UR screening

kshumpertkshumpert
in CDI Talk Archive
Good morning colleagues. I have a question for you regarding UR documentation. Does your case management/Ur staff document their screening process such as Interqual criteria within the patient record, somewhere else, or not at all? Our Recovery Auditors are really honing in on medical necessity reviews. I want to have a standardized process that is transparent with the inpatient screening process so that I can use this information in defense on my RAC appeals. Many thanks!

Comments

  • rmhosler1rmhosler1
    edited May 2016
    I believe our UR staff document this within the case management section
    of our parogon EMR, however I don't think they specifically list the
    criteria, they just do a summary.



    Mary A. Hosler, MSN RN
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org

  • paxnerospaxneros
    edited May 2016
    Our UM Staff document within our EMR in a special section for them.

    When I worked in UM we always entered our regulatory review into the computer, generated the report and placed it in the paper chart under Social service/Discharge Planning section on the floor.

    Thanks,

    NBrunson, RHIA,CDIP,CCS,CCDS
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Ours in not in our EMR but it is another database. However, we also contract with EHR and their letters stating the reason for inpatient admission is in the EMR.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • clare.garrardclare.garrard
    edited May 2016
    We use Morrisey case management software to document the Interqual review.

  • kshumpertkshumpert
    Why would the UR physician advisor notes go into the EMR but the UR nurses review stay within a separate system? I am trying to get the UR documentation and physician advisor documentation within the same folder. In my world, they go hand in hand and should be linked together. Thoughts?
  • robert.hodges2robert.hodges2
    edited May 2016
    I agree they should be linked, but I don't think they belong in the health record.



    Back in the day when I supervised case management (who did the utilization review in Midas using InterQual criteria) we kept it out of the health record since it is information primarily used by the insurance companies. I would be very reluctant if I was a physician doing a UR review to have my notes in the health record where they are then discoverable, especially if you disagree with the LOS or the diagnosis being treated by the attending. It could set up a few problems down the road. But the bottom line, should the UR physician notes be documented with the UR nurses notes, absolutely. Should they be in the health record, in my opinion, no.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



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  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I am not 100% sure of the reasoning for our system. UR is separate than CDI in our facility and we are in different departments. But we use MIDAS CERME(?) for the UR reviews and that does not (as far as I know) flow into our CERNER EMR. They use InterQual for their criteria. Then, the Medicare/BCBS patients that do not clearly meet InterQual are sent to EHR for MD review. They write a narrative consult in defense of their decision. That is then scanned into Cerner. EHR handles those appeals and I do not think they rely on the UR team for their defense. They use their own criteria/medical judgment.Since it is an outside MD doing the consult, it does not seem like they are working that closely together. Having the RN's note in there may not be a positive in these cases as her/his note would show that they did not meet InterQual and then the MD (likely) would state that they did.

    I'm not sure why the decision was made to have the MD note in the EMR. In my head it would make sense for neither the MD or the RN's notes to be in the EMR but to have both the RN and MD's notes in a separate database?

    I'm not really sure on this. Definitely not my expertise but that’s our system as far as I know.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
    rs MA 01923
  • janice.gaskinsjanice.gaskins
    edited May 2016
    We changed to All scripts in December of last year. Both Case
    Management and UM use it.
    Thank you in advance for your compliance with this notice.
  • sharon.colesharon.cole
    edited May 2016
    Our case managers use Interqual through Allscripts for medical necessity. Since CDI is under Case Management, we also use Allscripts for documentation and queries - although we submitted our own queries since the ones that came with Allscripts were leading.

    Sharon Cole, RN, CCDS
    CDI Specialist
    254.751.4256
    Sharon.cole@phn-waco.org
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