And you shall rise and show respect to the 4/17/17 aged.€¦ · And you shall rise and show...

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4/17/17

WilhideConsul;ng,Inc.(c) 1

UnderstandingVirginiaMedicaidCaseMixSystem

JudyWilhideBrandtjudy@judywilhide.com909-800-9124

Virginia Medicaid • Medicaidresidentdaysarepaidonaperdiemrate

•  LikeMedicareA•  BilledeachmonthwiththeHIPPSfromtheMDScontrollingpaymentforthedaysinthatmonth.

• WillonlyuseOBRAassessments• Virginiadual-eligibleprogramalsousedthissystem.

Ratesvaryfacilitytofacility

PA1 PA2 PB1 Direct Operating Cost (Case Mix Neutral) $83.18 $83.18 $83.18

RUG III, Grouper 34 Weight 0.59 0.62 0.63 RUG-Adjusted Direct Operating Rate $49.08 $51.57 $52.40

Indirect Operating Rate $66.96 $66.96 $66.96 Capital Rate $22.18 $22.18 $22.18

NATCEPs Rate $- $- $- CRC $0.06 $0.06 $0.06

Total Facility Per Diem by RUG Category $138.28 $140.77 $141.60

LinktoyourratesonJudyWilhide.com“resources”

Example: Admi4ed regular Medicaid

• Admission:6/12/15• AdmissionMDSARD:6/19/14Z0200=SE201• QuarterlyMDSARD9/19/15Z0200=CB102•  SE201controlspaymentfor:

•  6/12–9/18/15• CB102controlspaymentbeginning:

•  9/19/15

Example: Admi4ed Dual-Eligible: Medicare/Medicaid

• Admit:6/15/14• Admission/5DayMDSARD:6/19/14Z0200=RAD

• Medicare6/15–7/20• Medicaidbeginning7/21• BillMedicaidRAD7/21–daybeforenextOBRAARD

Medicaid Rules

• PaymentiscontrolledbythelastOBRAassessmentdoneun;ltheARDofthenextOBRAassessment

•  Admissionassessmentcontrolspaymentfromday1.

• NoStaterequirementonhowclosetogetherOBRAassessmentsmaybescheduled.

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OBRAScheduling

Admission

Quarterly

Quarterly

Quarterly

Annual

92daysARDtoARD

366daysARDtoARD

AdmTracker

SCSAResetsOBRAClock!

92daysARDtoARD

366daysARDtoARD

Admission

Quarterly

SCSA

Quarterly

Quarterly

Quarterly

Annual

AdmTracker

LateAssessments

•  IftheOBRAARDissetlate,thenursingfacilityshallbillthedefaultRUGcodeun;ltheARDofthenextOBRAassessment.

•  Annualmaybelatetwoways:– ARD>92daysfromlastOBRA– ARD>366daysfromlastcomprehensive

Final Valida=on Report

Thisiswherethelatewarningswill

appear

StaysLessthan14Days

•  Twochoices:– DoearlyAdmissionassessment– Billdefaultrate

•  MedicaidRUGIII,34grouper,version5.20

•  Candoearlyquarterlies•  MustdoSigChangewhenclinicalcondi;onwarrants

•  NeedtosetARDtomaximizeMedicaidRUG

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Basics

•  RUGIII-34grouperVersion5.20•  RUGassignedinZ0200

Z0250isNOTusedforANYcalcula;on.DMASisrunningadifferentgrouperinthatboxaspartofanon-goingstudy.Valida;onreportwarningsfor

Z0250canbeignored.

HIPPS Code Health Insurance Prospec=ve Payment System

RAB

RUGScore

01

AssessmentIden;fierCode

AnyA0310Aexcept“99”

MaybecombinedwithPPS

AICode

HIPPS Code

RAB02

RUGScore CaseMixIndex

1.24

EachRUGhasitsownCMI

RUG III (Version 5.20) 34 Grouper Examples

RUG CMISE3 2.10SE2 1.79RAD 1.66SE1 1.54SSC 1.44CC2 1.42SSB 1.33

RUGIIIGrouper

•  “Whilearesident”and“Whilenotaresident”arebothusedtocalculateRUGscore.– ExtensiveServicecanpaymorethanmoreRehab

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ADL SelfPerformance

Support ADLScore

BedMobility,Toile;ng,Transfers

0,1or7 Anynumber 12 Anynumber 33,4or8 2 43,4or8 3 5

Ea;ng: IVfluid NA 3Qualifyingtubefeeding

NA 3

0,1,or7 NA 12 NA 23,4or8 NA 3

Rehab

RAD 17-18RAC 14-16RAB 10-13RAA 4-9

•  Twowaystoqualify:– 5treatmentdaysofanycombina;onofOT,PTorSTforatleast150minutes

– Threetreatmentdaysofanycombina;onofOT,PTorSTforatleast45minutesand2+qualifyingrestora;venursingprograms

“Dis;nctC

alendar

Days”No

tused

ExtensiveServicesSubgroups:•  SE3-ClinicalIndicators4-5•  SE2-ClinicalIndicators2-3•  SE1-ClinicalIndicators0-1

ExtensiveServices

ServiceCount

SE3(4-5)

SE2(2-3)

SE1(0-1)

ADLScore>7

ExtensiveServices•  Mustmeetoneormoreofthefollowingservices:

–  Inlast7days,receivedparenteralorIVtherapy

–  Inthelast14days,received:•  IVmedica@on•  Suc@oning•  Trachcare•  Ventorrespiratortreatment

•  MusthaveADLscoreatleast7•  Lookbackperiodincludespriortoadmit

IVFluid

OtherExtensiveServicesQualifiers

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ExtensiveServicesCount:

5.ImpairedCogni;on

4.ClinicallyComplex

3.SpecialCare

2.IVMed

1.Parenteral/IVfluidExtensiveServicesDiagram

• ADLScore

>7

•  IVmed•  IVfluid• Trach• Vent• Suc;on

Qualifiers•  IVFluid•  IVMed• SpecialCare

• ClinicallyComplex

•  ImpairedCogni;on

ServicesCount

•  SE3•  SE2•  SE1

RUG

ServicesCount OurResident:Parenteral/IVFluid XIVMed XSpecialCare XClinicallyComplex XImpairedCogni;on -

ServicesCount=4RUG=SE3

ExampleIVFluidRUGIIICalcula;ondoesNOTuseintakerequirement

SpecialCareSubgroups:

SpecialCare ADL(>7)

SSC(17-18)

SSB(15-16)

SSA(7-14)

SpecialCare

•  ADLScoreatleast10and:– CPorMSorQuad

•  Feverand1ofthefollowing:– pneumonia– dehydra;on– vomi;ng– weightloss– tubefeeding**

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TubeFeeding:

•  Feedingtubeandeither– Atleast51%ofcaloriesbytubeOR– 26%to50%caloriesbytubeANDatleast501ccfluid/daybytube

FeedingTubeRUGIII34V5.20

UsedforRUGIV

UsedforRUGIII34V5.12

TubefeedingDOESuseintakerequirement,butdoesNOTuse“duringen;re7days”

SpecialCare,con;nued•  HadADLscoreofatleast7andoneofthefollowing:– Tubefeeding*andaphasia– 2+Pressureulcersand2+skintreatments– St3or4PUand2+skintreatments– Surgicalwoundoropenlesionand1+treatment–  radia;ontreatments– 7daysofrespiratorytherapy– ExtensiveServicesw/ADLscore<7

PrUSkinTreatments(2+)

•  Pressurereducingbed/chair(countas1)•  Turning/reposi;oning•  Nutri;onorHydra;oninterven;on•  PressureUlcerCare•  Applica;onofnonsurgicaldressings•  Applica;onofointments/medica;onsotherthantofeet

Surgicalwoundoropenlesionand1+treatment

•  Surgicalwoundcare•  Applica;onofdressings•  Applica;onofointments

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ClinicallyComplex

ClinicallyComplex

ADL CA2 CC2

CC1CB1CA1ADL

CB2

Notdepressed

Depressed

4-11

4-11

12-16 17-18

17-1812-16

ClinicallyComplex•  Anyoneofthefollowing:

–  ComaandnotawakeandcompletelyADLdependent–  Diabetesandinjec;on7daysandorderchanges2+days

•  NotjustINSULINorderchanges•  NotjustINSULINinjec;ons

–  hemiplegiaandADLscore10+–  pneumonia–  sep;cemia–  dehydra;on–  InternalBleeding–  Tubefeeding*

ClinicallyComplexCon;nued

– burns–  footlesionsorfootinfec;onwithapplica;onofdressingstofoot

– chemotherapy– dialysis– Oxygentherapy–  transfusions– MDvisits1+dayandRxchange4+days– MDvisit2+daysandRxchange2+days– SpecialCarew/ADLsum<7

TubeFeedingRecap

•  SpecialCare:– QualifyingTubefeedingwith:

•  FeverOR•  Aphasia

•  ClinicallyComplex:– QualifyingTubefeeding

EndSplit:SignsofDepressionCriteria

10ormoreonMoodIntervieworStaffAssessment

CC2 1.42CC1 1.25CB2 1.15CB1 1.07CA2 1.06CA1 0.95

ImpairedCogni;on

ImpairedCogni@on

ADL 4-5IA2

6-10IB1

4-5IA1ADL

6-10IB2

1=Restora@veNursing0-1

2=Restora@veNursing2+

ADLScore<=10

CPS:3orBIMSof9“moderatelyimpaired”

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NursingRestora;ve•  2ormorequalifyingnursingrehabservicesforatleast15

minon6ofthepast7days–  Scheduledtoile@ng&/orbladderretraining–  Passiveand/orac@veROM–  Splint/Braceassistance–  BedMobilityand/orgaittraining–  TransferTraining–  DressingorGroomingTraining–  Ea;ngorSwallowingTraining–  Amputa;onorProsthesisCare–  Communica;onTraining

BehaviorProblems

BehaviorProblems

ADL 4-5BA2

6-10BB1

4-5BA1ADL

6-10BB2

1=Restora@veNursing0-1

2=Restora@veNursing2+

ADLScore<10

BehaviorProblems•  Anyoneofthefollowingbehaviorsoccurredon4ormoreofthelast7days:– wandering–  verbalabuse–  physicalabuse–  inappropriatebehavior–  resistscare

•  Or,theresidentexperienceddelusionsand/orhallucina;onsatleastonceinthelast7days.

ReducedPhysicalFunc;on

ReducedPhysicalFunc;on

Restora;vePE2

PE1

PD2

PD1

PC2

PC1

PB2

PB1

PA2

PA1

ADLS

Restora;ve

Restora;ve

Restora;ve

Restora;ve

ADL16-18

ADL11-15

ADL9-10

ADL6-8

ADL4-52=Rest.Nsg2+1=Rest.Nsg0-1

Opera;onalPlanOpportuni;es

•  ADLScore•  RehabforMedicaidResidents

–  5treatmentdaysperweek–  3treatmentdays+qualifyingrestora;ve

•  ExtensiveServices:–  IVmed,Fluid,Clysis

•  Respiratorytherapy7days/weekfor15min–  TimeonMAR/TAR

•  Restora;veNursing•  Depressioninterview

MDSSchedule

•  ReviewtwoweekspriortoARD:– ADLScore?– Rehabin?– Fluids/Meds?– Restora;ve?–  InterviewpriortoARD?– DocumentQshiwduringthisperiod

•  ExtraQuarterlies•  OBRA;melycomple;onawareness

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StrategyExampleRehab:•  QuarterlysetJan10,2015RUGPD1144.43•  144.43x92=13,287.56•  HasPartBOTbeginningonFeb6for30min/day.ARDsetforFeb10.RUGRAB171.19.OTcon;nuesfor3weeks.

•  Jan10–Feb9:5488.34•  Feb10for92days:15,749.48

StrategyExampleIV:

•  QuarterlysetJan10,2015RUGPD1144.43•  144.43x92=13,287.56•  HasIVfluid/medbeginningFeb6.ARDsetforFeb6.RUGSE2213.24.

•  Jan10–Feb6:8232.51•  Feb6for92days:19,618.08

RUGIV48Grouper

Star;ngJuly1,2017

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0-1RAA

RAB

11-14

2-5

Rehab RAC

RAF

15-16

6-10

RAE

(1) Received150ormoreminutesandAtleast5dis;nctdaysofanycombina;onofthe3disciplines,OR(2) Received45ormoreminutesandAtleast3dis;nctdaysofanycombina;onofthe3disciplinesand2ormorerestora;venursingprogramsreceivedfor6ormoredays,

NursingRestora;ve:>=2on6daysinlookback

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Urinaryand/orboweltrainingprogram*

Passiveand/orac@veROM*

Splintand/orbraceassistance

BedMobilityand/orwalkingtraining*

TransferTraining

Dressingand/orGroomingTraining

Ea;ngand/orSwallowingTraining

Amputa;on/ProsthesisCareTraining

Communica;onTraining

*Countas1forRUGpurposes.

ExtensiveServices–ADL>2:

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ES3

Isola;onforAc;veInfec;ousDisease

TrachORVent

TrachANDVent

ES1

ES2

Whilearesident

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SpecialCareHigh

HC2SignsofDepression

HC1ADL6-10

HB2SignsofDepression

HB1ADL2-5

HD2SignsofDepression

HD1ADL11-14

SignsofDepression HE2

HE1ADL15-16

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SpecialCareHigh:ADL>=2DepressionEndSplit:>=10PHQ9/OV

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Comatose&ADL4/8

Sep;cemia

Diabetesw/dailyInsulininj&InsulinRxchangeson>2days

Quadriplegia&ADL>5

COPD&SOBlyingflat

IVFluid

RespiratoryTherapy7days

Fever&1:

• Pneumonia• WeightLoss• QualifyingFeedingTubeall7days:• >=51%calories• 26-50%calories&501ccfluid

(Feverand)IVFluid

•  Sec;onK:7daylookback

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Eithercount

(Feverand)QualifyingTubeFeeding

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Musthaveeither:26-50%AND501cc

OR51%

LD2SignsofDepression

LD1ADL11-14

LE2SignsofDepression

LE1ADL15-16

LC2SignsofDepression

LC1ADL6-10

LB2SignsofDepression

LB1ADL2-5

SpecialCareLow

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SpecialCareLow:ADL>=2DepressionEndSplit–10PHQ9/OV

CerebralPalsy&ADL>5.

Mul;pleSclerosis&ADL>5.

Parkinson’sDisease&ADL>5.

QualifyingTubeFeeding(en;re7days)

FootInfec;on,Diabe;cfootulcer,oropenlesionsonfootw/dressingstofeet.

Radia;ontherapywhileresident.

RespiratoryFailureandOxygentherapywhileresident.

Dialysiswhileresident.

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SpecialCareLow:ADL>=2DepressionEndSplit–10PHQ9/OV

>=2StIIPU&>=2skintreatments

>=1StIII,IV,orunstageableslough/escharPU&>=2skintreatments

>=2venous/arterialulcers&>=2skintreatments

1StIIPU&1venous/arterialulcer&>=2skintreatments.

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Qualifying“SkinTreatments”

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Pressurerelievingchairand/orbed*

Turning/reposi;oning

Nutri;onorhydra;oninterven;on

Ulcercare

Applica;onofdressings(nottofeet)

Applica;onofointments(nottofeet)

CE2SignsofDepression

CE1ADL15-16

ClinicallyComplex

CC2SignsofDepression

CC1ADL6-10

CD2SignsofDepression

CD1ADL11-14

CB2SignsofDepression

CB1ADL2-5

CA2SignsofDepression

CA1ADL0-1

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ClinicallyComplex:AnyADLScoreDepressionEndSplit10PHQ9/OV

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ExtensiveServices,SpecialCareHighorLowwithanADLscoreof<2

Pneumonia

HemiplegiaandADLscore>5

Surgicalwoundsoropenlesionsw/treatment

Burns

Chemotherapywhileresident

Oxygentherapywhileresident

IVMedica;onswhileresident

Transfusionswhileresident

BB22+

Restora@veBB1ADL2-5

BA22+

Restora@veBA1ADL0-1

BehavioralSymptoms&Cogni;vePerformance

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BehavioralSymptoms&Cogni;vePerformanceADL<=5

Restora;veNursingEndSplit

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Delusions

Hallucina;ons

Wandering*

Rejec;onofCare*

Otherbehavioralsymptomsnotdirectedtoothers*

Physicalorverbalbehavioralsymptomsdirectedtoothers*

BIMSScore<9orCPS>3

*>=4days

Any1ofthefollowing:

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PE22+

Restora@vePE1ADL15-16

ReducedPhysicalFunc;on

PC22+

Restora@vePC1ADL6-10

PD22+

Restora@vePD1ADL11-14

PB22+

Restora@vePB1ADL2-5

PA22+

Restora@vePA1ADL0-1

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Transi;on:July1,2017

•  IfthereisanOBRAassessmentwithanARDpriortoJuly1,2017,theRUGIIIRUGinZ0200willbeusedthroughtheendofJuneandtheRUGIV48grouperRUGwillbeusedstar;ngJuly1,2016.

•  TheRUGIV48grouperRUGisbeingcalculatedinZ0250.Ifyourorganiza;ondidnotloadthatgrouperintoZ0250(andalmostnobodydid)youhavetodothis:

ThisRUGmustgoontheJulyclaimforMedicaid

JudyWilhide.com Judy@JudyWilhide.com 909-800-9124 www.facebook/wilhideconsulting Twitter: @wilhidemds

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CONCLUSION Discussion/Questions

And you shall rise and show respect to the aged.