As you may know, Blue Cross & Blue Shield of Rhode Island (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 procedures and conditions that may have previously been automatically approved for inpatient level of care which now are appropriate to review in order to determine the appropriateness of inpatient level of care versus observation level of care.
BCBSRI is committed to having level of care criteria that reflect advances in medicine and care at all levels. As it relates to changes in InterQual, BCBSRI considers many factors as we assess updates for adoption and implementation. Some of the factors BCBSRI considers are: feedback from specialty providers, analysis of data, and review of changes implemented by the Centers for Medicare & Medicaid Services (CMS).
The 20 de abril21 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, 2021, Clinical Reference, Clinical Revisions, Apr. 2021. The new subsets are listed below:
- Gastrointestinal (GI) Bleeding
- Non-Traumatic Bleeding
- Anemia
As a result of these updates and revisions to guidelines and BCBSRI’s adoption, BCBSRI, will require its members receiving care, who can be treated and managed within the observation setting, be treated in that setting, instead of the acute inpatient setting.
In addition to the new subsets and updates to individual subsets, InterQual identified the following surgical procedures as being able to be performed in an outpatient setting:
- Pericardiocentesis
- Herniorrhaphy Inguinal or Femoral, Strangulated or Incarcerated
- Herniorrhaphy, Umbilical, Strangulated or Incarcerated
- Mastectomy, Prophylactic, Total or Simple, Bilateral
- Single-level Laminectomy + Fusion, Lumbar
- Single-level Discectomy +/- Fusion, Lumbar
- Single-level Hemilaminectomy (Laminotomy) +/- Discectomy + Fusion, Lumbar
- Control, Nose Bleed, Complicated
- Excision External Auditory Canal Lesion
- Facial/Jaw Reconstruction
- Oronasal Fistula Repair with Bone Grafting
- Osteotomy, Sagittal Split, Mandible Ramus
- Bilateral sagittal split osteotomy (BSSO)
- Bilateral sagittal split ramus osteotomy (SSRO)
- Removal or Revision, Arthroplasty, Elbow
Pediatric Procedural Revisions:
- Herniorrhaphy Inguinal or Femoral, Strangulated or Incarcerated
- Herniorrhaphy, Umbilical, Strangulated or Incarcerated
Those patients with complications can be upgraded to an inpatient level of care when appropriate and will be reviewed on a case-by-case basis.
These changes will be effective 1 de julio de 2021.
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 me at Peter.Nakhla@bcbsri.org