Irr Testing 2012 Milliman care Guidelines

10 Questions | Total Attempts: 231

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Irr Testing 2012 Milliman care Guidelines

IRR Testing for Inpatient Case Managers


Questions and Answers
  • 1. 
    Case # 1:  79 year old female admitted through the Emergency Department complaining of fever, productive cough, and shortness of breath.  No past medical history.
    • Temp 103.1, respiratory rate 31 per minute, bilateral wheezes, BP 86/52, heart rate 130, chest x-ray positive for infiltrates
    • O2 sat 88% on room air
    • IV fluids started along with IV antibiotics after blood cultures drawn.  O2 started at 3 liters via nasal cannula.
    • Was seen in PCP's office last week for upper respiratory infection and was started on oral antibiotics.
    • Currently on day # 5 out of 7 of oral antibiotic therapy with no improvement of symptoms.
    Choose the correct Milliman Care Guideline for this case
    • A. 

      M-160: Febrile illness, without Focal infection

    • B. 

      M-60: Asthma

    • C. 

      OC-030: Pneumonia: Observation Care

    • D. 

      M-282: Pneumonia: Community Acquired

  • 2. 
    Case # 1:  According to the Clinical Indications for Admission to Inpatient Care,  M-282:  Pneumonia, Community Acquired which of the following clinical indications for admission does this patient meet?  Check all that apply
    • A. 

      Hemodynamic Instability

    • B. 

      Oxygen Saturation less than 90% while breathing room air

    • C. 

      Complicated pleural effusions (eg. exudative, loculated)

    • D. 

      All of the above

  • 3. 
    Case # 1:  According to the Clinical Indications for Admission to Inpatient Care, M-282:  Pneumonia, Community Acquired what is this patient's Pneumonia Severity Index (PSI) score? Tip:  Refer to Supplemental Materials
    • A. 

      107

    • B. 

      57

    • C. 

      119

    • D. 

      129

  • 4. 
    Case # 1:  What is the stated Goal Length of Stay for M-282; Pneumonia, Community Acquired?
    • A. 

      1 day

    • B. 

      4 days

    • C. 

      3 days

    • D. 

      Ambulatory or 2 days

  • 5. 
    Case # 2:  78 year old man  presented to the Emergency Department with history of urinary retention due to apparent neurogenic bladder.
    • This member was being followed in the outpatient setting and has failed outpatient treatment, including oral antibiotics and placement of an indwelling urinary catheter.
    • Complaining of one day history of right flank pain, nausea/vomiting, fever to a high of 103.8 degrees, and cloudy foul smelling urine.
    • In the ED, had fever of 103 degrees, right flank pain, vomiting, lighheadedness, and a blood pressure of 80/40.
    • Urinalysis contained many WBCs and bacteria.
    • Urine and blood cultures were obtained.
    • Multiple IV fluid boluses were required to get systolic BP over 100.
    • IV fluids were continued and antibiotics were started, with the patient admitted for further evaluation and treatment. 
    Choose the correct Milliman Care Guideline for this case
    • A. 

      M-123: Dehydration

    • B. 

      MG-SIC: Systemic or Infectious Condition GRG

    • C. 

      M-300: Pyelonephritis, Acute

    • D. 

      M-326: Renal Failure, Acute

  • 6. 
    According to the Clinical Indications for Admission to Inpatient Care M-300:  Pyelonephritis, Acute which of the following clinical indications for admission does this member meet? Check all that apply
    • A. 

      Hemodynamic Instability

    • B. 

      Immunocompromised State (eg. AIDS, Diabetes, Sickle Cell Disease)

    • C. 

      Outpatient Treatment has failed or is not feasible

    • D. 

      All of the above

  • 7. 
    What is the stated Goal Length of Stay for the Guideline M-300:  Pyelonephritis, Acute?
    • A. 

      Ambulatory or One Day

    • B. 

      Ambulatory or Two Days

    • C. 

      None of the Above

  • 8. 
    Case # 3 A 68 year-old male with history of DM was brought to the emergency department (ED) by his wife because of swelling of the right leg just below the knee. The patient received an insect bite 2 weeks ago.  Over the past 24 hours he developed increased itching and swelling to the site and developed a fever to T 102 degrees F (38.9 degrees C).
    • Past history: one admission in the past 12 months for CHF. 
    • Medications: metformin, glipizide, Toprol XL and Lasix. 
    • Diabetes well controlled Hgb A1c less than 7.0 over last year. 
    • BP 140/86, T 100.2 degrees F P 98, R 18 Weight: 186 pounds.
    • Patient is alert, oriented and does not require assistance with ADL’s. 
    • Edema, warmth, and tenderness to palpation were present over the proximal right tibia.
    • Laboratory findings: Hgb 11.8, WBC 5000, C-reactive protein (CRP) 14 mg/L, erythrocyte sedimentation rate (ESR) 20.
    • A plain x-ray and MRI of the right leg were normal . 
    • Blood cultures were obtained and intravenous (IV) ceftriaxone was started.
    • He was admitted to the Medical Floor with a diagnosis of cellulitis, hospital requesting inpatient admission.
    Choose the correct Milliman Care Guideline for this case
    • A. 

      M-70: Cellulitis

    • B. 

      MG-MD: Musculoskeletal disease, GRG

    • C. 

      OC-053: Venom Exposure from Bite or Sting: Observation Care

  • 9. 
    According to the Clinical Indications for Admission to Inpatient Care M-70:  Cellulitis which of the following clinical indications for admission does the member in case # 3 meet? Check all that apply
    • A. 

      High risk co-morbid condition

    • B. 

      Failure of outpatient therapy

    • C. 

      Hemodynamic instability

    • D. 

      None of the above

  • 10. 
    Indicate next action for Case # 3
    • A. 

      Approve inpatient request for admission

    • B. 

      Refer to the Medical Director for review

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