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Perspectives from the Physician Reviewer

Perspectives from the Physician Reviewer. Jessica Whitley , MD, MBA, C-CDI. Objectives. Understand the role and qualifications of QIO physician peer reviews Explore the way in which a physician approaches chart review using a case study

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Perspectives from the Physician Reviewer

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  1. Perspectives from the Physician Reviewer Jessica Whitley, MD, MBA, C-CDI

  2. Objectives • Understand the role and qualifications of QIO physician peer reviews • Explore the way in which a physician approaches chart review using a case study • Review the diagnostic findings that should be present for case relevant diagnoses DocuComp LLC 2011

  3. Required Qualifications Physician Reviewers • Eligibility Requirements - A physician reviewer must be a board-certified doctor • Active Practice Requirements – A physician reviewer must either be engaged in active practice • Licensure Requirements – Generally, the physician reviewer must have the same licensure (current and unrestricted) as the physician whose services are under review.

  4. Physician Reviewer Responsibilities • The basic concept of the QIO medical review program is physician peer review of medical and hospital care to assure that: • Hospital admission and services provided are medically necessary and appropriate;  • The quality of care meets professionally recognized standards; • Services are provided in a setting or facility which is best suited to the patient’s needs; and, • The diagnostic and procedural information submitted for payment is validated in the medical record. 4

  5. Screening Criteria Used by Non-Physician Reviewers Ohio KePro • McKesson InterQual criteria which is updated annually • QIO-developed quality screens • CMS coverage guidelines • Published CMS criteria (e.g., rehabilitation criteria in the Medicare Intermediary Manual (MIM) • DRG validation guidelines • Coding guidelines • QIO-developed documentation guidelines • Other screens, criteria, and guidelines (e.g. practice guidelines that are well accepted by the medical community)

  6. Screening Criteria used by Physician Reviewers • Unlike the non-physician reviewer, the physician reviewer is not bound by criteria. The physician uses subjective medical judgment based on his/her clinical experience of what is medically necessary and what is adequate quality of care.

  7. Review of Cholecystitis • Symptoms: RUQ or epigastrium pain, fever, RUQ tenderness • Diagnosis: should be suspected with classic symptoms in addition to the finding of gallstones on imaging, and leukocytosis • Imaging: • Ultrasound with gallstones, gallbladder wall thickening or edema, sonographic “Murphy’s sign” • Cholescintigraphy/HIDA scan- indicated if the diagnosis remains uncertain following ultrasound-visualization of contrast within the common bile duct, gallbladder and small bowel within 30 to 60 minutes. The test is positive if the gallbladder does not visualize • CT scan: can easily demonstrate gallstones/gallbladder wall edema • Treatment: IVF, pain meds, NPO status, usually antibiotic therapy, surgery 8

  8. Systemic Inflammatory Response Syndrome 9

  9. Questions?

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