May 16, 2022

UPDATE – Level of Care Criteria Review

As you may know, BCBSRI uses InterQual® Criteria Guidelines (InterQual) offered through Change Healthcare as the basis for its medical necessity review criteria. As Change Healthcare makes updates and revisions to InterQual criteria, BCBSRI reviews the changes for adoption and implementation. These changes include both procedures and conditions that are new to InterQual, may have previously been automatically approved for inpatient level of care which are now appropriate to review in order to determine the appropriateness of inpatient level of care versus observation level of care and alternatively procedures that may reflect as being appropriately managed at the inpatient level of care. 

The April 2022 revisions encompass both the addition of new subsets as well as updates to the Inpatient Procedure List. In addition, criteria changes within individual subsets can be found under LOC: Acute Adult, 2022, Clinical Reference, Clinical Revisions, Apr. 2022. The new subsets are listed below:

  • Gastrointestinal (GI) Bleeding (Pedi)
  • Non-Traumatic Bleeding (Pedi)
  • Anemia (Pedi)

In addition to the new subsets and updates to individual subsets, InterQual added some new procedures to the inpatient list as well as surgical procedures identified with an asterisk (*) as being able to be performed in either the inpatient or outpatient setting:

  • Bronchoscopy: Life Threatening (Massive) Hemoptysis (new)
  • Bronchoscopy: Acute Chest Injury and Hemoptysis* (new)
  • Bronchoscopy: Acute Chest Injury and Blood-streaked Sputum* (new)
  • Appendiceal perforation (including abscess or phlegmon) (revision)
  • Laparoscopy, Diagnostic (Abdomen) for Abdominal or Pelvic Trauma* (new)
  • Laparotomy or Exploratory Laparotomy (revision)
  • Skin Graft*: Allogeneic Skin Graft (Allograft)* Autologous Skin Graft (Autograft)* Xenograft* (new)
  • Skin Substitute Graft: Second- or Third-Degree Burn* (new)
  • Burn, Excision, +/- Graft*: Full Thickness (3rd degree) * Deep Partial Thickness (2nd degree)* (revision)
  • Artificial Disc Replacement, Cervical*: Intervertebral Disc Prosthesis, Cervical* (new)
  • Scoliosis or Kyphosis Surgery
  • Vertebroplasty* or Kyphoplasty* (new)
  • Tonsillectomy* added Tonsillar Hemorrhage* (new)
  • Total Joint Replacement Hip and Knee Simultaneous Bilateral are Inpatient Level of Care

Pediatric Procedural Revisions:

  • Appendiceal perforation (including abscess or phlegmon) (revision)
  • Laparoscopy, Diagnostic (Abdomen) for Abdominal or Pelvic Trauma* (new)
  • Laparotomy or Exploratory Laparotomy (new)
  • Scoliosis or Kyphosis Surgery
  • Exstrophy of Bladder, Reconstruction (revision)
  • Cystorrhaphy* (revision)
  • Cystoplasty*(revision)
  • Cystourethroplasty (revision)
  • Nephrotomy* (revision)
  • Penectomy (excludes gender confirmation surgery)* (revision)
  • Pyelolithotomy* (revision)
  • Pyelotomy* (revision)

The above is meant to capture a general overview of the changes and each individual facility should review the revisions independently.

2022 Revisions to InterQual Subsets / IQ Inpatient List will be effective July 18, 2022.

We recognize these updates will likely require education within your facility and efforts on your behalf. If you have any question or would like to discuss these changes, please feel free to contact Karen Labbe at Karen.Labbe@bcbsri.org.