree.

Edit and delete reviewer comments

You can edit and/or delete comments until the review is completed.

  • Select Comments to open the Reviewer Comments dialog.
  • To edit a comment, select the edit icon pencil icon for the appropriate comment and then type the changes in the text box. Select Done to save your changes.
  • To delete a comment, select the delete icon Delete icon for the appropriate comment and then select DELETE in the confirmation message.
  • Select the X to close the dialog.

Note: In Medicare Content Navigator reviews, depending on how your system is configured, the Medicare Administrative Contractor question may be automatically answered.

  • Answer the questions by reviewing each one as it appears and providing answers by selecting one or more options, 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 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 icon.
  • Answer all required questions. Required questions appear with the word Required in red text next to the question.
  • When you reach the end of the questions, select View Recommendations button.

Selecting recommendations and codes

The results vary depending on the product (for example, not recommended, one recommendation, more than one recommendation, mutually exclusive recommendations and so on). When the medical review results in one or more recommendations, you select recommendations and codes as follows:

  • 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.
  • For recommendations that are part of a group, optionally sort the recommendations in alphabetical order.
  • 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:
  • 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.

  • Select a recommendation by clicking it.

    Selected recommendations change to green and automatically display the associated codes.

  • If benchmark length of stay values are available for a procedure, optionally, select a value:

  • Select Benchmarks.

    The Utilization Benchmarks dialog appears.

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

  • Select a procedure from the list.

    The dialog closes and the selected value appears in the Recommendations screen.

  • Select codes (CPT, HCPCS, DRG, and ICD-10) based on your organizational policy.

  • For CP: Procedures, BH: Services, and Medicare Procedures Navigator content, select CPT codes to determine the supported setting.

  • Select the source of the setting data (InterQual or CMS) according to the type of review being conducted.
  • Select codes based on the following criteria to determine the InterQual or CMS-supported setting:
  • 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.

  • If 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.

  • If you want to remove a code, select it again.

    Note: For information on selecting codes to determine setting, see Site of service.

  • View the codes you selected in the Selected tab. The value on the Selected tab reflects the number of codes you selected.
  • When you have finished selecting recommendations and codes, continue as follows:
  • If appropriate, select Decision Reasons button to use Decision Reasons for a review that did not meet criteria.
  • Select Review Summary buttonand then continue with Viewing and Printing the Review Summary.