2015 InterQual Criteria - Summary of Changes LOC: Acute ...

2015 InterQual Criteria - Summary of Changes

This document addresses review process updates, global and general changes. It lists changed subsets
but does not address changes to specific criteria points. Please reference the specific Clinical Revision
Document for the specific Product to view the detailed changes relative to the specific criteria points.

LOC: Acute Adult Criteria

Enhancements:

 Syncope criteria have been removed from the General Medical subset, restructured,
and now appears as its own subset.

Potential Care Management Impact:
This Clinical Revisions document outlines the updates McKesson Health Solutions has made to
the criteria to reflect the latest changes in the clinical evidence. Whether content has been
added or updated, a level of care changed or a new condition added that did not exist before;
certain criteria changes may affect your organization’s care management approach. Listed
below, McKesson Health Solutions has designated the major criteria updates that may impact
your organization with a () symbol.

Review Process Updates:
1. Updated process for Medicare beneficiaries who are impacted by the CMS 2-midnight rule:

2. Added clarifying information to the process of performing a review for a patient transferring
to a new facility:

 When a patient is transferred to a new facility, an episode day 1 review is not necessary
if criteria were met at the transferring facility. The accepting facility should conduct the
next review on the appropriate episode day.
For example:
A patient was admitted with a STEMI. The following day, he or she is transferred to
another facility. Conduct a review for episode day 2.
NOTE: When it is not known if criteria were met at the transferring facility the reviewer
at the accepting facility could:
 Perform a retrospective episode day 1 review by applying information found in
the transfer summary, report information or other documentation sent from the
original hospital. In this example, the episode day 1 retrospective review would
be for the date of admission to the transferring (original) facility and is
performed using information from the patient’s medical record from the
transferring facility.
 Complete an episode day 1 review for the day of transfer to the new facility. In
some cases a transfer is done due to worsening symptoms or lack of
improvement and it may be possible to complete an episode day 1 review based
on these new or worsening symptoms.
 Send the case for secondary review.

Global/General Criteria Changes:

1. At the ACUTE level of care, changed Responder criteria:
Changed:

New onset infection, ≥One:
WBC ≤13,000/cu.mm (13x109/L)
Bands < 6% (0.06)

To:
New onset infection, ≥One:
WBC ≤13,000/cu.mm (13x109/L)
Bands ≤10% (0.10)

*This change was made to align responder criteria with partial responder criteria.

Anticoagulation, One:
Anticoagulation regimen established
Warfarin with no evidence of bleeding, One:
INR ≥ 2.0
INR ≥ 2.5 and mechanical valve (excludes bioprosthetic valves)
IVC filter

*These criteria were updated based on the current available evidence and are supported by McKesson
consultants.

2. At the ACUTE level of care, changed Partial responder criteria:
Changed:

COPD, All:
Finding, ≥One:
O2 sat ≤ 91% (0.91) and < baseline
Po2≤ 60 mmHg (8.0 kPa)
Pco2 > baseline
Bronchodilator ≥ 6x/24h
Corticosteroid (includes PO)
Oxygenation, One:
O2 sat ≥ 92% (0.92) or baseline
O2 sat ≤ 91% (0.91) and < baseline requiring supplemental oxygen

To:
COPD, All:
Finding, ≥One:
O2 sat ≤ 91% (0.91) and < baseline
Po2≤ 60 mmHg (8.0 kPa)
Pco2 > baseline
Bronchodilator ≥4x/24h
Corticosteroid (includes PO)
Oxygenation, One:
O2 sat ≥ 92% (0.92) or baseline
O2 sat ≤ 91% (0.91) and < baseline requiring supplemental

* These criteria were updated based on the current available evidence and are supported by McKesson
consultants.

3. At the ACUTE level of care, on all days changed:
Changed:

Direct thrombin inhibitor, One:
Argatroban
Bivalirudin
Lepirudin

To:

Direct thrombin inhibitor, One:
Argatroban
Bivalirudin

* This change was made to streamline the review process as Lepirudin is no longer being manufactured.

4. At the ACUTE level of care, on continued stay changed:
Changed:

INR, All:
Finding, One:
INR < 2.0
INR < 2.5 and mechanical aortic valve

To:
INR non-therapeutic, All:

Finding, One:
INR < 2.0
INR < 2.5 and mechanical valve (excludes bioprosthetic valves), One:
Mitral
Mitral and aortic

* These criteria were updated based on the current available evidence and are supported by McKesson
consultants.

5. At the INTERMEDIATE level of care, on all days changed:
Changed:

Hypovolemia, Both:
Systolic BP < 100 mmHg
Volume expander ≤ 2d

To:

Hypovolemia, Both:
Systolic BP 90-99 mmHg
Volume expander ≤ 2d

*This change was made to clarify the intent of the criteria.

6. In the following subsets:
 COPD
 Heart Failure
 Infection: CNS
 Infection: Endocarditis
 Infection: GI/GU/GYN
 Pancreatitis
 Pneumonia
 Pulmonary Embolism
 Stroke/TIA

At the INTERMEDIATE level of care, on continued stay changed:
Changed:

 O2 sat ≤ 89%(0.89) requiring oxygen ≥ 40% (0.40), ≤2d
To:

 Oxygen ≥ 40% (0.40), ≤ 2d

*This change was made to streamline the review process.

7. At the CRITICAL level of care, on all days, changed:
Changed:

Complex dressing, ≥ One:
 q1-2h
 Requiring anesthesia

To:
Complex dressing, ≥One:
 q1-2h

 Requiring procedural anesthesia

*This change was made to clarify the intent of the criteria.

Criteria-Specific Changes/Acute Adult: (additions, deletions and modifications):
Reference LOC: Adult -Specific Changes section located in the Clinical Revisions for
the Products document for details related to the changes.
Subsets:

 ACS
 Anemia/Bleeding
 Antepartum
 Arrhythmia
 Asthma
 COPD
 Epilepsy
 Extended Stay
 Heart Failure
 Hypertensive Disorders of Pregnancy
 Inflammatory Bowel Disease
 Infection: CNS
 Infection: Endocarditis
 Infection: GI/GU/GYN
 Infection: Musculoskeletal
 Infection: Pneumonia
 Infection: Skin
 Labor and Delivery
 Pancreatitis
 Postpartum Complication After Discharge
 General Trauma
 General Medical
 General Surgical

LOC: Acute Pediatric Criteria

Potential Care Management Impact

This Clinical Revisions document outlines the updates McKesson Health Solutions has made to the
criteria to reflect the latest changes in the clinical evidence. Whether content has been added or
updated, a level of care changed or a new condition added that did not exist before; certain criteria
changes may affect your organization’s care management approach. Listed below, McKesson Health
Solutions has designated the major criteria updates that may impact your organization with a ()
symbol.

Review Process Updates:

1. A section has been added to address the Medicare Beneficiaries who are impacted by the

CMS 2-midnight rule. Refer to the detail on page one of this document under the LOC Acute

Adult for the specifics.

2. Added clarifying information to the process of performing a review for a patient transferring to a
new facility:

 When a patient is transferred to a new facility, an episode day 1 review is not necessary if
criteria were met at the transferring facility. The accepting facility should conduct the next
review on the appropriate episode day.
For example:
A patient was admitted with a STEMI. The following day, he or she is transferred to another
facility. Conduct a review for episode day 2.
NOTE: When it is not known if criteria were met at the transferring facility the reviewer
at the accepting facility could:
 Perform a retrospective episode day 1 review by applying information found in
the transfer summary, report information or other documentation sent from
the original hospital. In this example, the episode day 1 retrospective review
would be for the date of admission to the transferring (original) facility and is
performed using information from the patient’s medical record from the
transferring facility.
 Complete an episode day 1 review for the day of transfer to the new facility. In
some cases a transfer is done due to worsening symptoms or lack of
improvement and it may be possible to complete an episode day 1 review based
on these new or worsening symptoms.
 Send the case for secondary review

* This change was made to clarify the review process.

Global / General Criteria Changes:

1. At the ACUTE level of care, changed Responder criteria:
Changed:

New onset infection, ≥ One:
WBC ≤ 13,000/cu.mm (13x109/L)
Bands < 6% (0.06)

To:
New onset infection, ≥ One:
WBC ≤ 13,000/cu.mm (13x109/L)
Bands ≤10% (0.10)

*This change was made to align responder criteria with partial responder criteria.

Anticoagulation, One:
Anticoagulation regimen established
Warfarin with no evidence of bleeding, One:
INR ≥ 2.0
INR ≥ 2.5 and mechanical valve (excludes bioprosthetic valves)
IVC filter

*These criteria were updated based on the current available evidence and are supported by McKesson
consultants.

2. At the ACUTE level of care, on all days changed:
Changed:

Direct thrombin inhibitor, One:
Argatroban
Bivalirudin
Lepirudin

To:

Direct thrombin inhibitor, One:
Argatroban
Bivalirudin

* This change was made to streamline the review process as Lepirudin is no longer being manufactured.

3. At the ACUTE level of care, on continued stay changed:
Changed:

INR, All:
Finding, One:
INR < 2.0
INR < 2.5 and mechanical aortic valve

To:
INR non-therapeutic, All:
Finding, One:
INR < 2.0
INR < 2.5 and mechanical valve (excludes bioprosthetic valves), One:
Mitral
Mitral and aortic

* These criteria were updated based on the current available evidence and are supported by McKesson
consultants.

4. At the CRITICAL level of care, on all days, changed:
Changed:

Complex dressing, ≥ One:
 q1-2h
 Requiring anesthesia

To:
Complex dressing, ≥One:
 q1-2h
 Requiring procedural anesthesia

*This change was made to clarify the intent of the criteria.

Criteria-Specific Changes/Acute Pediatrics: (additions, deletions and modifications):
Reference LOC: Pediatric-Specific Changes section located in the Clinical Revisions for the
Product document for details related to the changes. This document

will speak to the changes on a high level. It is imperative users study the Clinical Revision
Document and become knowledgeable with the changes.

Subsets:

 Anemia/Bleeding
 Antepartum
 Asthma
 Bronchiolitis
 Cellulitis
 Epilepsy
 Extended Stay
 Failure to Thrive
 Hypertensive Disorders of Pregnancy
 Labor and Delivery
 Meningitis
 Pancreatitis
 Pneumonia
 Postpartum Complication After Discharge
 Pyelonephritis
 General Trauma
 General Medical
 Nursery
 General Surgical

Guidelines for Surgery and Procedures Performed in the
Inpatient Setting (Adult and Pediatric)

Global / General Criteria Changes:

New Procedures Added:

 Capsule Endoscopy (Pediatric)
 Cryoablation, Prostate
 Cystolithotomy (Pediatric)
 Endovascular Repair, Thoracic Aortic Aneurysm
 Transcatheter Aortic Valve Replacement (TAVR)
 Thyroidectomy, Partial or Total (Pediatric)

Limited Evidence/Secondary Review Required Procedures:
The current list of procedures that require secondary medical review for all indications is below.
Other subsets contain indications that will lead to that recommendation, but all indications in
the subset do not require secondary review.
Cardiothoracic:

 Antireflux Procedures, Endoscopic

 Lung Volume Reduction Surgery (LVRS)
 Transcatheter Aortic Valve Replacement (TAVR)
Neurosurgery:
 Artificial Disc Replacement, Cervical
 Artificial Disc Replacement, Lumbar
 Interspinous Process Decompression
Oro-Maxillo-Facial, Dental and Otolaryngology:
 Uvulopalatopharyngoplasty (UPPP)
Orthopedic – Lower Extremity:
 Total Joint Replacement (TJR), Ankle
Specialized Procedures:
 Discography, Spine, Lumbar
 Gastric Stimulation
Urology:
 Penile Implant

New Question Answer Choice:
Questions that offer a list of choices end in one of the three options below:

 Other clinical information (add comment)
 None of the above
 More choices
A new option is now available, “None of the above, more choices.” This option is used when
there is a list of criteria (e.g. symptoms, findings, diagnoses, medical conditions) that must be
reviewed prior to moving to the next question. If any of the listed criteria is present it must be
selected. If none of the listed criteria are present the user will select “None of the above, more
choices” to advance to the next question.

Criteria-Specific Changes
Adult and Pediatric Surgery and Procedures (removed, moved, changed, added,
changed name, or added asterisk*):
Reference InterQual Guidelines for Surgery and Procedures Performed in the
Inpatient Setting for the specific changes located in the 2015 Clinical Revisions.

There are 69 modifications (removed, moved, changed, added, changed name, or added
asterisk) in 10 categories:

 Cardiology
 Cardiothoracic
 General Surgery
 Ophthalmology
 Obstetrics & Gynecology

 Oro-Maxillo-Facial, Dental & Otolaryngology
 Pediatrics
 Specialized Procedures
 Urology
 Vascular

LOC: Long-Term Acute Care Criteria

There are no Enhancements to the Long-Term Acute Care Criteria.

Global / General Criteria Changes:

Intensity of Service:
Continued Stay,
Responder, medical and rehab potential maximized and discharge expected,
Changed:

Hemodynamic and neurologically stable
≥ 48h, All:

To:
Hemodynamic and neurologically stable
≥ 2d, All:

*This change was made to ensure consistency among subsets.

Partial Responder, potential for clinical and or functional improvement
Treatment of comorbid condition,
Changed:

Blood product transfusion at least q72h or volume expander
To:

Blood product transfusion at least q3d or volume expander
*This change was made to ensure consistency among subsets.

Discharge Screen:
-Skilled Medical or Therapy:
Changed:

 Medication reconciliation
To:

 Complete prior to facility transfer, All:
Comprehensive written discharge and teaching instructions reviewed
Medication reconciliation
Obtain and complete forms for facility
Obtain discharge summary and transmit to facility and medical practitioner
Arrange transportation

*This change was made to ensure consistency among subsets. All patients should have appropriate
documentation completed prior to discharge.

-Subacute Medical or Therapy:
Changed:

 Medication reconciliation
To:

 Complete prior to facility transfer, All:
Comprehensive written discharge and teaching instructions reviewed
Medication reconciliation
Obtain and complete forms for facility
Obtain discharge summary and transmit to facility and medical practitioner
Arrange transportation

*This change was made to ensure consistency among subsets. All patients should have appropriate
documentation completed prior to discharge.

Criteria-Specific Changes/Acute Adult: (additions, deletions and modifications):

Reference LOC: Long-Term Acute Care ‘Criteria Specific Changes’ section located in the Clinical
Revisions for the Products document for details related to the changes.
Changes are found in these subsets:

 Ventilator Weaning
SI: Weaning potential,
Changed:

NYHA class ≤ III or no heart failure
To:

Heart failure, One:
NYHA class ≤ III
Not present

*Clarifies the intent of the criteria

 Medically Complex

IS: Continued treatment of a primary condition,

Infection,
Pneumonia requiring aggressive mobilization of sections at least q4h,

Changed:
O2 sat < 91% (0.91) or arterial Po2< 60 mmHg (8.0 kPa)

To:
O2 sat < 91% (0.91) or arterial Po2< 60 mmHg (8.0 kPa) and <baseline

*Clarifies the intent of the criteria

IS: Continued treatment of a primary condition,

Resident of a nursing home and systemic or organ infection,

Changed:

O2 sat < 91% (0.91) or arterial Po2< 60 mmHg (8.0 kPa)

To:
O2 sat < 91% (0.91) or arterial Po2< 60 mmHg (8.0 kPa) and <baseline

*Clarifies the intent of the criteria

 Respiratory Complex
SI: Post cardiac or thoracic event,
Changed:

NYHA Class III or IV
To:

Heart failure and NYHA Class III or IV
*This change was made to ensure consistency among subsets.

IS: Continued Stay, One:
Responder, medical and rehab potential maximized and discharge expected,
Oxygenation,

Changed:
 Ventilator or NIPPV with settings established > 48h

To:
 Ventilator or NIPPV with settings established > 2d

*This change was made to ensure consistency among subsets.

 Wound/Skin
SI: Lower extremity wound and risk of limb loss

-Risk factor
Changed:

Evaluation planned ≤ 48h
To:

Evaluation planned ≤ 2d
*This change was made to ensure consistency among subsets.

SI: Active management or treatment of comorbid condition,
Changed:

Infection ≤ 30d
To:

Infection with systemic manifestation ≤30d
*This change was made to ensure consistency among subsets.

LOC: Subacute & SNF Criteria

Reference LOC: Subacute & SNF Criteria ‘Global Changes’ section located in the Clinical Revisions
for the Products document for details related to the changes.

Global Changes:

Multiple revisions to the SI & DS criteria components within the Subacute & SNF 2015 Criteria: please
reference above document for specifics.

Criteria-Specific Changes:

Level I (SNF):
SI

-Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
-Medical skilled nursing services at least daily,
Changed:
Diabetes and unstable BS
To:
Diabetes and uncontrolled blood sugar,

≥ One:
Fluctuation between hyperglycemia and hypoglycemia within last 24h
Fluctuation between hyperglycemia and normal blood sugar with no consistent

pattern
Symptomatic hyperglycemia or hypoglycemia
*Changes made to assist in identifying the symptoms of uncontrolled blood sugar.

-Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
-Medical skilled nursing services at least daily,
-GI or GU conditions,
Changed:
Neurogenic bladder (new)
To:
Neurogenic bladder (new) and failed OP management
*McKesson consultants agree treatment for neurogenic bladder is appropriate at Level I (SNF) for
patients who fail outpatient treatment for complications such as mental status change, UTI/sepsis, or
new hydronephrosis.

-Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
-Medical skilled nursing services at least daily,
-GI or GU conditions,
Added:
Pelvic or ureteral obstruction
*McKesson consultants agree treatment or education at the Level I (SNF) level of care is appropriate for
patients who have pelvic or ureteral obstruction that are being managed with bladder irrigation,
nephrostomy, or suprapubic tube.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline and 1-2h/d ≥ 5d/wk,
- Condition,
- Musculoskeletal condition,
Added:
Major joint replacement (hip, knee, or shoulder)
*This criteria were added based on the current available evidence and is supported by McKesson
consultants.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline and 1-2h/d ≥ 5d/wk,
- Condition,
- Musculoskeletal condition,
Changed:
Post amputation foot or forefoot (vascular or traumatic)
To:
Post amputation foot or forefoot
*All forms of amputation are appropriate for skilled therapy.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline and 1-2h/d ≥ 5d/wk,
- Condition,
- Musculoskeletal condition,
Changed:
Upper or bilateral extremity fracture with immobilization
To:
Upper extremity fracture with immobilization
Bilateral extremity fracture with immobilization
*This change was made to clarify the intent of the criteria.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline and 1-2h/d ≥ 5d/wk,
- Impairment (new) with functional activity limitation,
- Requiring at least supervision,
Changed:
Mobility
To:
Mobility (ambulation, bed mobility, or transfers)
*This change was made to clarify the intent of the criteria.

IS:

-Medical
Changed:

Fluids 50 mL/h and at least 500 mL/24h ≤3d
To:

IV Fluid ≤ 3d, Both:
≥50 mL/h
At least 500 mL/24h

*This change was made to clarify the intent of the criteria.

- Medical,
- Insulin (SC) (new regimen),
Changed:
BS ≥ 2x/24h with sliding scale
To:
Blood sugar ≥ 2x/24h with sliding scale
*This change was made to ensure consistency among subsets.

- Medical,
- Insulin (SC) (new regimen),
Changed:
BS stabilizing and discharge planning for home care or long-term care ≤ 24h
To:
Blood sugar stabilizing and discharge planning for home care or long-term care ≤24h
*This change was made to ensure consistency among subsets.

-Medical
Changed:

Mental status assessment ≥ 1x/24h,
≥One:
≥Medication (PO or parenteral),
≥≥One:
Adjustment and symptoms unresponsive or increased side effects
Initiation ≤ 2d

To:
Mental status assessment ≥ 1x/24h,
≥One:
Hepatic encephalopathy, Both:
Medication, ≥ One:
Lactulose
Neomycin
Rifaximin
Administration, ≥ One:
Symptoms unresponsive
Increased side effects
Initiation ≤ 2d
Mental status change, ≥ One:
Psychotropic medication (includes PO), ≥ One:
Adjustment and symptoms unresponsive
Adjustment and adverse side effects
Initiation ≤ 2d

*A review of the literature and McKesson consultants agree that patients with hepatic encephalopathy
are appropriate for treatment at the Level I (SNF) level of care.

- Medical,
- Respiratory intervention 7d/wk,
Changed:
Tracheostomy decannulation ≤ 5d
To:
Tracheostomy decannulation ≤1 wk
*This change was made to ensure consistency among subsets.

-Medical
Changed:

Wound or skin care, aseptic (excludes DSD), One:
Progressive healing ≤ 2wks or recalcitrant wound and wound care at least daily

To:
Wound or skin care, aseptic (excludes DSD), One:
Wound care at least daily, ≥ One:
Progressive healing ≤ 2 wks
Recalcitrant wound and treatment goals adjusted
Discharge planning ≤ 24h, Both:
Wound regimen established and manageable
Evaluation for home care or long-term care

*This change was made to allow for the safe discharge planning of patients with wounds.

Level II (SAC):
SI

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Medical skilled nursing services ≥ 4h/24h,
-Transplant candidate, recipient ≤ 30d or in lieu of continued Acute hospitalization,
-Pre-transplant (heart, lung, liver, bone marrow, or small bowel),
Changed:
Primary pulmonary hypertension or resistant, symptomatic end-stage lung disease and O2 sat
< 89% (0.89)
Resistant or intractable heart failure with NYHA class III or IV symptoms
Short gut syndrome and ongoing fluid or TPN adjustment required
To:
O2 sat < 89% (0.89), ≥ One:

Primary pulmonary hypertension
Resistant, symptomatic end-stage lung disease
NYHA class III or IV
Short gut syndrome and ongoing fluid, TPN, or PPN adjustment required
*McKesson consultants agree that the initiation of PPN is appropriate for the Level II (SAC) level of care.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline 2-3h/d ≥ 5d/wk,
- Condition,
- Musculoskeletal condition,
Changed:
Amputation, vascular or traumatic (1 limb)
To:
Post amputation (1 limb)
*All forms of amputation are appropriate for skilled therapy.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Therapy services with at least 1 discipline 2-3h/d ≥ 5d/wk,
-Condition,
-Spinal cord condition,
Changed:
Multiple myeloma
To:
Metastatic disease
*Skeletal metastasis of the vertebral column may be found in patients with multiple myeloma,
stage 2 breast cancer and non-small cell carcinoma of the lung.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Impairment (new) with functional activity limitation,
- Requiring at least minimum or limited assistance
Changed:
Mobility
To:
Mobility (ambulation, bed mobility, or transfers)
*This change was made to clarify the intent of the criteria.

- Illness, injury, or exacerbation ≤30d or discharged from inpatient facility,
- Impairment (new) with functional activity limitation requiring at least minimum or limited
assistance,
Changed:
ADL
Cognitive, language, speech, or swallowing
Mobility
Respiratory or ventilator dependent
To:
ADL
Cognitive, language, speech, or swallowing
Mobility
Respiratory
Ventilator dependent
*This change was made to streamline the review process.

IS
-Medical

Changed:
Chest tube, One:
Continuous suction
Heimlich valve
Chest tube removed ≤ 24h

To:
Chest tube, ≥One:
Continuous suction
Chest tube removed ≤ 24h
Heimlich valve
Repositioning within last 24
Water seal within last 24hr

*This change was made to clarify the intent of the criteria and to ensure consistency among subsets.

-Medical,
-IV therapy or medication,
Changed:
Anti-infective ≥ 2 drugs or ≥ 3x/24h
To:
Anti-infective, ≥ One:

≥2 drugs
≥3x/24h
*This change was made to clarify the intent of the criteria.

-Medical,
-IV therapy or medication,
Added:
TPN or PPN (initial) ≤ 2 wks
*McKesson consultants agree that the initiation of TPN or PPN is appropriate for the Level II (SAC) level
of care.

-Medical,
Changed:

Mental status assessment ≥ 3x/24h, ≥One:
Medication (PO or parenteral),≥One:
Adjustment and symptoms unresponsive or increased side effects
Initiation ≤ 2d

To:
Mental status assessment ≥ 3x/24h,One:
Hepatic encephalopathy, Both:
Medication, ≥ One:
Lactulose (includes PO or PR)
Neomycin (includes PO)
Rifaximin (includes PO)
Administration, ≥ One:

Symptoms unresponsive
Increased side effects
Initiation ≤2d
Mental status change, One:
Psychotropic medication (includes PO), One:
Adjustment and symptoms unresponsive
Adjustment and adverse side effects
Initiation ≤ 2d
*A review of the literature and McKesson consultants agree that patients with hepatic encephalopathy
can be effectively treated at the Level II (SAC) level of care.

DS
- Home,
- Clinical Stability,

Changed:
DVT resolving or stable, ≥ One:
PT ≥ 1.5x ULN or INR ≥ 2.0 ≥ 2d
SC anticoagulant and patient or caregiver demonstrates ability to administer safely

To:
DVT, One:
Anticoagulation regimen established
Warfarin with no evidence of bleeding, One:
INR ≥ 2.0
INR ≥ 2.5 and mechanical valve (excludes bioprosthetic valves)

*This criteria were added based on the current available evidence and is supported by McKesson
consultants.

Level III (Complex Care)
SI

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Cardio or peripheral vascular or respiratory condition
- Hypoxia on room air w/in 3d prior to admission,
Changed:
O2 sat 89-91% (0.89-0.91) w/o chronic respiratory disease
To:
O2 sat 89-91% (0.89-0.91) and < baseline w/o chronic respiratory disease
*This change was made to ensure consistency among subsets.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
- Cardio or peripheral vascular or respiratory condition
- Hypoxia on room air w/in 3d prior to admission,
Changed:
O2 sat 85-89% (0.85-0.89) and chronic respiratory disease
To:
O2 sat 85-89% (0.85-0.89) and < baseline with chronic respiratory disease
*This change was made to ensure consistency among subsets.
- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,

-Musculoskeletal condition,
Changed:

Amputation, vascular or traumatic (1 limb)
To:

Post amputation (1 limb)
*All forms of amputation are appropriate for skilled therapy.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility,
-Spinal cord condition,
Changed:
Multiple myeloma
To:
Metastatic disease
*Skeletal metastasis of the vertebral column may be found in patients with multiple myeloma, stage 2
breast cancer and non-small cell carcinoma of the lung.

- Illness, injury, or exacerbation 30d or in lieu of continued Acute hospitalization,
-Transplant candidate, recipient 30d or in lieu of continued Acute hospitalization,
- Pre-transplant (heart, lung, liver, bone marrow, or small bowel),
Changed:
Primary pulmonary hypertension or resistant, symptomatic end-stage lung disease and O2 sat
< 89% (0.89)
Resistant or intractable heart failure with NYHA class III or IV symptoms
To:
O2 sat < 89% (0.89), < One:

Primary pulmonary hypertension
Resistant, symptomatic end-stage lung disease
NYHA class III or IV
*This change was made to streamline the review process.

- Illness, injury, or exacerbation ≤ 30d or in lieu of continued Acute hospitalization,
-Transplant candidate, recipient ≤ 30d or in lieu of continued Acute hospitalization,
-Pre-transplant (heart, lung, liver, bone marrow, or small bowel),
Changed:
Short gut syndrome and ongoing fluid or TPN adjustment required
To:
Short gut syndrome and ongoing fluid, TPN, or PPN adjustment required
*McKesson consultants agree that the initiation of PPN is appropriate for the Level III (Complex Care)
level of care.

-Skilled Services,
-Therapy 2-3h/d ≥ 5d/wk,
Changed:
Respiratory or ventilator dependent
To:
Respiratory
Ventilator dependent
*This change was made to streamline the review process.

- Skilled services,
- Therapy 2-3h/d ≥ 5d/wk,
Changed:
Mobility
To:
Mobility (ambulation, bed mobility, or transfers)
*This change was made to clarify the intent of the criteria.

IS
-Medical

Changed:
Chest tube, One:
Continuous suction
Heimlich valve
Chest tube removed ≤ 24h

To:
Chest tube, ≥ One:
Continuous suction
Chest tube removed ≤ 24h
Heimlich valve
Repositioning within last 24h
Water seal within last 24h

*This change was made to clarify the intent of the criteria and to ensure consistency among subsets.

- Medical,
- IV therapy or medication,
Changed:
Anti-infective ≥ 2 drugs or ≥ 3x/24h
To:
Anti-infective, One:

≥2 drugs
≥3x/24h
*This change was made to clarify the intent of the criteria.

- Medical,
- IV therapy or medication,
Added,
TPN or PPN (initial) ≤ 2wks
*McKesson consultants agree that TPN or PPN is appropriate for the Level III (Complex Care) level of
care.

- Medical,
Changed:

Mental status assessment ≥ 3x/24h, ≥One:
Medication (PO or parenteral), ≥One:
Adjustment and symptoms unresponsive or increased side effects
Initiation ≤ 2d
Behavioral symptom (new onset or worsening) and psychiatric consult ≤ 24h
Symptom or behavior improving or resolved ≤ 2d and discharge planning

To:
Mental status assessment ≥ 3x/24h, One:
Hepatic encephalopathy Both:
Medication, ≥ One:
Lactulose (includes PO or PR)
Neomycin (includes PO)
Rifaximin (includes PO)
Administration, ≥ One:
Symptoms unresponsive
Increased side effects
Initiation ≤ 2d
Mental status change, ≥ One:
Psychotropic medication (includes PO), One:
Adjustment and symptoms unresponsive
Adjustment and adverse side effects
Initiation ≤ 2d
Behavioral symptom (new or worsening) and psychiatric consult ≤ 24h

*A review of the literature and McKesson consultants agree that patients with hepatic encephalopathy
can be effectively treated at the Level III (Complex Care) level of care.

- Medical,
- Pain management,
-Uncontrolled pain,
Changed:
Continuous parenteral analgesic
Analgesic or muscle relaxant ≥3x/24h
PCA
Analgesic transition to PO ≤ 2d
To:
Analgesic or muscle relaxant ≥ 3x/24h
PCA or continuous parenteral analgesic
*This change was made to clarify the intent of the criteria and streamline the review process.

- Medical,
- Ventilator management,
Changed:
Ventilator and oxygen requirement stable and discharge planning ≤ 48h, One:
To:
Ventilator and oxygen requirement stable and discharge planning ≤ 2d, One:
*This change was made to ensure consistency among subsets.

- Medical,
- Wound or skin care,
Changed:
Wound or skin care, One:

Progressive healing ≤ 2wks or recalcitrant wound, ≥ One:
> 15 min and ≥ 3x/24h
Negative pressure wound therapy, ≥ One:
Clean wound with dressing change ≥ 3x/wk
Infected wound with dressing change at least daily

To:
Wound or skin care, Both:
Finding, ≥ One:
Progressive healing ≤ 2 wks
Recalcitrant wound and treatment goals adjusted
Intervention, ≥ One:
Wound or skin care > 15 min and ≥ 3x/24h, All:
Negative pressure wound therapy, One:
Clean wound with dressing change ≥ 3x/wk
Infected wound with dressingchange at least daily

*This change was made to clarify the intent of the criteria and streamline the review process.

- Medical,
- Wound or skin care,
Changed:
Discharge planning ≤ 24h, Both:

Wound regimen established and manageable
Evaluation for home care, SNF, or long-term care
To:
Wound or skin care and discharge planning ≤ 24h, Both:
Wound regimen established and manageable
Evaluation for home care, SNF, or long-term care
*This change was made to clarify the intent of the criteria.

-Therapy,
- Continued progressive therapy program w/ @ least 1 discipline and 2-3h/d of therapy ≥5d/wk,
- Functional status,
Changed:
Functional plateau reached or minimal functional gains (ADLs, mobility, cognition) ≤ 1 wk and
discharge planning
To:
Functional plateau reached or minimal functional gains (ADLs, mobility, cognition) and
discharge planning ≤ 1 wk
*This change was made to ensure consistency among subsets.

DS
- Home,
- Clinical stability,
- Medical,

Changed:
DVT resolving or stable, ≥ One:
PT ≥ 1.5x ULN or INR ≥ 2.0 ≥ 2d
SC anticoagulant and patient or caregiver demonstrates ability to administer safely

To:
DVT, One:
Anticoagulation regimen established
Warfarin with no evidence of bleeding, One:
INR ≥ 2.0
INR ≥ 2.5 and mechanical valve (excludes bioprosthetic valves)

*This criteria were added based on the current available evidence and is supported by McKesson
consultants.

Pediatric Subacute:
SI

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility (eg, high-risk infant),
- Medical skilled nursing services ≥ 4h/24h,
- Cardio or peripheral vascular or respiratory condition,
Changed:
Cardiomyopathy or heart failure
To:
Cardiomyopathy
Heart failure

Changed:
Chronic lung disease or developmental disabilities requiring respiratory intervention and at

risk for complications
To:

Chronic lung disease requiring respiratory intervention and at risk for complication
Developmental abnormality and at risk for complication
*This change was made to clarify the intent of the criteria.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility (eg, high-risk infant),
- Medical skilled nursing services ≥ 4h/24h,
- Cardio or peripheral vascular or respiratory condition,
- Chronic or long-term mechanical ventilation (includes NIPPV) ≤ 6h/d,
Changed:
O2 sat > 93% (0.93) without ventilator or NIPPV setting change last 48h
To:
O2 sat > 93% (0.93) without ventilator or NIPPV setting change last 2d
*This change was made to ensure consistency among subsets.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility (eg, high-risk infant),
- Medical skilled nursing services ≥ 4h/24h,
- Cardio or peripheral vascular or respiratory condition,
Changed:
Tracheostomy (new) with initial trach change prior to admission and stoma site stable
To:
Tracheostomy (new), Both:

Initial tracheostomy change prior to admission
Stoma site stable
*This change was made to clarify the intent of the criteria.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility (eg, high-risk infant),
- Medical skilled nursing services ≥ 4h/24h,
- GI or GU condition,
Changed:
Chronic renal insufficiency requiring peritoneal dialysis (initial) at least 4 exchanges within 24h

TPN, PPN, or enteral nutrition (initial), ≥One:
Bowel rest with prolonged NPO
Failure to Thrive (FTT) after initial inpatient treatment
Inability to ingest food
Malnutrition

Pre-intestinal (small bowel) transplant and ongoing fluid or TPN adjustment required
To:

Chronic renal insufficiency requiring peritoneal dialysis (initial)
Inadequate oral intake requiring nutritional support, ≥ One:

Bowel rest with prolonged NPO
Failure to thrive (FTT) after initial inpatient treatment
Inability to ingest food
Malnutrition
Small bowel transplant
*This change was made to clarify the intent of the criteria. TPN, PPN or enteral nutrition criteria has
been restructured under the Intensity of Service. (IS)

- Illness, injury, or exacerbation ≤30d or discharged from inpatient facility (eg, high-risk infant),
-Therapy services (age appropriate) with at least 1 discipline 2-3h/d ≥5d/wk,
- Condition,
Moved under “Medical skilled nursing services ≥ 4h/24h,
Uncontrolled pain and neurological or musculoskeletal etiology, All:

Failed outpatient physical or occupational therapy ≥ 2 trials
Failed pharmacologic or nonpharmacologic treatment ≥2 trials
Inability to work, attend school, or manage developmentally appropriate ADLs
*Uncontrolled pain and applicable sub criteria were moved from Therapy services to Medical skilled
nursing services to ensure consistency among subsets.

- Illness, injury, or exacerbation ≤30d or discharged from inpatient facility (eg, high-risk infant),
-Therapy services (age appropriate) with at least 1 discipline 2-3h/d ≥5d/wk,
- Condition,
-Musculoskeletal condition,
Changed:
Amputation, vascular, traumatic, or malignancy (1 limb)
To:
Post amputation (1 limb)
*All forms of amputation are appropriate for skilled therapy.

- Illness, injury, or exacerbation ≤ 30d or discharged from inpatient facility (eg, high-risk infant),
- Impairment (new) with functional activity limitation requiring at least minimum assistance,
Changed:
Respiratory or ventilator dependent
To:
Respiratory
Ventilator dependent
*This change was made to streamline the review process.

IS 
-Medical

Changed:
Chest tube, One:
Continuous suction
Heimlich valve
Chest tube removed ≤ 24h

To:
Chest tube, ≥ One:
Continuous suction
Chest tube removed ≤ 24h
Heimlich valve
Repositioning within last 24h
Water seal within last 24h

*This change was made to clarify the intent of the criteria and to ensure consistency among subsets.

- Medical,
- IV therapy,
Changed:
Anti-infective ≥ 2 drugs or ≥ 3x/24h
To:
Anti-infective ≥ One:

≥2 drugs
≥3x/24h
*This change was made to clarify the intent of the criteria.

- Medical,
- IV therapy,
Added:
TPN or PPN ≤ 2 wks, One:

Initial
Transition to enteral or PO nutrition
*McKesson consultants agree that TPN or PPN is appropriate for the Pediatric Subacute level of care.

- Medical,
- Mental status assessment ≥ 3x/24h,
Changed:
Medication (PO or parenteral), ≥ One:
To:
Medication (includes PO), ≥ One:
*This change was made to clarify the intent of the criteria.

- Medical,
- Mental status assessment ≥ 3x/24h,
Changed:
Symptom or behavior improving or resolved ≤ 2d and discharge planning
To:
Symptom or behavior improving or resolved and discharge planning ≤2d
*This change was made to ensure consistency among subsets.

- Medical,
- Pain management,
Changed:
Continuous parenteral analgesic
PCA
To:
PCA or continuous parenteral analgesic
*This change was made to clarify the intent of the criteria.

- Medical,
Changed:

Patient or caregiver education, One:
To:

Patient and family or caregiver education, One:
*This change was made to clarify the intent of the criteria.

Changed:
Nutritional support, One:
Enteral feeding, ≥ One:

To:
Enteral feeding, ≥ One:

*This change was made to streamline the review process.

- Medical,
- Ventilator management or NIPPV,
Changed:
Ventilator and oxygen requirement stable ≤ 48h One and discharge planning:
To:
Ventilator and oxygen requirement stable and discharge planning ≤ 2d, One:
*This change was made to ensure consistency among subsets.

-Medical
-Wound or skin care,
Changed:
Progressive healing 2wks or recalcitrant wound and wound care > 15 min and ≥ 3x/24h
To:
Finding, ≥ One:

Progressive healing ≤ 2 wks
Recalcitrant wound and treatment goals adjusted
Intervention, ≥ One:
Wound or skin care >15 min and ≥ 3x/24h
Negative pressure wound therapy, One:

Clean wound with dressing change ≥ 3x/wk
Infected wound with dressing change at least daily
*This change was made to clarify the intent of the criteria.

LOC: Rehabilitation Criteria

Reference LOC: Rehabilitation Criteria ‘Global Changes’ section located in the Clinical Revisions
for the Products document for details related to the changes.

Global Changes:

Multiple revisions to the IS & DS criteria components within the Rehabilitation 2015 Criteria: please
reference above document for specifics.

Criteria-Specific Changes/Rehabilitation: (additions, deletions and modifications):
Reference LOC: Rehabilitation Criteria-Specific Changes section located in the Clinical Revisions
for the Products document for details related to the changes.

 Burns: Severity of Illness and Intensity of Service
 CNS/TBI: Severity of Illness
 Medically Intensive: Severity of Illness and Discharge Screens
 Spinal Cord Injury: Intensity of Service
 Subacute Rehabilitation: Severity of Illness and Intensity of Service
 Pediatric Rehabilitation: Severity of Illness and Intensity of Service

LOC: Home Care

Enhancements:

For 2015: InterQual Home Care Criteria have been transition from the nested decision tree format to the
Question and Answer (Q&A) format. The criteria now appear in two subsets:

 Home Care Services, Adult
 Home Care Services, Pediatric

Global Changes:

Multiple changes to Adult and Pediatric subsets please see the Clinical Revisions Document for specifics.

CP: Imaging Criteria

Global / General Criteria Changes:

New Question Answer Choice:
Questions that offer a list of choices end in one of the three options below:
 “Other clinical information (add comment)”
 “None of the above”
 “More choices”

A new option is now available, “None of the above, more choices”. This option is used when there is a
list of criteria (e.g., symptoms, findings, diagnoses, medical conditions) that must be reviewed prior to
moving to the next question. If any of the listed criteria is present it must be selected. If none of the
criteria are present the user will select “None of the above, more choices” to advance to the next
question.

Category-Criteria Specific Changes/Imaging : ( additions, deletions, and
changed):

Reference CP: Imaging Criteria – Specific Changes section located in the Clinical Revisions for the
Products document for details related to the changes.

Category and Subset:

 Abdomen & Pelvis
 Chest & Heart
 General
 Head & Neck
Imaging Medical Code Revisions Table-
Medical Code Revisions are found on a four page table which is sorted by the Subset
Description (Guideline Name) Test code description (Recommendation)/CPT/HCPC/
Revision/Rationale columns. The codes may be added, corrected, or deleted.
Reference CP: Imaging Criteria – Specific Changes section located in the Clinical Revisions for the
Products document.

LOC: Outpatient Rehabilitation & Chiropractic Criteria

Enhancements:

No enhancements for the ORC LOC for 2015.

Global / General Criteria Changes:

No global/general criteria changes.

Criteria-Specific Changes/ORC: (additions, deletions and modifications):

Reference LOC: Outpatient Rehabilitation & Chiropractic Specific Changes section located in the
Clinical Revisions for the Products document for details related to the changes. There are
approximately 33 changes.

Subsets:
 Ligamentous Injury, Ankle: Rehabilitation
 Soft Tissue Disorders, Foot & Ankle: Rehabilitation
 Tendon Rupture, Achilles: Rehabilitation
 Ligamentous Injury, Knee: Rehabilitation
 Meniscal Injury, Knee: Rehabilitation
 Osteoarthritis, Knee: Rehabilitation
 Soft Tissue Disorders, Knee: Rehabilitation

CP: Durable Medical Equipment (DME) Criteria

New Subset:

The following subset was added:
 Continuous Glucose Monitors, Minimally Invasive

Revisions:

Subsets:
 Wheelchairs or Strollers, Pediatric
 Cardioverter Defibrillator, Wearable (WCD)
 Patient Life System – Senior

DME Medical Code Revisions Table-
Medical Code Revisions are found on a five page table which is sorted by the Subset Description
(Guideline Name) /Test code description (Recommendation)/Test Code/CPT/HCPC/
Revision/Rationale columns. The codes may be added, corrected, or deleted.
Reference CP: DME – Specific Changes section located in the Clinical Revisions for the Products
document.

CP: Molecular Diagnostics (MDX) Criteria

“CES Only” Format for Selected Subsets:

The question and answer portion of the content in selected subsets will no longer be updated
or displayed, however, the Clinical Evidence Summary (CES) will continue to be reviewed and
updated. The following subsets are affected by this change:

 Avian Influenza (CES only)
 Canidida, Gardnerella, Trichomonas (C.G.T.) for Vaginitis (CES only)
 Candidiasis (CES only)
 Chlamydia trachomatis Neisseria gonorrhoeae (CT NG) (CES only)
 Cytomeglaovirus (CMS)( (CES only)
 Enterovirus (CES only)
 Epstein-Barr Virus (EBV) (CES only)
 Group A Beta-Hemolytic Streptococcus (GABHS) Pharyngitis (CES only)
 Group B Streptococcus (GBS) Screening in Pregnancy (CES only)
 Hepatitis B Virus (HBV) (CES only)
 Hepatitis G Virus (HGV) (CES only)
 Herpes Simplex Virus (HSV) (CES only)
 Human Immunodeficiency Virus (HIV-1) Drug Resistance (CES only)
 Mycobacterium Tuberculosis (Acid Fast Bacillus) (CES only)
 Pertussis (Bordetella) (CES only)
 Toxoplasmosis (CES only)
 Varicella Zoster Virus (VZV) (CES only)

New Subsets:

The following new subsets have been added:
 Multi-Gene Panel for Inherited Breast Cancer
 Neurofibromatosis 1 (NF1)
 Neurofibromatosis 2 (NF2)
 Retinoblastoma

The following new “CES only” subsets have been added:
 Circulating Tumor Cells (CTC) (CES only)
 HLA-DRB1*04 Genotyping for Juvenile Idopathic Arthritis (JIA) (CES only)
 Immunohistochemistry (IHC) (CES only)
 Multi-Gene Panel Testing for Non-Inherited Breast Cancer (CES only)
 Whole-Exome Next-Generation Sequencing (WES) for Oncology (CES only)
 Whole-Genome Next-Generation Sequencing (WGS) for Oncology (CES only)

Subset Name Change:

“BRAF or KRAS Testing for Drug Response” was changed to “BRAF, KRAS, or NRAS Testing for
Drug Response”

Revisions:

 BRAF, KRAS, or NRAS Testing for Drug Response
 FMR1 Related Disorders (Fragile X Syndrome)
 Hepatitis C Virus (HCV)
 Human Epidermal Growth Factor Receptor 2 (HER2) Testing for Drug Response
 KIT Testing for Imatinib Response
 Lynch Syndrome (LS)
 MUTYH-Associated Polyposis (MAP)
 PDGFRA Testing for Imatinib Response in Gastrointestinal Stromal Tumors (GIST’s)

MDX Medical Code Revisions Table-
Medical Code Revisions are found on a three page table which is sorted by the Subset
Description (Guideline Name) /Test code description (Recommendation)/Test Code/CPT/HCPC/
Revision/Rationale columns. The codes may be added, corrected, or deleted.
Reference CP: MDX – Specific Changes section located in the Clinical Revisions for the Products
document.

CP: Specialty Referral Criteria

Category-Criteria Specific Changes/Specialty Referral : ( additions, deletions,
and changed):
Reference CP: Specialty Referral Criteria – Specific Changes section located in the
Clinical Revisions for the Products document for details related to the changes.

Category and Subset:

 Cardiovascular Disorders

o Hypertension
o Lipid Disorders
o Valvular Heart Disease

 Endocrine Disorders

o Thyroid Disorders

 Gastroenterologic Disorders

o Cancer Surveillance
o Gastroesophageal Reflux Disease (GERD)
o Gastrointestinal (GI) Bleeding
o Neoplasms of the Gastrointestinal (GI) System
o Peptic Ulcer Disease

 Pulmonary Disorders

o Hemoptysis
o Imaging Study Abnormalities (Pulmonary Disorders)
o Interstitial Lung Disease
o Neoplasms of the Respiratory System
o Pulmonary Embolus (PE)
o Sleep Apnea

 Renal & Urologic Disorders

o Benign Prostatic Hyperplasia (BPH)
o Nephrolithiasis (Kidney/Ureteral/Bladder Stones)
o Penile and Urethral Disorders
o Physical Examination Findings (Renal and Urologic Disorders)
o PSA Abnormalities