dial-in instructions · activities of daily living (adl) coding on rug assignment and reimbursement...

47
Conference Name: An Encore Presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule Scheduled Conference Date: Thursday, February 9th, 2006 Scheduled Conference Time: 1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.– 12:30 p.m. (Mountain), 10:00 a.m.–11:30 a.m (Pacific) Scheduled Conference Duration: 90 Minutes PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If your area does NOT observe daylight savings, times will be one hour earlier. Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written materials for anyone else who is listening. In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time. Dial-In Instructions: 1. Dial 800/514-0835 and follow the voice prompts. 2. You will be greeted by an operator 3. Give the operator your pass code 020906 and the last name of the person who registered for the audioconference. 4. The operator will verify the name of your facility. 5. You will then be placed into the conference. Technical Difficulties 1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at 800/910- 4685. 2. If you should need technical assistance during the audio portion of the program, please press the star (*) key followed by the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the conference, dial 800/910-4685. PLEASE NOTE: This is an encore presentation of the original broadcast including the original 30-minute question and answer session. Program Evaluation Survey In your materials on page 2, we have included a Program Evaluation Letter that has the URL link to our program survey. We would appreciate it if when you return to your office you would go to the link provided and complete the survey. Continuing Education Documentation If CE’s are offered with this program, a separate link containing important information will be provided along with the pro- gram materials. Please follow the instructions in the CE documentation. Dial-In Instructions

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Page 1: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Conference Name: An Encore Presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Scheduled Conference Date: Thursday, February 9th, 2006

Scheduled Conference Time: 1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.– 12:30 p.m. (Mountain), 10:00 a.m.–11:30 a.m (Pacific)

Scheduled Conference Duration: 90 Minutes

PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If yourarea does NOT observe daylight savings, times will be one hour earlier.

Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone.

Permission is given to make copies of the written materials for anyone else who is listening.

In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time.

Dial-In Instructions:1. Dial 800/514-0835 and follow the voice prompts.2. You will be greeted by an operator3. Give the operator your pass code 020906 and the last name of the person who registered for the audioconference.4. The operator will verify the name of your facility.5. You will then be placed into the conference.

Technical Difficulties1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at 800/910-

4685.2. If you should need technical assistance during the audio portion of the program, please press the star (*) key followed

by the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the conference,dial 800/910-4685.

PLEASE NOTE: This is an encore presentation of the original broadcast including the original 30-minute question and answer session.

Program Evaluation Survey In your materials on page 2, we have included a Program Evaluation Letter that has the URL link to our program survey.We would appreciate it if when you return to your office you would go to the link provided and complete the survey.

Continuing Education Documentation If CE’s are offered with this program, a separate link containing important information will be provided along with the pro-gram materials. Please follow the instructions in the CE documentation.

Dial-In Instructions

Page 2: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

200 Hoods Lane PO Box 1168 Marblehead MA 01945 TEL 781 639 1872 FAX 781 639 7857 URL www.hcpro.com

Program EvaluationDear Audioconference Participant,

Thank you for attending the HCPro audioconference today. We hope that you find theinformation provided valuable.

In our effort to ensure that our customers have a positive experience when taking part inour audioconferences we are requesting your feedback. We would also like to request thatyou forward the link to others in your facility that attended the audioconference.

We realize that your time is valuable, so we’ve limited the evaluation to a few brief ques-tions. Please click on the link below.

http ://www.zoomerang.com/sur vey.zg i?p=WEB224XMD4VQ2R

The information provided from the evaluation is crucial towards our goal of delivering thebest possible products and services. To insure that your completed form receives ourattention, please return to us within six days from the date of this audioconference.

We appreciate your time and suggestions. We hope that you will continue to rely on HCProaudioconferences as an important resource for pertinent and timely information.

PLEASE NOTE:You must complete the Nursing Evaluation available at:

http ://www.zoomerang.com/sur vey.zg i?p=WEB224XVYL2Y9H

within 30 days of the program in order to receive your credits. After 30 days, the evalua-tion for this activity will be closed and the certificate of completion will be sent to you byemail.

Sincerely,

Frank MorelloDirector of MultimediaHCPro, Inc.

Page 3: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

An encore presentation - RUGs53: Navigating the new

payment categories from theSNF PPS Final Rule

1:00 p.m.–2:30 p.m. (Eastern)

12:00 p.m.–1:30 p.m. (Central)

11:00 a.m.–12:30 p.m. (Mountain)

10:00 a.m.–11:30 a.m. (Pacific)

presents . . .

A 90-minute interactive audioconference

Thursday, February 9, 2006

Page 4: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

ii An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

In our materials we strive to provide our audience with useful, timely information. The live audioconferencewill follow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We havenoticed that other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet,page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do notinclude each speaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts,and graphs. We hope that you find this information useful in the future.

HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations,which owns the JCAHO trademark.

Page 5: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

iiiAn encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

The “An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPSFinal Rule” audioconference materials package is published by HCPro, 200 Hoods Lane, P.O. Box 1168,Marblehead, MA 01945.

Copyright 2006, HCPro, Inc.

Attendance at the audioconference is restricted to employees, consultants, and members of the medical staffof the Licensee.

The audioconference materials are intended solely for use in conjunction with the associated HCPro audio-conference. Licensee may make copies of these materials for your internal use by attendees of the audiocon-ference only. All such copies must bear this legend. Dissemination of any information in these materials or theaudioconference to any party other than the Licensee or its employees is strictly prohibited.

Advice given is general, and attendees and readers of the materials should consult professional counsel forspecific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission onAccreditation of Healthcare Organizations, which owns the JCAHO trademark.

For more information, contact

HCPro, Inc. 200 Hoods LaneP.O. Box 1168Marblehead, MA 01945Phone: 800/650-6787Fax: 781/639-0179E-mail: [email protected] site: www.hcpro.com

Page 6: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

iv An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Dear colleague,

Thank you for participating in our “An encore presentation - RUGs 53:Navigating the new payment categories from the SNF PPS FinalRule” audioconference with Ronald Orth, RN, NHA, RAC-C, moderatedby Noelle Shough. We are excited about the opportunity to interact withyou directly and encourage you to take advantage of the opportunity toask our experts your questions during the audioconference. If you wouldlike to submit a question before the audioconference, please send it [email protected] and provide the program date in the subject line. Wecannot guarantee your question will be answered during the program, butwe will do our best to take a good cross section of questions.

If at any time you have comments, suggestions, or ideas about how wemight improve our audioconferences, or if you have any questions aboutthe audioconference itself, please do not hesitate to contact me. And if youwould like any additional information about other products and services,please contact our Customer Service Department at 800/650-6787.

Along with these audioconference materials, we have enclosed a fax eval-uation. We value your opinion. After the audioconference, please take aminute to complete the evaluation to let us know what you think.

Thanks again for working with us.

Best regards,

Shannon TierneyAudioconference coordinatorFax: 781/639-2982E-mail: [email protected]

200 Hoods LaneP.O. Box 1168

Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511

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vAn encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Presentation by Ronald Orth, RN, NHA, RAC-C

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25RUG III PPS Grouper Version 5.20—Case Mix Indices

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27RUG 53 Classification System, Version 5.20

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29ARD Selector Worksheet

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Contents

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vi An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Agenda

I. Why RUG refinement

II. Introduction to nine new RUG categoriesA. Qualifiers

III. Overview of Case Mix Maximization

IV. Introduction to 5.20 grouper logic

V. Impact of Assessment Reference Date (ARD) and Activities of Daily Living (ADL) coding on RUG assignment and reimbursement

VI. CMS transition plan from 44 RUG to 53 RUG systemA. Billing purposes

Live Q&A

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viiAn encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Speaker profiles

Noelle Shough, Moderator

Noelle Shough is the Executive Editor of Long-Term Care. She edits books, newsletters, and e-zines thatfocus on the MDS, Medicare billing, survey, and staff training. In her six-year stint at HCPro, she has alsowritten and researched in the areas of rehab, credentialing, patient safety, nurse management, physicianpractices, and compliance.

Ronald Orth, RN, NHA, RAC-C

Ronald Orth is the owner and president of Clinical Reimbursement Solutions, LLC. He has more than 20years of experience in the healthcare field and has spent the past eight years specializing in the area ofMedicare SNF regulations and the PPS reimbursement system. Orth holds an associate degree in nursingand a bachelor’s degree in healthcare administration. He also holds a nursing home administrator’s license inthe state of Arizona.

Clinical Reimbursement Solutions offers an array of consulting services in the area of clinical reimbursement.For additional information, visit www.clinicalreimbursement.com.

Page 10: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Exhibit A

Presentation by Ronald Orth, RN, NHA, RAC-C

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EXHIBIT A

2 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

1

RUGS 53: Navigating theNew Payment Categories

Clinical Reimbursement Solutions, LLCClinical Reimbursement Solutions, LLC

2

Why RUG Refinements??

• RUGs system inadequate in defining clinicalcomplexities of NH population

• Miscalculation of Medicare savings by CMS

• Increased costs since 1995 cost reports

• Some organizations ill prepared for changein reimbursement system

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3An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

3

Impact on Industry

• 9 of the top 10 nursing home organizationsfiled bankruptcy

• Represents approx. 10% of the industry

• Unable to meet contractual agreements

• Generated concern that NH placement maybecome difficult for many acute careproviders

4

Government Response

• BBRA of 1999

– Temporary increase in payment rates by 20%for 15 of the RUG classification

– 4% increase in all RUG classifications

– Mandated refinement of RUGs system orpayment system

– Caused a Case Mix Index Maximization‘Anomaly’

– Rehab Medium RUGs paid more than Rehab High

– Rehab Medium had lower Case Mix Index

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EXHIBIT A

4 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

5

Government Response cont’d

• BIPA of 2000

– Requires CMS to conduct a study of alternatecase-mix classification systems for SNF PPS

– Add-on for Rehab RUGs changed from 20%to 6.7%

– 6.7% add-on to remaining RUGs

– Continuation of 20% add-on for 12 NursingRUGs implemented in 1999

Problem Solved?

6

Broken Case Mix Maximization

• SE3 had lower CMI than many of theRehab RUGs however it paid MORE.

• Proper Case Mix Maximization = higherCMI higher payment

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5An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

7

Broken Case MixMaximization cont’d

SE3 36 $374.96

RMC 37 $344.10

Lower

Weight

Higher

Payment

8

RUG Refinements 2006

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EXHIBIT A

6 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Rehabilitation

Extensive Services

Special Care

Clinically Complex

Cognitively Impaired

Reduced Phys. Funct.

Behavioral

Reduced Phys. Funct.

Behavioral

Cognitively Impaired

Clinically Complex

Special Care

Extensive Services

Rehabilitation

Rehab/Extensive

PresentPresent FutureFuture

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7An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

11

New RUG LevelsRehabilitation/Extensive ServicesRehabilitation/Extensive Services

Category ADL Score

RUX 16-18

RUL 7-15

RVX 16-18RVL 7 -15

RHX 13-18

RHL 7-12

RMX 15-18

RML 7-14

RLX 7 -18

12

New RUG Criteria

Rehabilitation Component

• Remains unchanged from current system

• Therapy projection rules remain unchanged for 5-day and return/readmission assessments

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EXHIBIT A

8 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

13

New RUG Criteria cont’d

Extensive Services Component

Must have ONE of the Extensive Services

K5a IV Fluids/TPN (7-day lookback)

P1ac IV Meds (14-day lookback)

P1ai Suctioning (14-day lookback)

P1aj Trach (14-day lookback)

P1al Vent/Respirator (14-day lookback)

ANDAND……

14

New RUG Criteria cont’d

ADL Component

ADL Score must be >=7

Same as current Extensive

Services criteria

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9An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

15

Case Example

Resident received 250 minutes PT over 5days, 150 minutes OT over 5 days. IVmedications given in past 14 days, ADLscore 10.

Current RUG = RHB

New RUG = RHL (so you think!!)

Things that Make you go Hmmmmm……

16

New CMI and Hierarchy

• New system has resolved hierarchalissue

• Can be viewed as looking at two differentsystems

• 53 RUG System

• 44 RUG System

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EXHIBIT A

10 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

30RLB30RLB

31SE231SE2

32RLX32RMA

33RMA33RLX

34RMB34RHA

35RHA35RMB

36RMC36RMC

37RHB37RHB

38SE338RVA

39RHC39RHC

40RVA40SE3

41RHL41RHL

42RHX42RHX

43RVB43RVB

44RML44RML

45RVC45RVC

46RVL46RVL

47RMX47RMX

48RVX48RUA

49RUA49RVX

50RUB50RUB

51RUC51RUC

52RUL52RUL

53RUX53RUX

Rural CMIRUGUrban CMIRUG

RUGIII 53 CMIRUGIII 53 CMI

Grouper Version 5.20Grouper Version 5.20

1. Resident can qualify

for multiple RUGs

2. Index Maximized –

will assign RUG

with highest CMI

3. Higher the CMI

higher the Payment

4. CMI Values 1-53

18

Case Mix Index Maximization

Mr. Smith’s 14-day MDS reveals the following:

5-days and 500 minutes of therapy

Dialysis

Short Term Memory Problem

Poor Decision Making

IV Meds

Pneumonia

Fever

ADL Score 10

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11An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

19

Case Mix IndexMaximization cont’d

Mr. Smith’s would qualify for the followingRUG Categories:

5-days and 500 minutes of therapy

(RV,RH,RM)

Dialysis (Clinically Complex)

Short Term Memory Problem/Poor Decision Making (Impaired Cognition)

IV Meds (Extensive Services)

Pneumonia (Clinically Complex)

Fever (w/pneumonia = Special Care)

20

Strategies for Success

Main Considerations

�Accurate ARD Selections

�Accurate ADL Capturing

�Capturing Hospital Services

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EXHIBIT A

12 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

21

Strategic ARD Selection

On Day 5 – Can capture 325 minutes and IV Meds, ADL Score 10

Day 6 – Can capture 350 minutes, however no IV Meds, ADL score 10

Which do you choose?

22

Strategic ARD Selection cont’d

Day 5 – Can capture 325 minutes and IV Meds, ADL Score 10 = RHL (41)

Day 6 – Can capture 350 minutes, however noIV meds, ADL score 10 = RHB (37)

Although resident qualifies for the RHL RUG category,grouper will place in RML due to higher CMI score.

Difference = $60.81/day

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13An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

RUG-III Nursing Therapy Nursing Therapy Non-case Mix Non-case Mix Total

Category Index Index Component Component Therapy Comp Compo-RUX 1.90 2.25 $261.42 $233.19 $70.22 $564.83

RUL 1.40 2.25 $192.63 $233.19 $70.22 $496.04

RVX 1.54 1.41 $211.89 $146.13 $70.22 $428.24

RVL 1.33 1.41 $182.99 $146.13 $70.22 $399.34

RHX 1.42 0.94 $195.38 $97.42 $70.22 $363.02

RHL 1.37 0.94 $188.50 $97.42 $70.22 $356.14

RMX 1.93 0.77 $265.55 $79.80 $70.22 $415.57

RML 1.68 0.77 $231.15 $79.80 $70.22 $381.17

RUC 1.28 2.25 $176.12 $233.19 $70.22 $479.53

RUB 0.99 2.25 $136.21 $233.19 $70.22 $439.62

RUA 0.84 2.25 $115.58 $233.19 $70.22 $418.99

RVC 1.23 1.41 $169.24 $146.13 $70.22 $385.59

RVB 1.09 1.41 $149.97 $146.13 $70.22 $366.32

RVA 0.82 1.41 $112.82 $146.13 $70.22 $329.17

RHC 1.22 0.94 $167.86 $97.42 $70.22 $335.30

RHB 1.11 0.94 $152.72 $97.42 $70.22 $320.36

RHA 0.94 0.94 $129.33 $97.42 $70.22 $296.97

RMC 1.15 0.77 $158.23 $79.80 $70.22 $308.25

RMB 1.09 0.77 $149.97 $79.80 $70.22 $299.99

RMA 1.04 0.77 $143.09 $79.80 $70.22 $293.11

SE3 1.86 $255.92 $13.65 $70.22 $339.79

SE2 1.49 $205.01 $13.65 $70.22 $288.88

SE1 1.26 $173.36 $13.65 $70.22 $257.23

SSC 1.23 $169.24 $13.65 $70.22 $253.11

SSB 1.13 $155.48 $13.65 $70.22 $239.35

SSA 1.10 $151.35 $13.65 $70.22 $235.22

CC2 1.22 $167.86 13.65 70.22 $251.73

24

Strategic ARD Selection

On Day 5 – Can capture 325 minutes and IV Meds, ADL Score 10

Day 6 – Can capture 350 minutes, however no IV Meds, ADL score 10

Which do you choose?

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EXHIBIT A

14 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

25

Strategic ARD Selection cont’d

Day 5 – Can capture 325 minutes and IV Meds, ADL Score 10 = RHL (41)RHL (41)

Although resident qualifies for the RHL RUGAlthough resident qualifies for the RHL RUGcategory, grouper will place in RML (44) due tocategory, grouper will place in RML (44) due to

higher CMI score.higher CMI score.

Day 8 – Can capture 510 minutes, however no IV meds, ADL score 10 = RVB (43)

Difference = $ 14.85Difference = $ 14.85

26

Strategic ARD Selection cont’d

Day 1 – Can capture SE3 RUG score, no therapy yet initiated

Day 3 – Can capture 300 minutes, can continue to capture enough extensive services to get SE2, ADL score 15

Day 8 – Unable to capture any extensive services qualifiers, ADL score up to16, therapy minutes 585.

Which do you choose?Which do you choose?

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15An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

27

Strategic ARD Selection cont’d

Day 1 – Can capture SE3 RUG score, no therapy yet initiated = SE3 (40)

Day 3 – Can capture 300 minutes, can continue to capture enough extensive services to get SE2, ADL score 15 = RMX (47)RMX (47)

Day 8 – Unable to capture any extensive services qualifiers, ADL score up to 16, therapy minutes 585 = RVC (45)

28

Strategic ARD Selection cont’d

Day 1 – Can capture SE3 RUG score, no therapy yet initiated

Day 3 – Can capture 300 minutes, can continue to capture enough extensive services to get SE2, ADL score 15

Day 8 – Unable to capture any extensive services qualifiers, ADL score up to 15, therapy minutes 725.

Which do you choose?Which do you choose?

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EXHIBIT A

16 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

29

Strategic ARD Selection cont’d

Day 1 – Can capture SE3 RUG score, no therapy yet initiated = SE3 (40)

Day 3 – Can capture 300 minutes, can continue to capture enough extensive services

to get SE2, ADL score 15 = RMX (47)

Day 8 – Unable to capture any extensive services qualifiers, ADL score up to 15, therapy minutes 585 = RUB (50)RUB (50)

30

Strategic ARD Selection cont’d

• Do not RUSH to choose date

• Must be flexible

• Must be reviewed frequently

• May have to wait until last day ofobservation period to determine best date

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17An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

31

Strategic ARD Selection cont’d

Accurate ARD selection will greatly

depend on:

– Obtaining and reviewing hospital records forextensive service qualifiers

– Identify furthermost ARD date to capture newextensive/rehab RUG

– Establish estimated therapy plan for first 8 days

– ARD planning between the MDS Coord and Rehabmanager/staff

– Estimation/calculation of ADL score on frequent basis

32

Accurate ADL Capturing

ADLs drive nursing index of each RUG score

Number of RUGs requiring an ADL score > 6increases from 6 to 15

• Rehab/Extensive 9 RUGs

• Extensive Services 3 RUGs

• Special Care 3 RUGs

Page 27: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT A

18 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

33

Accurate ADL Capturing cont’d

Financial Impact of Inaccurate ADL coding

225 minutes therapy, IV meds, ADL score of 6

RUG = RMA = $293.11

225 Minutes therapy, IV meds, ADL score 8

RUG = RML = $381.17

Difference $ 88.06 x 14 days = $1232.84

34

Accurate ADL Capturing cont’d

Financial Impact of Inaccurate ADL coding

550 minutes therapy, IV meds, ADL score of 15

RUG = RVL = $399.34

550 Minutes therapy, IV meds, ADL score 16

RUG = RVX = $428.24

Difference $ 28.90 x 14 days = $404.60

Page 28: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

19An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

35

Medicare ADL < 7Loss during first 14 days

SE3 SSA: ($104.57/day)

($1,463.98)

SE2 SSA: ($53.66/day)($751.24)

SE1 SSA: ($22.01/day)

($308.14)

36

Accurate ADL Capturing cont’d

Key points to remember regarding ADLS

• (A) Self Performance is 3 occurrences inassessment period, not 3 shifts

• (B) Support Provided need ONLY occur ONCEin lookback period

• Review all areas of the clinical record, includingtherapy notes

• Interview staff, resident if documentation notavailable

• Assess ADL status in person, if needed

• Clarify conflicting data in separate note, ifneeded

Page 29: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT A

20 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

37

Hospital Documentation

• CMS did not eliminate the lookback period

into the hospital, imperative to receive the

following

• MARS, TARS

• IV Records

• I & O

• H & P

• Most recent labs

• Physician progress notes/orders

• Nurses Notes

38

Hospital Documentation cont’d

Don’t forget aboutreadmissions to the SNF after

a rehospitalization!!!!

Page 30: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

21An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

39

Hospital Documentation cont’d

• Be alert to key hosp. admitting diagnosis

• Chest Pain

• MI

• CHF

• Pulmonary Edema

• Pneumonia

• UTI

• Dehydration

40

Billing Implications

Page 31: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT A

22 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

41

Billing Implications

• New RUGs effective 1/1/06

– Service Dates beginning 1/1/06

– Assessments may be billed under bothsystems (44 Rug & 53 Rug)

– CMS has a transition plan

42

Billing Implications cont’d

• Transition Plan

– CMS is requesting software vendors tobe compliant with 53 RUG grouper by11/22/05

– Software should calculate both RUGscores between 11/22/05 and 1/13/06

Page 32: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

23An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT A

43

Billing Implications cont’d

• Transition Plan

– Assessments with an ARD 11/22/05have the potential to be billed underboth systems.

– Assessments with an ARD up to 1/13/06have the potential to be billed underboth systems

44

Billing Implications cont’d

• Transition Plan

– Will need to review current billingprocesses to ensure billing the approp.RUG score effective 1/1/06

– No change in HIPPS codes

Page 33: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT A

24 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

45

Billing Implications cont’d

• Transition Plan

– Submission reports will display both RUG

classifications beginning 11/22/05 thru

1/13/2006

ClinicalClinical

Reimbursement Reimbursement

Solutions, LLC Solutions, LLC

““Keeping you Informed, Compliant and SuccessfulKeeping you Informed, Compliant and Successful””

www.clinicalreimbursement.comwww.clinicalreimbursement.com

Page 34: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Exhibit B

RUG III PPS Grouper Version 5.20—Case Mix Indices

Source: Ronald Orth, RN, NHA, RAC-C. Reprinted with permission.

Page 35: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT B

26 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Page 36: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Exhibit C

RUG III PPS Grouper Version 5.20—Case Mix Indices

Source: Ronald Orth, RN, NHA, RAC-C. Reprinted with permission.

Page 37: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

EXHIBIT C

28 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

Page 38: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Exhibit D

ARD Selector Worksheet

Source: Ronald Orth, RN, NHA, RAC-C. Reprinted with permission.

Page 39: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

30 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

EXHIBIT D

Page 40: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

Resources

Page 41: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

PPS Alertfor Long-Term Care

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Comprehensive Error Rate Testing program and the next incarnation of DAVE• Painstaking dissections of all the trickiest coding sections of the form, such as the ADLs in Section

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Page 42: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

33An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

RESOURCES

Speaker resources

Ronald Orth, RN, NHA, RAC-CClinical Reimbursement Solutions, LLC215 W Maple Street, Suite 107Milwaukee, WI 53204Phone: 888/225-7147E-mail: [email protected] site: www.clinicalreimbursement.com

HCPro sites

HCPro: www.hcpro.com

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Visit HCPro’s Web site and take advantage of our online resources. At hcpro.com you’ll find the latest newsand tips in the areas of

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Page 43: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

RESOURCES

34 An encore presentation - RUGs 53: Navigating the new payment categories from the SNF PPS Final Rule

The Greeley Company: www.greeley.com

Get connected with leading healthcare consultants and educators at The Greeley Company’s Web site. Thisonline service provides the fastest, most convenient, and most up-to-date information about our quality con-sulting, national-education offerings, and multimedia training products for healthcare leaders. Visitors will finda complete listing of our services that include consulting, seminars, and conferences.

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Page 44: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

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Page 45: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

New!• Discharge Planning Summit• Core Privileging Advanced Course• Front-End Solutions Workshop• Physician Performance Profile Course

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Page 46: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

April 6-7, 2006, The Ritz-Carlton Hotel, Phoenix, AZ

NEW! Case Management Institute: Managing by influence to maximize the effectiveness of your case management program

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Page 47: Dial-In Instructions · Activities of Daily Living (ADL) coding on RUG assignment and reimbursement VI. CMS transition plan from 44 RUG to 53 RUG system A. Billing purposes Live Q&A

June 1–2, 2006, The Ritz-Carlton, Amelia Island, Amelia Island, FL

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Spring 2006 Seminar Calendar