CM Key Concepts

Interqual

100

The purpose of conducting IQ reviews

What is to determine and/or demonstrate medical necessity—NOT to make the criteria meet.

200

This type of review is a level of care determination tool for real-time decision support in the emergency department

What is Initial review

300

With exception of straight Medi-cal patients, IQ should be completed according to this time frame

What is every 48hrs

400

The first thing you should do if the patient doesn’t meet IP criteria

What is run IQ to see if pt meets obs

500

The process you should follow when patient does not meet observation status, or inpatient status

What is engage the medical team regarding documentation in the medical record and ask if there is medical indications currently not documented, if not discuss alternative settings of care outside of the hospital system. If the admitting team wants to proceed with hospital stay, Escalate case to physician advisor via the secondary review navigator process and page PA as well.

Code 44

100

The change in status from this to this defines a Code 44

Inpatient to observation; or INP to overnight recovery

200

These 4 conditions must be met in order to process the case as a code 44

• The change in status from inpatient to outpatient is made prior to discharge.
• The Attending physician concurs with the utilization review committee’s decision to change patient status
• The Attending physician concurrence is documented in the medical record.
• A Physician advisor concurs prior to The hospital has not submitted a claim to Medicare.

300

This document needs to provided to the patient prior to discharge in order for the Code 44 to be processed

What is MOON letter

400

Name at least 3 of the exclusion criteria for <2MN cases to remain as inpatient status

• C List ( Inpatient Only Procedure) Was Performed
• Transfer from or to another acute hospital where care spans > 2MN
• Leaving AMA
• Initiation of new mechanical ventilation
• Election of Hospice services rather than acute care
• Death
• Vast Improvement in condition( this is very rare and would need documentation of medical necessity by the physician in the Medical record of such)

500

This type of Medicare is managed by a commercial payor

What is Medicare Advantage or Medicare part C

Obs Criteria

100

These are common Observation diagnosis

What is Syncope and Chest pain

200

This payor does not recognize observation status

What is Fee for Service Medi-cal

300

Observation charges are calculated on this cadence

What is Hourly

400

Observation patients are converted to inpatient after they have been here for this amount of time

What is 2 midnights 

500

The allowable time for observation per CMS

What is 6 to 48 hours