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Medical Review Criteria for Managing Care®: Ambulatory

  • The bible for health plan benefit interpretation guidelines.
  • More than 2,000 detailed clinical review criteria guidelines and evidence-based benefit interpretations.
  • Provides utilization management and claims departments with essential information to assist in medically-necessary benefit determinations.
  • Includes specific indications for medically necessary ambulatory care or inpatient tests and procedures.
  • Extensive literature references and other authoritative resources in each guideline, with web links.
  • List of LOS benchmarks by DRG for Medicare, commercial and Medicaid populations.
  • Table of Contents
    • Preface
    • Introduction
    • Allergy & Immunology
    • Anesthesia
    • Blood Bank Guidelines
    • Cardiology
    • Cardiovascular and Peripheral Vascular Surgery
    • Complementary and Alternative Medicine
    • Dermatology
    • Disposable Medical Supplies (DMS) and Durable Medical Equipment (DME)
    • Medical Education and Training
    • Emergency Medical Services
    • Otolaryngology, Oral Surgery and Dental Services
    • Gastroenterology
    • General Surgery
    • Hematology & Medical Oncology
    • Laboratory
    • Miscellaneous
    • Nephrology
    • Neurology and Neurosurgery
    • Nuclear Medicine
    • Nutritional Therapy
    • Obstetrics and Gynecology
    • Opthalmology
    • Pediatrics
    • Pharmacy
    • Plastic and Reconstructive Surgery
    • Pulmonary
    • Radiology
    • Radiation Therapy and Radiation Oncology
    • Skeletal-Muscular System
    • Urology
    • Vascular Laboratory
    • Addenda

Acute Care Inpatient Guidelines

  • More than 350 guidelines that contain acute care inpatient review criteria with MS-DRG and APR-DRG Length of Stay data.
  • Evidence-based, with comprehensive reference links.
  • Includes a section entirely devoted to Managing Unplanned Readmissions, which includes issues, innovative programs, resources and strategies needed to manage CMS targeted readmission diagnoses and avoid financial penalties.
  • Detailed review criteria by MS-DRG focus on medical necessity and appropriateness of care.
  • Search guidelines by DRG, CPT/HCPCS, ICD-9 or keyword.
  • Table of Contents
    • Pre Stem Cell and Organ Transplantation
    • MDC1 Diseases and Disorders of the Nervous System
    • MDC2 Diseases and Disorders of the Eye
    • MDC3 Diseases and Disorders of the Ear, Nose, Mouth and Throat
    • MDC4 Diseases and Disorders of the Respiratory System
    • MDC5 Diseases and Disorders of the Circulatory System
    • MDC6 Diseases and Disorders of the Digestive System
    • MDC7 Diseases and Disorders of the Hepatobilliary System and Pancreas
    • MDC8 Diseases and Disorders of the Musculoskeletal System and Connective Tissues
    • MDC9 Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast
    • MDC10 Diseases and Disorders of the Endocrine, Nutritional and Metabolic Diseases and Disorders
    • MDC11 Diseases and Disorders of the Kidney and Urinary Tract; Dialysis
    • MDC12 Diseases and Disorders of the Male Reproductive System
    • MDC13 Diseases and Disorders of the Female Reproductive System
    • MDC14 Diseases and Disorders of Pregnancy, Childbirth and Puerpium
    • MDC15 Diseases and Disorders of Neonates (Perinatal Period)
    • MDC16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders
    • MDC17 Diseases and Disorders of Myeloproliferative DDs (Poorly Differentiated Neoplasms)
    • MDC18 Diseases and Disorders of the Infectious and Parasitic Diseases
    • MDC19 Diseases and Disorders of the Mental Diseases and Disorders
    • MDC20 Diseases and Disorders of the Alcohol/Drug Use or Induced Mental Disorders
    • MDC21 Diseases and Disorders of the Injuries, Poison and Toxic Effect of Drugs
    • MDC22 Diseases and Disorders - Burns
    • MDC23 Factors Influencing Health Status
    • MDC24 Multiple Significant Trauma
    • MDC25 Human Immunodeficiency Virus Infection
    • INP Addenda
    • INP Inpatient References and Resources
    • INP Length of Stay, DRG, Second Opinions, Never Events and Preventable Adverse Events
    • INP Unplanned Readmissions: Management Strategies

Managing Physical/Occupational/Speech Therapy and Rehabilitation Care

  • Detailed review criteria for adult/pediatric OT, PT, speech therapy plus therapy-related DME.
  • Detailed review criteria guidelines for inpatient rehabilitation unit/hospital admission, continued stay and discharge.
  • The recommended number of visits required to treat specific conditions and instruct patients for self-directed home care.
  • Resources include example protocols and quality monitors throughout including the Oregon Pediatric guidelines for rehabilitation, web sites.
  • Table of Contents
    • Preface
    • Physical, Occupational and Speech Therapy Services - Utilization Management Issues
    • Modalities
    • Speech-Language Pathology Therapy
    • Visit Authorization Guidelines, Shoulder and Thorax
    • Visit Authorization Guidelines, Hip and Pelvis
    • Visit Authorization Guidelines, Upper Extremities
    • Visit Authorization Guidelines, Lower Extremities
    • Visit Authorization Guidelines, Disease or Disorder Specific Guidelines
    • Visit Authorization Guidelines, Back, Including Cervical, Thoracic and Lumbar-Sacral Spine
    • Visit Authorization Guidelines by Skeletal Structure or Disorder - Overview
    • Rehabilitation Services
    • Disposable Medical Supplies (DMS)/Durable Medical Equipment (DME)
    • Home Exercise Programs + Patient Education Materials
    • Addenda
    • Stroke & Traumatic Brain Injury Rehabilitation
    • Cardiac Rehabilitation Program Guidelines
    • Pulmonary Rehabilitation Program Guidelines

Managing Behavioral Healthcare; Review Criteria, Case Management

  • Detailed behavioral health review criteria guidelines and benefit interpretations for inpatient and outpatient care by diagnostic entity, including office visit edits.
  • Strategies for quality-based efficient delivery of integrated effective behavioral healthcare management.
  • Adult and children’s behavioral health LOS and CM.
  • Table of Contents
    • Introduction
    • Managing Behavioral Healthcare
    • Provider Issues
    • Special Populations
    • Case Management
    • Neurodevelopmental Disorders
    • Substance-related and Addictive Disorders
    • Alzheimer's Disease and Other Dementias
    • Delirium
    • Eating Disorders
    • Schizophrenia Spectrum and Other Psychotic Disorders
    • Depressive Disorders
    • Anxiety Disorders
    • Dissociative Disorders
    • Personality Disorders
    • Disruptive, Impulse Control, and Conduct Disorders
    • Utilization Management/Behavioral Healthcare
    • Consent Forms for Behavioral Healthcare
    • Behavioral Health Medical Records
    • Quality Management & Quality Improvement
    • Behavioral Healthcare Glossaries
    • Addenda
    • Bipolar Disorder and related disorders
    • Obsessive-Compulsive (OCD) and related disorders
    • Somatic Symptom and Related Disorders
    • Trauma- and Stressor-related Disorders

Managing Post-Acute Care and Other Extended Care Services

  • Comprehensive policies, procedures and plans for quality-based, cost effective management strategies and review criteria for post-acute care in a subacute unit, SNF, institution, hospice and/or the home under managed care contracts and Medicare.
  • Review criteria guidelines/benefit "interps".
  • Numerous forms and coverage information.
  • Extensive references.
  • Resources such as stroke, cardiac and pulmonary rehabilitation guidelines.
  • Table of Contents
    • Introduction
    • Post-Acute and Extended Care Requirements
    • Case or Care Management/Transitional Care Planning
    • Skilled Nursing Facility Care and Related Services
    • Defining Skilled Services
    • Managing Extended Care Services
    • Podiatry Services
    • Chiropractic Services
    • Inpatient Rehabilitation
    • Clinical Diagnoses for Rehabilitation - Criteria
    • Forms
    • Potpourri
    • Quality Assurance and Improvement
    • Home Healthcare
    • Hospice
    • Education-Related Guidelines
    • Length of Stay; MS-DRG Table
    • Abbreviations, Acronyms, Facilities
    • References and Resources
    • Stroke and Traumatic Brain Injury Rehabilitation
    • Cardiac Rehabilitation
    • Pulmonary Rehabilitation
    • CAD, PAD and Stroke: Preventive Health Care
    • Disposable Medical Supplies (DMS) and Durable Medical Equipment (DME)

Disease State Management Strategies I: Clinical Guidelines for Primary Care

  • Medical (asthma, COPD, diabetes, hypertension, smoking cessation, cardiovascular disease prevention, hormonal therapy) and obstetrical (LOS and the prevention of preterm deliveries) clinical guidelines plus “Wellness” or preventive healthcare standards by age and sex and Prevention of Stroke & CAD. Resources include related patient education, extensive references and web links.
  • Table of Contents
    • Introduction
    • Asthma - Ambulatory Care Management
    • Chronic Obstructive Pulmonary Disease
    • Diabetes mellitus
    • Coronary/Peripheral Artery Disease (CAD/PAD) and Stroke
    • Hormone Replacement Therapy (HRT)
    • Hypertension guideline
    • Obstetrical/Neonatal Length of Stay
    • Preterm Labor & Delivery - Prevention
    • Smoking/Tobacco Cessation Management
    • Heart Failure (HF)
    • Preventive Healthcare/Wellness Guidelines

Disease State Management Strategies II: Clinical Behavioral Health Guidelines

  • This popular behavioral health resource features detailed clinical guidelines for the effective management of common, costly disorders such as ADHD, Alzheimer’s disease, alcohol abuse or dependence, major depression, bipolar, obsessive-compulsive, anxiety/phobias/panic disorders including PTSD, personality, conduct and oppositional defiant disorders. References and resource materials plus websites follow each guideline.  The American Psychiatric Association DSM 5 diagnostic criteria is applied.
  • Table of Contents
    • Disease State Management for Behavioral Health - Introduction
    • Alzheimer's Disease & Other Dementias/Neurocognitive Disorders
    • Attention Deficit Hyperactivity Disorder (ADHD)
    • Alcohol, Substance Abuse and Dependency
    • Anxiety, Phobias and Panic Disorder
    • Bipolar Disorder
    • Major Depression
    • Disruptive, Impulse Control & Conduct Disorder
    • Obsessive-Compulsive Disorder (OCD)
    • Personality Disorders
    • Post-Traumatic Stress Disorder (PTSD)
    • Schizophrenia
    • Guidelines for the Evaluation of Mental Disorders due to General Medical Condition

Case or Care Management

  • Plans, policies, procedures and strategies that work to improve quality and efficiency of care while controlling costs for medical and mental health care.
  • This application is ideal for accreditation and quality improvement strategies.