InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry
Overview Select Level of Care Intensive Outpatient Program (1, 2) Notes
InterQual® criteria (IQ) is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. IQ may contain advanced clinical knowledge which we recommend you discuss with your physician upon disclosure to you. Use permitted by and subject to license with Change Healthcare LLC and/or one of its subsidiaries. IQ reflects clinical interpretations and analyses and cannot alone either (a) resolve medical ambiguities of particular situations; or (b) provide the sole basis for definitive decisions. IQ is intended solely for use as screening guidelines with respect to medical appropriateness of healthcare services. All ultimate care decisions are strictly and solely the obligation and responsibility of your health care provider. © 2019 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved.
Overview
Informational Notes
The Adult and Geriatric Psychiatry Criteria are for the review of patients who are ages 18 and older.
InterQual® content contains numerous references to gender. Depending on the context, these references may refer to either genotypic or phenotypic gender. At the individual patient level, a variety of factors, including, but not limited to, gender identity and gender reassignment via surgery or hormonal manipulation, may affect the applicability of some InterQual criteria. This is most often the case with genetic testing and procedures that assume the presence of gender−specific anatomy. With these considerations in mind, all references to gender in InterQual have been reviewed and modified when appropriate. InterQual users should carefully consider issues related to patient genotype and anatomy, especially for transgender individuals, when appropriate.
InterQual® criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence−based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, American Psychological Association, American Society of Addiction Medicine, Centers for Medicare and Medicaid Services, Choosing Wisely, Cochrane Library, National Institute of Alcohol Abuse and Alcoholism, National Institute for Health and Care Excellence, National Institute on Drug Abuse, PubMed, Substance Abuse and Mental Health Services Administration, and other key medical societies. The Association of Ambulatory Behavioral Healthcare, Commission on Accreditation of Rehabilitation Facilities, and the Joint Commission were also searched. Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been utilized. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose−response gradient and the likely effect of plausible confounders.
Licensed for use exclusively by Beacon Health Page 1 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry INTENSIVE OUTPATIENT PROGRAM, One: (1, 2) Episode Day 1, All: Functional impairment, ≥ One: (3) Eating disorder, Both: (4) − Transfer from Residential Treatment Center within last week − Difficulty implementing healthy eating principles (4) Moderate in severity and change in baseline within last month, ≥ One: Impairment in primary role performance, ≥ One: − Absent 4 or more consecutive days from school or work (5, 6) − Placed on educational or employment performance plan and having difficulty meeting expectations − Self−employed and unable to meet work obligations − Suspended or placed on leave of absence from work or school − Unemployed or retired and unable to structure daytime hours Impairment in social relations, ≥ One: − Alleged perpetrator of abuse within last month − Arrest or protection order or restraining order due to domestic dispute − Increasing interpersonal conflict (7) − Increasing social alienation or isolation (8) − Precipitating stressful life event within last 3 months (9, 10) − Unable to perform IADLs and not chronic in nature Symptom severity increasing within last week and interfering with daily functioning, ≥ One: − Anxiety disorder and associated symptom (11, 12) − Assaultive or threatening within last 24 hours and able to prevent reoccurrence − Body dysmorphic disorder (13) − Compulsion (14) Co−occurring substance use disorder, ≥ One: (15) − High−risk sexual behaviors (16) − Increasing substance use and unable to apply skills to reduce or prevent use Substance free and high risk of relapse, ≥ One: − Decreased ability to utilize adequate coping strategies (17) − Decreased self−efficacy or motivation to remain abstinent (18) − Increase in individual relapse warning signs (19) − Loss of positive support system or recovery network (20) Distorted thinking, ≥ One: − Misinterpretation of interactions − Paranoia causing verbal or physical altercations with others (21) Depressive disorder or major depressive episode and associated symptom ≥ One: − Excessive or inappropriate guilt (22) − Feelings of worthlessness − Hopelessness − Impaired ability to make decisions − Loss of appetite with weight loss or lack of consistent weight gain − Overeating with persistent weight gain (23) − Psychomotor agitation or retardation (24) − Recurrent thoughts of death − Unable to think clearly or concentrate (25) Disruptive or impulse−control or conduct disorder and associated symptom, ≥ One: − Bullying or intimidating or threatening others − Deliberate or vindictive behavior damages property or harms others − Driving at excessive speeds − Fire setting to relieve tension without harm to self or others − Risky substance use − Shoplifting − Stalking − Stealing Eating disorder symptom, ≥ One: − Compulsive exercise daily or most days and persistent weight loss over last 2 weeks
Licensed for use exclusively by Beacon Health Page 2 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Food rituals and persistent weight loss over last 2 weeks (26) − Preoccupation with food or body or weight gain interferes with IADLs or interpersonal relationships − Purging behavior 1 to 2 times daily on most days (27) − Recent and continuing weight loss and weight greater than 85%(0.85) ideal body weight (28, 29) − Restricting or refusing food intake at one to two meals daily on most days and persistent weight loss over last 2 weeks Emotional dysregulation severe, ≥ One: Angry or impulsive outbursts at least 3 times per week in at least 2 different situations, ≥ One: (30, 31) − Physical outbursts (32) − Verbal outbursts − Extreme mood lability Fire setting history and risk of re−occurrence, ≥ One: − Increased preoccupation − Possession of fire setting material − Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause (33) − Hoarding that causes difficulty in maintaining a safe environment for self or others (34) − Homicidal thoughts increasing without intent or plan Hypomanic symptom, ≥ Two: − Decreased need for sleep − Distractibility (35) − Excessive involvement in activities with potential for negative consequences (36) − Flight of ideas (37) − Grandiosity (38) − Increased talkativeness − Inflated self−esteem − Pressured speech (39) − Increasing difficulty resisting urges to harm self − Nonsuicidal self−injury increasing in frequency or intensity (40, 41) − Obsessions (42) − Posttraumatic stress disorder and associated symptom (43) Psychotic symptom, ≥ One: − Delusions (44) − Disorganized speech or thinking (45) − Disorganized behavior (46) − Hallucinations (47) − Negative symptoms (48) − Sexually inappropriate (49) − Skin picking resulting in tissue damage or systemic infection not attributable to medical cause (50) − Suicidal thoughts increasing without intent or plan − Transportation available (51) Episode Day 2−24, One: Symptom improved and discharge expected today, One: (52) − Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (see Outpatient criteria) Symptom improving or expected to improve and not clinically stable for discharge, Both: Finding within last 5 authorized program days, Both: Functional impairment, ≥ One: − Absent at least one day per week from work or school (6, 53) − Deterioration in care of dependent children or vulnerable adults Difficulty implementing substance free living skills, ≥ One: − Persistent inability to apply effective coping skills in high risk situations (17) − Substance use and continued motivation (54) − Unable to ask for help or develop positive supports − Unable to disengage from substance abusing peer group − Easily frustrated − Increasing social isolation or alienation (8) Interpersonal conflict, ≥ One:
Licensed for use exclusively by Beacon Health Page 3 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Increasing verbal hostility − Accusatory or manipulative − Recurrent angry outbursts (30) − Persistent difficulty or decreased productivity at work or school − Stalking − Unable to concentrate and complete tasks Symptom, ≥ One: − Anxiety disorder and associated symptom (11, 12) − Assaultive or threatening within last 24 hours and able to prevent reoccurrence − Compulsions (14) Co−occurring substance use disorder, ≥ One: − High−risk sexual behaviors (16) − Increasing substance use and unable to apply skills to reduce or prevent use Substance free and high risk for substance use, ≥ One: − Decreased self−efficacy or motivation to remain abstinent (18) − Denying or refusing to discuss triggers or cravings − Drug glorification (55) − Drug−seeking (56) − Increased thoughts about using substance − Increased cravings or urges to use substance Intentionally putting self into triggering situations, ≥ One: − Going to places they used to drink or use − Spending time with people who drink or use − Not asking for help when needed − Overwhelming guilt or remorse or shame (57) − Preoccupation with using substances or past substance use and associated experiences (58) − Provoking arguments or alienating supports − Severe cravings Distorted thinking, ≥ One: − Misinterpretation of interactions − Paranoia causing verbal or physical altercations with others (21) Depressive disorder or major depressive episode and associated symptom, ≥ One: − Early morning awakening, difficulty falling asleep or middle of the night awakening and total hours slept decreasing − Excessive or inappropriate guilt (22) − Feelings of worthlessness − Hopelessness − Impaired ability to make decisions − Loss of appetite with weight loss or lack of consistent weight gain − Overeating with persistent weight gain (23) − Psychomotor agitation or retardation (24) − Recurrent thoughts of death − Unable to think clearly or concentrate (25) Disruptive or impulse−control or conduct disorder and associated symptom ≥ One: − Bullying or intimidating or threatening others − Deliberate or vindictive behavior damages property or harms others − Driving at excessive speeds − Fire setting to relieve tension without harm to self or others − Risky substance use − Shoplifting − Stalking − Stealing Eating disorder symptom, ≥ One: − Binge eating (59) − Compulsive exercise daily or most days and persistent weight loss over last 2 weeks − Food rituals and persistent weight loss over last 2 weeks (26) − Intense fear of weight gain or obesity
Licensed for use exclusively by Beacon Health Page 4 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Purging behavior 1 to 2 times daily on most days (27) − Recent and continuing weight loss and weight greater than 85%(0.85) ideal body weight (28, 29) − Restricting or refusing food intake at 1 to 2 meals daily on most days and persistent weight loss over last 2 weeks Emotional dysregulation severe, ≥ One: Angry or impulsive outbursts at least 3 times per week in at least 2 different situations, ≥ One: (31) − Physical outbursts − Verbal outbursts − Extreme mood lability Fire setting history and risk of re−occurrence, ≥ One: − Increased preoccupation − Possession of fire setting material − Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause (33) − Hoarding that causes difficulty in maintaining a safe environment for self or others (34) Hypomanic symptom, ≥ One: − Decreased need for sleep − Distractibility (35) − Excessive involvement in activities with potential for negative consequences (36) − Flight of ideas (37) − Grandiosity (38) − Increased talkativeness − Inflated self−esteem − Pressured speech (39) − Increasing difficulty resisting urges to harm self − Nonsuicidal self−injury increasing in frequency or intensity (40, 41) − Obsessions (42) − Posttraumatic stress disorder and associated symptom (43) Psychotic symptom, ≥ One: − Delusions (44) − Disorganized speech or thinking (45) − Disorganized behavior (46) − Hallucinations (47) − Negative symptoms (48) − Sexually inappropriate (49) − Skin picking resulting in tissue damage or systemic infection not attributable to medical cause (50) Intervention, All: − Goal−directed treatment plan (60) − Individual or group or family therapy at least 2 times per week − Psychoeducation (61) − Skills development training (62) Symptom worsening and more intensive level of care indicated, One: (63) − Acute danger to self or others or gravely disabled and requiring nursing observation and psychiatrist availability 24 hours per day (see Inpatient criteria) (64) − Co−occurring substance use disorder and withdrawal syndrome severe or life threatening (see InterQual® Substance Use Disorders Inpatient Detoxification criteria) Exacerbation of severe symptoms and agrees to voluntary admission (see Residential Crisis Program criteria), All: − Does not require services of an acute inpatient − Requires 24 hour per day clinical monitoring − Severe and persistent mental illness or autism spectrum disorder or intellectual disability Eating disorder symptom severe (see Residential Treatment Center criteria), Both: − Requires intensive structure treatment and medical monitoring to prevent further deterioration in condition − Treatment not expected to be successful in less intensive level of care Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support, One: − Unable to be safely and effectively managed within the community (see Residential Treatment Center criteria) Licensed for use exclusively by Beacon Health Page 5 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Unable to live independently and high risk of harm to self or others without intensive supervision within the community (see Supervised Living criteria) Patient requires structured program and skilled clinical assessment at least 5 days per week (see Partial Hospital Program criteria), All: − High risk of rehospitalization − Support able to provide monitoring or assistance during non−program hours − Symptoms severe (65) Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Day Treatment Program criteria), ≥ One: − Able to live within the community − In need of ADL or IADL or vocational training − In lieu of residential based care or patient homebound and requires skilled nursing care or assessment at least 1 time per week (see Home Care criteria) Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Intensive Community−Based Treatment criteria), Both: − Able to live within community − Unable to perform IADLs without assistance Episode Day 25−X, Extended Stay, One: Symptom improved and discharge expected today, One: (52) − Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (see Outpatient criteria) Symptom improving or expected to improve and not clinically stable for discharge, Both: Finding within last 5 authorized program days, Both: Functional impairment, ≥ One: − Absent at least one day per week from work or school (6, 53) − Deterioration in care of dependent children or vulnerable adults Difficulty implementing substance free living skills, ≥ One: − Persistent inability to apply effective coping skills in high risk situations (17) − Substance use and continued motivation (54) − Unable to ask for help or develop positive supports − Unable to disengage from substance abusing peer group − Easily frustrated − Increasing social isolation or alienation (8) Interpersonal conflict, ≥ One: − Increasing verbal hostility − Accusatory or manipulative − Recurrent angry outbursts (30) − Persistent difficulty or decreased productivity at work or school − Stalking − Unable to concentrate and complete tasks Symptom, ≥ One: − Anxiety disorder and associated symptom (11, 12) − Assaultive or threatening within last 24 hours and able to prevent reoccurrence − Compulsions (14) Co−occurring substance use disorder, ≥ One: − High−risk sexual behaviors (16) − Increasing substance use and unable to apply skills to reduce or prevent use Substance free and high risk for substance use, ≥ One: − Decreased self−efficacy or motivation to remain abstinent (18) − Denying or refusing to discuss triggers or cravings − Drug glorification (55) − Drug−seeking (56) − Increased thoughts about using substance − Increased cravings or urges to use substance Intentionally putting self into triggering situations, ≥ One: − Going to places they used to drink or use − Spending time with people who drink or use
Licensed for use exclusively by Beacon Health Page 6 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Not asking for help when needed − Overwhelming guilt or remorse or shame (57) − Preoccupation with using substances or past substance use and associated experiences (58) − Provoking arguments or alienating supports − Severe cravings Distorted thinking, ≥ One: − Misinterpretation of interactions − Paranoia causing verbal or physical altercations with others (21) Depressive disorder or major depressive episode and associated symptom, ≥ One: − Early morning awakening, difficulty falling asleep or middle of the night awakening and total hours slept decreasing − Excessive or inappropriate guilt (22) − Feelings of worthlessness − Hopelessness − Impaired ability to make decisions − Loss of appetite with weight loss or lack of consistent weight gain − Overeating with persistent weight gain (23) − Psychomotor agitation or retardation (24) − Recurrent thoughts of death − Unable to think clearly or concentrate (25) Disruptive or impulse−control or conduct disorder and associated symptom ≥ One: − Bullying or intimidating or threatening others − Deliberate or vindictive behavior damages property or harms others − Driving at excessive speeds − Fire setting to relieve tension without harm to self or others − Risky substance use − Shoplifting − Stalking − Stealing Eating disorder symptom, ≥ One: − Binge eating (59) − Compulsive exercise daily or most days and persistent weight loss over last 2 weeks − Food rituals and persistent weight loss over last 2 weeks (26) − Intense fear of weight gain or obesity − Purging behavior 1 to 2 times daily on most days (27) − Recent and continuing weight loss and weight greater than 85%(0.85) ideal body weight (28, 29) − Restricting or refusing food intake at 1 to 2 meals daily on most days and persistent weight loss over last 2 weeks Emotional dysregulation severe, ≥ One: Angry or impulsive outbursts at least 3 times per week in at least 2 different situations, ≥ One: (31) − Physical outbursts − Verbal outbursts − Extreme mood lability Fire setting history and risk of re−occurrence, ≥ One: − Increased preoccupation − Possession of fire setting material − Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause (33) − Hoarding that causes difficulty in maintaining a safe environment for self or others (34) Hypomanic symptom, ≥ One: − Decreased need for sleep − Distractibility (35) − Excessive involvement in activities with potential for negative consequences (36) − Flight of ideas (37) − Grandiosity (38) − Increased talkativeness − Inflated self−esteem − Pressured speech (39)
Licensed for use exclusively by Beacon Health Page 7 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Increasing difficulty resisting urges to harm self − Nonsuicidal self−injury increasing in frequency or intensity (40, 41) − Obsessions (42) − Posttraumatic stress disorder and associated symptom (43) Psychotic symptom, ≥ One: − Delusions (44) − Disorganized speech or thinking (45) − Disorganized behavior (46) − Hallucinations (47) − Negative symptoms (48) − Sexually inappropriate (49) − Skin picking resulting in tissue damage or systemic infection not attributable to medical cause (50) Intervention, All: − Goal−directed treatment plan (60) − Individual or group or family therapy at least 2 times per week − Psychoeducation (61) − Skills development training (62) Symptom worsening and more intensive level of care indicated, One: (63) − Acute danger to self or others or gravely disabled and requiring nursing observation and psychiatrist availability 24 hours per day (see Inpatient criteria) (64) − Co−occurring substance use disorder and withdrawal syndrome severe or life threatening (see InterQual® Substance Use Disorders Inpatient Detoxification criteria) Exacerbation of severe symptoms and agrees to voluntary admission (see Residential Crisis Program criteria), All: − Does not require services of an acute inpatient − Requires 24 hour per day clinical monitoring − Severe and persistent mental illness or autism spectrum disorder or intellectual disability Eating disorder symptom severe (see Residential Treatment Center criteria), Both: − Requires intensive structure treatment and medical monitoring to prevent further deterioration in condition − Treatment not expected to be successful in less intensive level of care Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support, One: − Unable to be safely and effectively managed within the community (see Residential Treatment Center criteria) − Unable to live independently and high risk of harm to self or others without intensive supervision within the community (see Supervised Living criteria) Patient requires structured program and skilled clinical assessment at least 5 days per week (see Partial Hospital Program criteria), All: − High risk of rehospitalization − Support able to provide monitoring or assistance during non−program hours − Symptoms severe (65) Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Day Treatment Program criteria), ≥ One: − Able to live within the community − In need of ADL or IADL or vocational training − In lieu of residential based care or patient homebound and requires skilled nursing care or assessment at least 1 time per week (see Home Care criteria) Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Intensive Community−Based Treatment criteria), Both: − Able to live within community − Unable to perform IADLs without assistance
Licensed for use exclusively by Beacon Health Page 8 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry Notes:
1: Introduction The Intensive Outpatient Program criteria are used for a patient who has been admitted or is expected to be admitted to an Intensive Outpatient Program. An Intensive Outpatient Program (IOP) is a time−limited, separate and distinct ambulatory program (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015) that includes a scheduled series of sessions appropriate to the individual treatment plan of a patient. The program is offered in the day or evening hours and can be a step−down from a more restrictive level of care or a step−up to prevent need for a more restrictive level of treatment (The Commission on Accreditation of Rehabilitation Facilities, Behavioral Health Standards Manual. 2017). The goals of IOP are to prevent or reduce the need for inpatient hospitalization and to reduce or stabilize symptoms and functional impairment of a psychiatric or co−occurring substance use disorder. Medically necessary treatment is provided within a structured therapeutic milieu (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015). Evaluation and treatment Programming may differ based upon legislative and geographical variances and is subject to organizational policy; however, at a minimum it should include: • Care coordination with other care providers and social services (American Psychiatric Association, Am J Psychiatry 2007, 164(7 Suppl): 5−53; American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222) • Individual or group or family therapy at least two times per week (The Commission on Accreditation of Rehabilitation Facilities, Behavioral Health Standards Manual. 2017). • Medication reconciliation initiated within first visit • Programming for 9 or more contact hours per week (The Commission on Accreditation of Rehabilitation Facilities, Behavioral Health Standards Manual. 2017) • Psychiatric or medication evaluation as needed • Psychosocial assessment within first visit • Substance evaluation within first 2 visits • Toxicology screen, self−help, 12−step, education group as needed (may be patient or family education group)
2: Active attendance and participation are necessary for an individual to benefit from treatment (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015).
3: An intensive outpatient program is appropriate for an individual with marked functional impairment in multiple areas of daily life (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015).
4: Integration of healthy eating principles requires a modification in the patient's thinking regarding choices or situations in order to maintain a therapeutic body weight and to remain medically stable. Examples include avoiding a high carbohydrate diet that includes large portions of refined sugars and restructuring daily activities to avoid isolation and the opportunity to engage in excess eating, binging, or purging behaviors when bored or stressed.
5: Excused absences (e.g., MD appointment, job interview, influenza) should not be included when calculating the percentage of program attendance.
6: Absent from school refers to missing the entire day, not just a few classes within a day.
Licensed for use exclusively by Beacon Health Page 9 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry 7: Interpersonal conflict may include bullying, verbal abusiveness, taunting, or argumentative behaviors.
8: Social isolation or alienation refers to a noticeable decrease in a patient's interactions with others or a patient's feeling outcast. Others may notice increased social isolation by the patient or a patient may describe not "fitting in" although he/she appears to be socially engaged with friends, family, and activities.
9: A precipitating life event can include a change in lifestyle or living situation, death of a loved one, or change in an academic or professional situation (e.g., divorce, separation, marriage, birth of child, moving, job change, entering college).
10: A stressful life event may be a contributor to symptom relapse in individuals with schizophrenia (American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition. 2006; p. 565−762.)
11: Anxiety is an emotion that can become clinically significant when nervousness, dread, apprehension, or fear produces significant pain or impairment, or cannot be managed effectively.
12: In addition to subjective feelings of nervousness or anxiousness, other somatic, behavioral, and psychological symptoms can be associated with anxiety: • Behavioral symptoms include disturbed sleep, nightmares, acting "keyed up" or "on edge," and avoiding feared situations or objects. • Psychological symptoms include depersonalization (feeling unreal); derealization (feeling that the world is unreal); fear of "going crazy," losing control, or dying; and difficulty concentrating. • Somatic symptoms include palpitations (a pounding or accelerated heart rate); sweating, trembling, shaking, chills, or hot flashes; the sensation of shortness of breath, smothering, or choking; chest pain or discomfort; headache; nausea, vomiting, stomach aches, or other abdominal distress; diarrhea; urinary frequency; dizziness; paresthesia; or muscle tension. Reference (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013)
13: A patient with body dysmorphic disorder believes that their physical appearance is flawed. These flaws are barely noticeable, if at all seen, by others. The patient often engages in rituals, both mental and physical, to lessen distress. Examples of such rituals include, but are not limited to, body checking, asking for reassurance, body comparisons, mirror checking and excessive grooming (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).
14: Compulsions are repetitive physical acts (e.g., hand washing, ordering, checking under bed, checking locks on door) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform to prevent or reduce distress or to prevent some dreaded event or situation.
15: Substance use may be a contributor to symptom relapse in individuals with schizophrenia (American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition. 2006; p. 565−762.).
16: High−risk sexual activity may include unprotected sexual contact with individuals who may be IV drug users or HIV
Licensed for use exclusively by Beacon Health Page 10 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry positive; sexual contact with strangers or prostitutes; or multiple unprotected sexual contacts.
17: An individual who has decreased or difficulty applying adequate coping skills may be unable to apply skills including, but not limited to, distraction, relaxation, self−assertion, imagery, avoidance, good problem−solving or refusal skills, use of support systems, conflict resolution, and anger management.
18: Self−efficacy is a person's belief in his or her ability to mobilize the motivation, cognitive resources, and courses of action needed to exercise control over environmental demands. A decrease in self−efficacy refers to an individual's decreased belief in his or her ability to remain abstinent.
19: Individual relapse warning signs are specific to each patient. They consist of behaviors or thoughts that the patient identifies as possible precipitants to relapse. Examples include, but are not limited to, driving by the liquor store the patient used to go to; hanging out with friends who have abused substances with; going into bars to "test themselves"; and starting an argument with their significant other as an excuse to use substances. These warning signs should be documented in the medical record based on the evaluation of the patient, and are often found in the substance evaluation, psychosocial assessment, or presenting symptoms sections of the record (Copeland, Action planning for prevention and recovery. 2002).
20: Support system includes social, emotional, caregiving, or environmental resources that can provide empathy, structure, oversight, or tangible aids such as goods, services, and housing: • Formal supports consist of social welfare, social service, and health care providers or agencies. • Informal supports include family, friends, educators, clergy, sponsors, church groups, neighborhood organizations, clubs, and self−help groups.
21: Paranoia refers to extreme suspiciousness or the false belief that one is being harassed, harmed, persecuted, or unfairly treated. Paranoid individuals may interpret the environment as being hostile when it is not. Examples of paranoia are fear of poisoning, concerns that one is being followed by or investigated by the police, and concerns that staff members may be agents of the devil. If these thoughts evolve into beliefs that are fixed and the patient does not respond to rational explanations, these thoughts qualify as delusions.
22: Inappropriate guilt is when a person assumes blame for negative events or circumstances for which the patient has no responsibility.
23: A change in appetite is a common symptom of depression that typically manifests as a loss of appetite, or less commonly as an increased appetite with cravings for fats or sugars.
24: Psychomotor agitation refers to excessive motor activity in association with an inner feeling of tension. The activity is usually repetitive and non−productive (e.g., pacing, fidgeting, wringing of hands, and the inability to sit still). Psychomotor retardation refers to a generalized and excessive slowing of movement and speech.
25: Unable to think clearly or concentrate refers to the patient's inability to focus attention or to be goal−directed.
26: Rituals formed around food and eating are common in individuals with eating disorders and examples include, but are not limited to, excessive chewing but refusal to swallow food, cutting food into excessively small pieces, hoarding of food, excessive food preparation for others, and food ingestion in a particular manner or pattern.
Licensed for use exclusively by Beacon Health Page 11 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry
27: Purging refers to the methods patients with eating disorders use to rid themselves of food that has been ingested. Such methods include, but are not limited to, use of diuretics, laxatives, and enemas or self−induced vomiting.
28: Ideal body weight (IBW) is a weight that is believed to be the maximum healthy weight for a person. It is based primarily on height, but can be modified by factors such as gender, age, body build, and degree of muscular development. No single formula for calculating IBW is universally employed. Multiple calculators of IBW can be found online which calculate IBW based on just height, or based on height, age, and gender. Utilizing the same calculation for all cases will ensure consistent application of the criteria. Organizational policy determines which calculation should be used to determine IBW.
29: Evidence in the medical literature to support the effectiveness of this intervention or service is mixed or unclear. The criteria point reflects current best evidence and practice. It is the product of a peer review process involving multiple clinicians with diverse expertise in varied practice and geographic settings.
30: Angry outbursts can include, but are not limited to, punching a fist into the wall, throwing or smashing items, or tantrums of yelling and screaming.
31: At least two different situations would include school, home, work, or with peers.
32: An examples of physical outbursts include, but are not limited to, kicking, punching, hitting, burning, and other physical acts of aggression.
33: Hair pulling disorder is also known as trichotillomania (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).
34: Hoarding that causes difficulty in maintaining a safe environment for self or others implies that the patients active living areas such as the kitchen, bathroom, or bedroom cannot be used without putting forth a deal of effort to move the clutter caused by excessive acquisition or collection of items. Clutter prevents access and/or substantially diminishes usability of active living areas. The clutter may be stacked in unstable piles that pose risk of falling and blocking pathways. In the case of an emergency, the patient may have difficulty exiting his/her home due to obstructed or blocked exit ways or doors. Clutter may become a potential fire hazard (e.g. if located near electrical outlets, lights, heating units, stoves or ovens) or may become a health safety risk (i.e. if the patient chooses to hoard food items, used food containers, or if the patients home becomes infested with insects or rodents). In some cases, there may be legal action taken against the patient as their residence is not only unsafe to themselves but also to those around them.
35: Distractibility refers to the inability to sustain attention. The patient's attention shifts quickly, with little apparent reason, from one topic to another, or the patient is attracted to irrelevant and trivial stimuli in the environment.
36: Patients who are manic or hypomanic may exhibit an inability to control their pursuit of, or involvement in, activities despite the potential for significant negative consequences. Behaviors often include excessive overspending (e.g., shopping sprees or large purchases), stealing, random sexual liaisons or extended sexual encounters with single or multiple partners, or exercising to the point of total exhaustion.
Licensed for use exclusively by Beacon Health Page 12 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry
37: Flight of ideas refers to racing thoughts punctuated by abrupt changes from topic to topic. Frequently, speech becomes disorganized and incoherent.
38: Grandiosity refers to the inflated sense of one's own value, power, knowledge, abilities, identity, or importance.
39: Pressured speech is an increase in the amount, speed, or volume of a patient's speech. It is often difficult for the listener to interrupt or for the patient to stop speaking. The patient may often speak without purpose or in the absence of a listener.
40: Nonsuicidal self−injury is the intentional damaging of any part of one's body (e.g., cutting or burning the skin) without suicidal intent.
41: An increase in the intensity of a patient's self−injury may be evidenced by the making of progressively deeper cuts, more extensive self−injury, or injuring the genitalia. Cuts to the neck or face are significant indicators of increasing pathology.
42: Obsessions are persistent, recurrent urges, thoughts, or images which the individual attempts to ignore or defuse by doing some other action such as counting, repetitive handwashing, or pacing (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).
43: Symptoms associated with posttraumatic stress disorder cause significant distress or impairment in functioning and may include, but are not limited to: • Avoidance of memories, thoughts, feelings, people, places, objects, or activities that are reminders of the trauma • Changes in thoughts or mood associated with the traumatic event including difficulty remembering aspects of the trauma, or persistent negative emotions such as fear, anger, guilt, and/or shame • Dissociative symptoms, including depersonalization (feeling detached from one's body or thoughts and being an outside observer looking in) or derealization (feeling that the world is unreal) • Emotional numbing, including suppression of positive affective responses such as feeling happy, feeling loved, or experiencing affection; loss of interest in things previously enjoyed; increased sensitivity to negative events or emotions; feeling detached or estranged from others • Increased arousal, including hypervigilance or having an exaggerated startle response • More extreme reactivity, including an increase in irritability; sleep or concentration disturbance; aggression; violence; or self−destructive or reckless behavior • Re−experiencing the trauma in the form of flashbacks, intrusive memories, or dreams Reference (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013)
44: Delusions are false beliefs that do not conform to reality and are not affected by clear evidence to the contrary.
45: Disorganized thinking is evident when the listener cannot understand how or why the patient has moved from one topic to the next. There is little or no meaningful relationship between ideas, topics, or themes. This can range from being "derailed" or "off−track" to tangential or incoherent speech. Speech is not only evaluated for coherence but for rate, volume, and pressure.
46:
Licensed for use exclusively by Beacon Health Page 13 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry Disorganized behavior refers to non−goal−directed or purposeless behavior including, but not limited to, aimlessness, inability to start or complete a task, or sequencing problems.
47: A hallucination is a sensory perception that occurs without external stimulation of the sensory organ (e.g., vision, hearing, touch, taste, smell). Patients may or may not be able to distinguish between the hallucination and reality. Types of hallucinations are: • Auditory: a false perception of sound, typically voices that are experienced as coming from either inside or outside of one's head and are different from one's own thoughts. Command hallucinations consist of a false perception of a voice telling the patient to do something, typically destructive to oneself or others • Gustatory: a false perception of taste, usually unpleasant • Olfactory: a false perception of smell, usually unpleasant • Somatic: a false perception of a physical experience within the body • Tactile: a false perception of being touched or of something on or under the skin (e.g., bugs crawling) • Visual: falsely perceived images, either formed (e.g., people) or unformed (e.g., flashes of light)
48: Negative symptoms may include: • Alogia, or lack of thoughts or words (often referred to as poverty of speech) • Anhedonia, a lack of enjoyment in activities previously found pleasurable • Apathy, which refers to a lack of motivation, restricted emotional and cognitive engagement, and diminished purposeful behavior • Asociality, which refers to a lack of interest in social interactions • Avolition, which refers to the inability to initiate or sustain goal−directed activity • Decreased range and intensity of emotional expression
49: Sexually inappropriate behavior can include, but is not limited to, public sexual exposure (including masturbation), attempts to seduce or violate others through sexual rubbing or touching, inappropriate sexual remarks, or requests to have others touch them or perform sexual acts on them.
50: Skin picking disorder is also known as excoriation disorder (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).
51: Available transportation includes either the patient's ability to drive, walk, or access public transportation to come to treatment or the ability of family, friends, or the treatment facility to transport the patient.
52: Selection of this criteria point indicates that the patient is responding to treatment and is clinically stable for discharge to an alternate level of care. To determine the most appropriate level of care go to the recommended level of care.
53: Absences are due to psychiatric symptoms and are not related to physical illness (e.g., influenza).
54: Continued motivation refers to the individual's willingness to continue and comply with treatment in order to stop using substances. Motivation can be determined by the individual's purposeful positive−directed behaviors to become substance free.
55: Drug glorification refers to ascribing positive attributes to drug usage (e.g., associating creativity and productivity with drug use or believing drug use is the route to enlightenment).
Licensed for use exclusively by Beacon Health Page 14 of 15
InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry
56: Drug−seeking behavior in or out of a program can include asking for PRN medications frequently, frequent somatic complaints, stealing, lying, manipulating, dealing, and swapping sexual favors for drugs. Patients in a program may feign a medical condition to procure medication.
57: Overwhelming guilt, remorse, or shame can be a profound emotional response in a patient when the patient has finally accepted their addiction, the consequences of their past behavior, and the impact this has had on family, friends, career, and other aspects of life important to the patient.
58: Patients preoccupied with substance use may replicate certain behaviors such as making pipes out of common items (e.g., a pen, toilet paper tubing), rolling cigarettes as they would a joint, or playing with sugar as though they were cutting cocaine into lines.
59: Binge eating refers to the consumption of an amount of food that is significantly larger than most people would eat during a similar time period under similar circumstances.
60: A goal−directed treatment plan refers to a short−term plan that focuses on identifiable problems or stressors. It is time−oriented and has measurable outcomes.
61: Psychoeducation refers to teaching an individual or family about the symptoms, treatments, and prognosis of the disorder (Zhao et al., The Cochrane database of systematic reviews 2015, 4: CD010823).
62: Skills development training refers to the process of identifying skill gaps and educating on methods to improve them. These may include, but are not limited to, communication, coping, interpersonal abilities, problem solving, school, social interactions.
63: Selection of this criteria point indicates that the patient's symptom is worsening and may require a more intensive level of care. To determine the most appropriate level of care go to the recommended level of care.
64: Gravely disabled is a term that generally refers to an individual who, as a result of a psychiatric or substance use disorder, is in acute danger of serious physical harm due to an inability or failure to provide the essential human needs of food, clothing, shelter, and essential medical care. The individual lacks the capacity to make an informed decision concerning his/her need for treatment and lacks the support to provide needed care. Gravely disabled is a term most often used for the emergency involuntary commitment of an individual to an inpatient unit and the definition of gravely disabled may differ based on legislative and geographical variances.
65: Symptom severity refers to the DSM−5 level of severity rating (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).
Licensed for use exclusively by Beacon Health Page 15 of 15