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Kentucky Case-Mix Classification, Accuracy, Documentation, and Management

PART 11

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Objectives

1. Understand RUG Grouper Reimbursement Model & classification method

2. Review RUG conditions & services for each category group and pertinent to therapy

3. Discuss rehabilitation and restorative program criteria & utilization 4. Review supporting documentation guidelines 5. Identify best practices for accurate case mix reimbursement

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General Concepts of Time-Weighted Methodology

Generated MDS CMI # of Days

Average Weight

CMI

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Calculation of Days

• Includes Day of Admission – Not discharge

• Count 1st Day of Quarter Until:– ARD of next assessment– End of quarter or– Until discharge

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Missing Assessment Report

• OBRA target date > 138 days prior. – Other than discharge or death record

• No OBRA record submitted for current episode >60 days prior• Default rate=

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Missing Assessment Report

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Time Weighted: Determination of Payer Source

Medicare

•PPS assessment & no Medicaid # entered in A0700

Medicaid

•Medicaid# entered or + for pending in A0700

Other

•Non-PPS assessment•No valid Medicaid

number in A0700•NOT Medicaid

Pending+

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Index Maximizing Classification

RUG CMI

RAA 1.21

SSA 1.41

• Designated Case-Mix Indices (CMI) for each RUG Group

• Placed into Only 1 Case-mix Class• 1st zstep: RUG Group(s)

Qualifications• Choose the RUG Group with

Highest CMI

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Resident Roster Example

A complete list of the Item Set Codes can be found in the RAI Manual in Chapter 2.

1.61

1.61

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Resident Roster Summary Page

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MDS Calendar Quarter & Posting Schedule

Report Type

MDS Calendar Quarter

January 1 toMarch 31

April 1 toJune 30

July 1 toSeptember 30

October 1 toDecember 31

First Preliminary April 29 July 30 October 30 January 30

Second Preliminary May 31 August 31 November 30 February 28

Final July 29 October 29 January 29 April 28

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Final ValidationReport

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Review Roster for Errors

• Payer Source• Correct Assessment Type• Missing Assessments• Changes with or incorrect RUG• Default Days

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Rate Periods

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RUG-III 34 Grouper Reimbursement Models

Extensive Services

Rehabilitation

Special Care

Clinically Complex

Impaired Cognition

Behavioral Problem

Reduced Physical Function

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ADL Assistance

CONSIDERATIONS: • Variations by shift, within shifts or day to day• All activities 24 hours a day• Accurate documentation = true amount of

staff time & resources required to care for the resident

• Includes direct care observed/reported by others & staff including contract/agency staff

• Double-check accuracy of software• EDUCATE, EDUCATE, EDUCATE• Consider review of one ADL topic a week in

Daily Huddle Meetings

PURPOSE: • Document and communicate the

patient’s functional status• Track progress or decline in

function• Allows for accurate care plans• Allows appropriate

reimbursement for the care you are providing.

• Helps determine staffing levels

Section K ADL Score

K0510A. Parental/IV feeding while/while not a resident

=3 OR

K0510B. Feeding tube while/while not a resident & K0710A3. Total calories 51% or more

=3 OR

K0510B. Feeding tube while/while not a resident & K0710A3. Total calories 26-50% + K710B3. 501cc/day or more average fluid intake

=3

Step 1: Sum of Bed Mobility, Transfer & Toilet Use Step 2: Eating: If no parental/IV or feeding tube, return to G0110H.Total ADL Score= Sum of Step #1 + Step #2

Calculation of ADL Score

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Phase Out of Section G from MDS

• CMS Allowed States the Option to Collect Section GG Items – For accurate comparison RUGs vs. PDPM – Development of crosswalk from Section G to GG– For development of more accurate payment weights to better

measure acuity levels

RUG-III 34 Grouper

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Rapid RUG Guide

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Extensive Services Count Special Treatments, Procedures, or Programs Count

Parental/IV while/while not a resident in last 7 days 1

Suctioning while/while not a resident in last 14 days 0

Tracheostomy care while/while not a resident in last 14 days 0

IV medication while/while not a resident in last 14 days 1

Sum of Extensive Services Count 0-2

Evaluate for special care, clinically complex or impaired cognition No match=0For each matching=1

Total Extensive Services Count 0-5

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Extensive Services Count

Classification Total Extensive Services Count

ADL Score CMI

SE3 4 or 5 7-18 2.35

SE2 2 or 3 7-18

1.91

SE1 0 or 17-18

1.63

If ADL score <7=Special Care

Parental/IV Feeding

The following fluids may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need.7-day Reference Period

When to Code: • ACTIVE diagnosis of dehydration must be present in

order to code• IV fluids or hyperalimentation, including total parenteral

nutrition (TPN), administered continuously or intermittently

• IV fluids running at KVO • IV fluids contained in IV Piggybacks• Hypodermoclysis and subcutaneous ports in hydration

therapy• IV fluids to prevent dehydrationWhen not to Code:

– Fluids used for reconstitution/dilution– Part of routine operation or procedure or recovery room– IVs given during chemo– IV medications– Additives: electrolytes & insulin (IV meds)

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Other Extensive Services

• Suctioning– Tracheal and/or

nasopharyngeal suctioning– NOT oral suctioning– Code if resident performs

• Tracheostomy Care – Cleansing of the tracheostomy

and/or cannula– Code if resident performs

IV Medications

• Biological or Drug Given By:– IV push– Epidural – Intrathecal – Baclofen pumps – Drip via central line or peripheral

line

• Do Not Code: – Flushes for patency or IV fluids

without medications– Subcutaneous pumps – IV medications given during

dialysis or chemotherapy– Dextrose 50% & Lactated Ringers

as IV meds

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Extensive Service Capture

Hospital Records:– Were records received and reviewed

upon admission/readmission/ER visit?

– Are electronic hospital records accessed if we have ability or can we obtain access?

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Case Example #1

Mr. J admitted 3/28/21 with Medicare as primary & secondary is Medicaid. He had IV fluids, IV meds & blood transfusion 3/24/21.

Therapy is unable to have 5 days of therapy by 4/2/21. What ARD would you use?

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Case Example #1Special Treatments, Procedures, or Programs Count Parental/IV while/while not a resident 1

Suctioning while/while not a resident 0

Tracheostomy care while/while not a resident 0

IV medication while/while not a resident 1

Sum of Extensive Services Count 2

Evaluate for special care, clinically complex or impaired cognition 1 point for each matchingBlood transfusion=Clinically complex

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Total Extensive Services Count 3

ARD no later than 3/30/21 SE2 CMI= 1.91

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Case Example #2

Mrs. S was sent to the ER on 4/17/21 and received a bolus of IV fluids for dehydration and IV antibiotic for UTI. She was sent back to the facility the same day with oral antibiotics to continue for 7 days.

What should the MDS Coordinator do?

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Case Example #2 Answer

First of all, the ER documentation should be retrieved.

Next, schedule an assessment to capture extensive services. The ARD should be ASAP because extensive services CMI would begin with the ARD if this is a quarterly or significant change (unless the admission assessment has not been completed yet).

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Rehabilitation

•150 Minutes and 5 days or more (15 min per day minimum) in any combination of therapy in last 7 days OR

•45 Minutes and 3 days or more (15 min per day minimum) in any combination of therapy in last 7 days AND at least 2 nursing rehabilitation services

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Rehabilitation Classification Example

What could have been done differently?

Grouper is single level: Total of 150 minutes & combination of 5 days

ARD

Monday Tuesday Wednesday Thursday Friday

OT PT OT PT OT PT OT PT OT PT

30min.

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Rehabilitation Classification Example Answer

150 minutes & a combination of 5 days was achieved by Wednesday. OT saw 3 days & PT saw 3 days Monday thru Wednesday for a total of 6 days and 174 minutes total minutes. If this was realized & communicated to the MDS Coordinator on Wednesday, the ARD could have been changed to Wednesday instead of Friday.

Monday Tuesday WednesdayARD

Thursday Friday

OT PT OT PT OT PT OT PT OT PT

30min.

26 33 32 28 25 34 29 30 24

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Rehabilitation Grouper Category

RUG Class ADL Score CMI

RAD 17-18 1.90

RAC 14-16 1.61

RAB 10-13 1.46

RAA 4-9 1.21

Therapy RUG

Start of therapy– Data retrieved from:• MDS Section O

• Admission MDS – Rehab RUG will begin on day 1

• If criteria met during reference period

• Quarterly & Significant Change MDS – Rehab RUG will begin with ARD

• Important to meet rehab criteria classification as soon as clinically indicated

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Special Care Grouper Category

RUG Class ADL Score CMI

SSC 17-18 1.58

SSB 15-16 1.46

SSA 7-14 1.41

If ADL score is >7=Clinically Complex

Diagnosis Identification

Active Diagnosis: • MD has documented dx

within last 60 days AND• Active in 7-day look-back

period.

Special Care Diagnosis: ADL Score>=10

• Cerebral Palsy• Quadriplegia• Multiple Sclerosis

Quadriplegia • Complete paralysis that affects ALL 4 limbs.• Caused by injury to the spinal cord in area of the

neck.• Usually defined by which vertebrae injured & how

complete the severing of the spinal cord is.

EXAMPLES: Spastic quad type cerebral palsy is not due to a

spinal cord injury and would be coded in I4400. Cerebral Palsy.

Functional quadriplegia refers to complete immobility due to severe physical illness or frailty that extends to all limbs and would be coded in I8000.

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Fever

• 7-day reference period• Temperature 2.4 degrees F higher than

baseline• Baseline temperature should be established

prior to the ARD• A temperature of 100.4 degrees F on

admission

TIPS: Routinely establish baseline temp. shortly after admission & update annually. Monitor nurse’s notes, vital reports, etc. for residents with fever.

Fever plus one of the following:

Pneumonia

Vomit ing

Dehydrat ion

Weight loss

Tube feed ing*

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Special Care Conditions

Pneumonia

• Must be an active diagnosis. Examples: CXR, S/S of pneumonia (i.e. cough, lung sounds), MD orders for treatment, therapy for functional limitations due to pneumonia.

Vomiting• Regurgitation of stomach contents in last 7 days; not phlegm from throat.

Dehydration

• Intake < 1500 ml. One or > clinical signs/indicators of dehydration such as dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, abnormal labs in last 7 days. Fluid loss > intake.

Weight Loss• 5% in last month or 10% or more in last 6 months.

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Tube Feeding Requirements

• 51% or more of total calories OR

• 26% to 50% of total calories AND 501 cc or more per day fluid intake in last 7 days

• For purpose of nutrition or hydration

• Include documentation with calculation of % of calories.

Special Care High: Feeding Tube + Aphasia

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Special Care: Respiratory Therapy

Provided by a qualified professional

•Respiratory therapists or respiratory nurses•Respiratory nurse must be proficient in the respiratory modalities

Services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function.

Includes coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc.

Treatment time is documented in minutes.

•Must include at least 15 minutes per day.

TIP: Consider adding order template that includes respiratory assessment and monitoring before and after service (i.e. lung sounds, pulse, respirations, oxygen saturation). Provide respiratory training with every nurse in orientation. 42

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Other Special Care Conditions

• Radiation while a resident– Intermittent– Radiation implant

• Two or > pressure or venous or arterial ulcers any stage*

• Any Stage 3 or 4 Pressure Ulcer*• Open lesions*

– Develop as a result of diseases and conditions (e.g. syphilis and cancer)

*With selected skin treatment

Surgical Wound*– Healing & non-healing, open or closed

surgical incisions, skin grafts or drainage sites

– Pressure ulcer that is excised & a graft and/or flap applied

Do Not Code: – Healed surgical sites & stomas or

lacerations that require suturing or butterfly closure

– PICC sites, central line sites, and peripheral IV sites

– Surgical debridement of pressure ulcer– Eye or oral surgery

Selected Skin Treatments

2 or > Ulcer Selected Skin Treatments

• Pressure relieving device to chair and/or bed – Does not include egg crate or doughnut/ring

• Turning/repositioning program– Specific approaches & frequency with

monitoring & evaluation. • Nutrition or hydration intervention

– Include documentation for purpose of preventing or treating the specific skin condition

• Pressure ulcer care• Application of dressing (other than to feet)• Application of ointments/medications (other than

to feet)

Open Lesion & Surgical Wound 1 or > Selected Skin Treatments

• Surgical wound care– Does not include:

• Care for eye/oral surgery• Surgical debridement of pressure ulcer• Observation only of wound

• Application of non-surgical dressings (other than to feet)– Does not include:

• Band-Aid or Tegaderm applied prior to only checking if intact

• Application of ointments/medications (other than to feet)

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End of Part 1

Part 2 will begin with theClinically Complex Category

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QUESTIONS

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References

• Centers for Medicare & Medicaid Services. https://qtso.cms.gov/reference-and-manuals/cms-approved-mds-30-final-section-s-items-are-available-download

• Centers for Medicare & Medicaid Services. (2020, September 28). CASPER Reporting User’s Guide for MDS Providers. https://qtso.cms.gov/reference-and-manuals/casper-reporting-users-guide-mds-providers

• RAI Manual• Myers and Stauffer. (November, 2019). Stakeholder Update:

Nursing Facility Payment Modernization Case Mix Overview.