Which tools are commonly used to determine the appropriate level of care for newly hospitalized patients?

• A. MCG
• B. InterQual (McKesson)
• C. Centers for Medicare & Medicaid Services National Coverage Database
• D. MCG, InterQual (McKesson), and CMS National Coverage Database

Answer: (D)

The key idea is using standardized criteria to decide how intensively a patient needs to be managed and where they should receive care. Two widely used clinical decision tools—MCG and InterQual—provide structured criteria that help clinicians and utilization teams determine whether a patient requires inpatient admission, can be managed in observation, or may be eligible for discharge planning. They look at the patient’s condition, required level of monitoring and services, and risk of deterioration, offering consistent guidance across cases.

The CMS National Coverage Database adds the payer perspective by documenting national coverage determinations that define when services are considered medically necessary under Medicare. These rules influence what level of care is reimbursable and appropriate under those programs, shaping decisions about admission and treatment in ways that align with coverage policy.

Using all three together gives a hospital a robust, defensible framework: MCG and InterQual provide clinical appropriateness criteria for the level of care, while the CMS National Coverage Database aligns those decisions with payer requirements. This combination is why the best choice includes all three resources.