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UNDERSTANDING AND MANAGING
PRICE-BASED MEDICAID: STRATEGIES FOR FINE TUNING YOUR
FACILITY’S OPERATIONAL AND FINANCIAL PERFORMANCE
Susan Hickson-Painter, RN, RAC-CT Sam Phillips, CPA, MBA, RAC-CT Walker-Phillips Healthcare Consulting 2707 Brambleton Avenue., SW Roanoke, Virginia 24018 [email protected] 888.996.2228 www.w-phc.com
LEARNING OBJECTIVES - FINANCIAL
Overview of the Medicaid price-based payment plan. Understand how Medicaid price-based rates are determined and why Cost
Reports can be more important now, than in the past. How Medicaid Case-Mix Index (CMI) scores drive your Medicaid payment
rates more than ever. Medicaid cost report base years establish payment rates for 3 years. FY17 is
a base period and a very important period to manage costs. Provide tips to appropriately optimize reimbursement in this important period.
Review of your facility’s RUG-IV 48-classification group Medicaid rates.
How the Medicare-A PPS reimbursement compares to the Medicaid price-based payment plan.
Tips to improve your Fair Rental Value (FRV) capital payment rate. Advice on how to obtain improved reimbursement early for large capital
projects.
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L Summary of Priced-Based Payment System
DMAS transitioned from the previous RUG-III 34-grouper to the current RUG-IV 48-grouper (MDS 3.0) on July 1, 2017.
Resident specific Medicaid RUG score(s) listed on the Medicaid claims starting November 1, 2014.
Effective July 1, 2017, facilities are now paid up to 48 different facility specific Medicaid RUG rates (similar to Medicare-A PPS Billing).
Must be good communication between the MDS and billing office to ensure that the correct MDS assessment(s) are utilized on the claim (similar to Medicare-A claims).
Providers will notice that scores for RUG-IV 48-Grouper are generally lower than scores for RUG-III 34-Grouper (but not for everyone).
Providers could experience a significant reimbursement surprise next month!
DMAS is producing quarterly reports summarizing each provider’s RUG-III and RUG-IV data.
Providers should track RUG-IV 48-Grouper scores weekly and not rely on DMAS report (not timely reporting).
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L Summary of Priced-Based Payment System (continued)
SY18 rates were calculated using direct and indirect costs from PFY14 Medicaid cost reports inflated to SFY18 (rates effective July 1, 2017).
Sets Medicaid rates through SFY20.
Calculated day-weighted median (DWM) by peer group.
Multiply DWM times price-based adjustment factors. 105% (106.8% for SFY18) for direct
100.735% (101.3% for SFY18) for indirect
Inflate price-based peer group rates to SFY 18 rate year.
Adjust peer group rates for cost floors for each facility, if applicable.
Cost reports will continue to be required annually and base years could change (Danger, Danger!!!).
Cost reports will be desk settled and subject to field audits as in past (could be very, very big deal in base years).
FRV is reported separately on annual basis.
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L Summary of Priced-Based Payment System (continued)
Price-Based Peer Groups
Direct Peer Groups
Northern Virginia MSA (Urban 3)
Other MSAs (Urban 4)
Northern Rural (Rural 1)
Southern Rural (Rural 2)
Indirect Peer Groups
Northern Virginia MSA (Urban 3)
Other MSA (Urban 4)
Northern Rural (Rural 1)
Southern Rural (Rural 2)
Rest of State – 60 beds or less (Small)
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L Impact of Medicaid CMI – 1% Increase Annually
Urban 3 (NOVA) Example Estimated Impact of 1% Increase in Medicaid CMI
SFY18 Direct Base Rate $ 119.05
Estimated Medicaid/CCC-Custodial/Hospice Days (2016) 25,550
Average Daily Census Medicaid/CCC-Custodial/Hospice Days 70
Impact of Medicaid CMI Improvement of 1% (annually) $ 30,000
Normalized RUG-III CMI (Q42016) 1.0885
Normalized RUG-IV CMI (Q42016) 0.995
Percent Change from RUG-III to RUG-IV - 8.60%
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L Summary of Priced-Based Payment System (continued)
Calculate direct (case-mix neutralized) and indirect costs per day from PFY14 inflated to SFY18 for each facility.
No minimum occupancy requirement for direct or indirect (note: 88% occupancy requirement does still exist for FRV).
Calculate “spending floor” by multiplying peer group per diem by 95% (direct is case-mix neutral).
Limits potential gain of low cost facilities and losses for higher cost facilities.
Compares each facility's’ cost per day to its peer group spending floor separately for direct and indirect.
If cost per day is more than peer group spending floor (95% of peer group per diem), use peer group rate.
If cost is less than peer group spending floor, pay peer group rate minus the difference between facility cost and peer group spending floor.
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L Summary of Priced-Based Payment System (continued)
SFY18 Direct Price Urban 4 (Other MSAs) $ 101.55
SFY18 Direct Spending Floor
95% X Direct Price (101.55 x 0.95) 96.47
Direct Costs inflated to SFY18 82.78
Floor Impact Floor - Cost, 0 if negative (96.47 – 82.78) 13.69
Adjusted Direct Price Direct Price - Floor Impact (115.62 – 15.08) $ 87.86
Price-Based Example (Adjusted for Floor)
Actual example and… provider is above Indirect Spending Floor
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L NATCEP and Criminal Records Check
Criminal Records Check (CRC): PFY total costs divided by total days – (no inflation).
NATCEP and CRC will be updated annually.
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L FY18 RUG-IV 48-Grouper Example
Urban 3 Example / RUGS-IV 48-Grouper ES3 HE2 RAE LC1 CA2 PA1
SFY18 Direct Base Rate $ 119.05 $ 119.05 $ 119.05 $ 119.05 $ 119.05 $ 119.05
RUGS III-34 Weight 3.00 1.88 1.65 1.02 0.73 0.45
SFY18 Direct Per Diem 357.15 223.81 145.00 121.43 86.91 53.57 SFY18 Fixed Per Diem (Indirect, SY17 FRV, SY17 NATCEP, and SY17 CRC) 115.82 115.82 115.82 115.82 115.82 115.82
Final Per Diem $ 472.97 $ 339.63 $ 312.25 $ 237.25 $ 202.73 $ 169.39
July 1, 2017 thru June 30, 2018 The direct rate component of each claim will be calculated based on the RUGS score during the claim period.
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L 48/34-Grouper Comparison
DMAS Quarterly Measurement (Facility Indexed to Statewide Average) - Sample Facility 34-Grouper 48-Grouper % Change
Q42016 1.0885 0.995 - 8.60%
Q32016 1.1223 1.0453 - 6.90%
Q22016 1.0576 1.0023 - 5.20%
Q12016 1.0801 1.0239 - 5.20%
Q42015 1.0688 1.0205 - 4.50%
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L Why Cost Reports Can Be More Important Now than in the past Under the prior system, bad cost reports could impact reimbursement for one year. Now bad cost reports can impact providers for 3 years. Price-based rates are computed from provider cost reports every 3 years (base years: 2014, 2017, 2020 etc.). Keep in mind that base years could change (discussions related to this during most recent rebasing period). Majority of providers’ payments will be impacted by their cost reports in at least one of the following ways:
If under 95% spending floor for either direct or indirect – reimbursement will be limited. If not under 95% spending floor; provider’s cost report could be used to compute peer group pricing – this will impact every provider in peer group.
Inappropriate cost reports will impact provider’s reimbursement rate; some significantly. To properly manage your reimbursement, you need to know your costs by categories annually. You cannot wait to review your costs when you prepare your base year cost report – you may loose opportunities to be reimbursed your proper costs.
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L Why Cost Reports Can Be More Important Now than in the Past (continued)
Cannot stress enough how important proper base year cost report optimization is. Annual cost reports and proper costing are essential to proactively manage your Medicaid reimbursement rates.
Audits will continue to occur and could have multi-year implications (each dollar removed could impact rate by approximately 2.1X).
We will most likely see Medicaid MDS/CMI audit activity (especially since now using non-normalized CMI scores / surprised we haven’t already seen this).
Base year cost reports will impact rates for 3 rate periods .
During last rebasing we saw some calculations that reduced reimbursement at single buildings by over $1 million; per year x 3 years.
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L Why Cost Reports Can Be More Important Now than in the Past (continued)
Be careful with your base period cost report; it could have significant reimbursement implications.
CY17 cost reports will become your Medicaid payment rates approximately 2 years after cost report filing and will impact provider for 3 years!!!
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L Medicare-A PPS and Medicaid Priced-Based
Medicare-A PPS
Price-based
Patient-specific
Case mix adjusted – nursing plus ancillaries
66-Grouper
MDS 3.0
Medicaid Price-Based
Price-based but with “peer spending group floor”, capital, NATCEP, and CRC by facility
Patient-specific (starting 11/01/14)
Case mix adjusted – nursing plus ancillaries
48-Grouper (was 34-Grouper)
MDS 3.0 (was MDS 2.0)
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L 66-Grouper vs. 48-Grouper
Both utilize MDS 3.0 (34-Grouper used MDS 2.0).
Rehabilitation categories are reduced.
Most rehab provided under Medicare Part-B.
Minutes of rehab do not determine rehab category as long as category achieved.
Category is based upon need for skilled rehab and ADL scores.
The RUG Level for Medicaid is computed by DMAS using the MDS data elements transmitted by each facility to the VDH (Virginia Department of Health).
Each valid Assessment is assigned a RUG Category and an associated CMI.
Resident specific Medicaid RUG score(s) are listed on the Medicaid claim and residents are paid up to 48 different facility specific Medicaid RUG rates (similar to Medicare-A PPS Billing).
No two facilities are paid the same Medicaid rate (unlike Medicare-A).
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L Fair Rental Value (FRV) Capital Rates
Non-hospital based facilities are reimbursed utilizing the DMAS FRV payment methodology.
Only historical costs that are reimbursed are capital related taxes and insurance.
SFY18 capital rates are based on CY16 FRV reports for non-hospital based providers.
Acquisition costs related to any sale or change in the ownership of a nursing facility or the assets of a nursing facility shall not be included in the schedule of assets if the transaction occurred after June 30, 2000.
Management of Medicaid FRV rates are very important.
Facilities need to diligently retire of disposed assets from their R-1 Schedule of Assets.
Old assets removed from the R-1 Schedule of Assets can be as beneficial to your Medicaid FRV rate as adding new assets (very few providers do this well).
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L Fair Rental Value (FRV) Capital Rates (continued)
How do I remove assets from my R-1 Schedule of Assets if they are not identifiable on my Fixed Asset Schedule?
Building related assets grouped together and not reported in detail (especially non-profit operators).
Inherited R-1 Schedule of Assets from prior operator. How do we know what to remove?
The good news is neither does Myers and Stauffer, LC. CPI index calculations
“Good faith” disposal
Internal fixed asset schedule
Important to time FRV additions during calendar year period if appropriate (not provider FYE).
Must exceed $50,000 by R-1 Schedule of Assets category to be included on Schedule of Assets ($25,000 for facilities with 30 or fewer beds).
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L Fair Rental Value (FRV) Capital Rates (continued)
“Facility average age” is the weighted average of the ages of all capitalized assets of the facility (this is what you can control).
Facility average age floor of 21 years (need to know this before starting major renovation project).
R-1 Schedule of Asset Categories: Land Improvements
Building and Fixed Equipment
Major Moveable Equipment
Be aware of new bed or new facility FRV rate opportunities.
Hospital-based facilities are not using the FRV methodology for capital costs.
Capital reimbursement is based on allowable costs per the related hospital cost report.
Make sure your hospital reimbursement department is aware of this important item.
Hospital reimbursement departments often forget about the NF and typically don’t understand the reimbursement implications.
DMAS will pay hospital-based facilities’ capital costs based on their last settled capital per diem.
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L FRV Mid-Year FRV Rate Adjustments
Nursing facilities that put into service a major renovation or new beds may request a mid-year fair rental value per diem rate change.
Major renovation defined as an increase in capital of $3,000 per bed (e.g., must spend $300,000 in 100 bed facility).
Nursing facility shall submit complete pro forma documentation at least 60 days prior to the effective date, and the new rate shall be effective at the beginning of the month following the end of the 60 days.
Provider shall submit final documentation within 60 days of the new rate effective date, and the department shall review final documentation and modify the rate if necessary effective 60 days after the implementation of the new rate.
No mid-year rate changes shall be made for an effective date after April 30th of the fiscal year.
Myers and Stauffer, LC has shown increased interest in limiting capital additions on Schedule R-1 Schedule of Assets.
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L Presentation Takeaways - Financial
Do I know where my facility is in relation to my Medicaid Direct and Indirect Prices and Spending Floors?
Interim measurements
Spending in base year
Review of capitalization policies (more flexibility than most think)
Are we doing everything we can to appropriately optimize our Medicaid FRV rate?
Retirement of old assets
Mid-year FRV filing if applicable
Planning fixed asset purchases in a CY so as to exceed spending limit
Do we have an active Medicaid (and Medicare – it is not just about rehab) CMI management program in place?
Do we track RUG-IV 48-Grouper rates weekly?
Are we monitoring Medicaid CMI scores daily, especially low rates?
Do I know how my July 1st Medicaid rates are going to impact my facility (remember, RUG-IV 48-Grouper rates are generally lower)?
LEARNING OBJECTIVES - CLINICAL
Guidelines for RUG-IV 48-Grouper are to code the MDS items as directed in the Resident Assessment Manual (RAI).
Targeted overview of the RUGS-IV 48-Grouper Cover what has changed from the old RUGS-III 34-Grouper to the new
RUGS-IV 48-Group. How proper management of the facility’s Medicaid MDS can improve
payment rates. Interdisciplinary approach and why this is more critical than ever –
especially social services. Medicare-B and how it impacts Medicaid reimbursement. Restorative nursing program and how it can be an important quality and
reimbursement item. Total mood severity score based upon resident mood interview. No regulatory changes related to how frequently an MDS can be completed.
RU
G-IV
48-G
RO
UP
ER
AD
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ALC
ULA
TIO
NS
ADL Calculation Score The Activities of Daily Living (ADL) score is a component of the calculation for the placement in all RUG-IV groups. The ADL score is based upon the four “late loss” ADLs (bed mobility, transfer, toilet use, and eating). This score indicates the level or functional assistance of support required by the resident and is a vital component of the classification process.
ADL scores have changed – more difficult to obtain higher scores . Must be good ADL training and retraining.
Self-Performance
Column 1 =
And
Support Provided
Column 2 =
ADL
Score =
Record Score
-, 0, 1, 7 or 8 and -, 0, 1, 2, 3 or 8 0 Bed Mobility = _____
2 and -, 0, 1, 2, 3 or 8 1 Transfer = ________
3 and -, 0, 1 or 2 2 Toilet Use = ________
4 and -, 0, 1 or 2 3
3 or 4 and 3 4
AD
L C
ALC
ULA
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NS
ADL Calculation Score
sss
Self-Performance
Column 1 = And
Support Provided
Column 2 =
ADL
Score = Record Score
-, 0, 1, 2, 7 or 8 and -, 0, 1 or 8 0 Eating = _________
-, 0, 1, 2, 7 or 8 and 2 or 3 2
3 or4 and -, 0 or 1 2
3 and 2 or 3 3
4 and 2 or 3 4
The total ADL score ranges from 0 through 16; a score of 0 represents independence whereas a score of 16 represents total dependence.
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L-EX
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Category I: Extensive Services
Extensive Services Conditions or Services
O0100E, 2 Tracheostomy care (while a resident)
O0100F, 2 Ventilator or respirator (while a resident)
O0100M, 2 Infection isolation (while a resident)
If the assessment is coded with at least one of the above conditions or services, and the ADL score is 2 or more, the assessment classifies as Extensive Service; the resident classifies into Extensive Services.
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Category I: Extensive Services (continued)
Extensive Service Conditions or Services (while a resident) RUG-IV Class CMI
A. Tracheostomy care and ventilator/respirator ES3 3.00
B. Tracheostomy care or ventilator/respirator ES2 2.23
C. Infection isolation without tracheostomy care and without
ventilator/respirator
ES1 2.22
Isolation or Quarantine 4 criteria must be met
1. Active infection with highly transmissible pathogen(s) 2. Precautions over and above standard precautions (contact,
droplet and/or airborne) 3. In a room alone because of infection and cannot have a
roommate 4. Resident must remain in his/her room – requires all services be
brought to the resident Does not apply for
UTIs, encapsulated pneumonia, wound infections
CLIN
ICA
L-RE
HA
BIL
ITA
TIO
N
Category II: Rehabilitation
Rehabilitation classification is any combination of the disciplines of licensed speech-language pathology, occupational therapy or physical therapy services. Restorative Nursing programs are also considered for the low intensity therapy level. Determine whether the assessment is coded for therapy minutes and days:
O0400 Therapies
O0400A - Speech-Language Pathology and Audiology Services
O0400A, 1
O0400A, 2
O0400A, 3
O0400A, 4
Individual Minutes
Concurrent Minutes
Group Minutes
Days
O0400B - Occupational Therapy
O0400B, 1
O0400B, 2
O0400B, 3
O0400B, 4
Individual Minutes
Concurrent Minutes
Group Minutes
Days
O0400C - Physical Therapy
O0400C, 1
O0400C, 2
O0400C, 3
O0400C, 4
Individual Minutes
Concurrent Minutes
Group Minutes
Days
O0420 Distinct Calendar Days of Therapy
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BIL
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N
Category II: Rehabilitation (continued)
(1) Received 150 or more minutes and at least 5 distinct days of any combination of the 3 disciplines
OR (2) Received 45 or more minutes and at least 3 distinct days of any combination of the 3 disciplines and 2 or more restorative nursing programs received for 6 or more days.
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L-RE
HA
BIL
ITA
TIO
N
Category II: Rehabilitation (continued)
Restorative Nursing Programs
H0200C H0500 Current toileting program or trial# Bowel toileting program#
O0500A
O0500B
Range of motion (passive)# Range of motion (active)#
O0500C Splint or brace assistance
O0500D O0500F Bed mobility# Walking#
O0500E Transfer
O0500G Dressing and/or grooming
O0500H Eating and/or swallowing
O0500I Amputation/Prosthesis care
O0500J Communication
# For RUG classification count as one program even if both provided
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L-RE
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BIL
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N
Category II: Rehabilitation (continued)
The final classification for Rehabilitation is based on the following:
ADL Score RUG-IV Class CMI
15 - 16 RAE 1.65
11 - 14 RAD 1.58
6 - 10 RAC 1.36
2 - 5 RAB 1.10 0 - 1 RAA 0.82
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L-SP
EC
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AR
E H
IGH
Category III: Special Care High
Special Care High Conditions or Services
B0100 Comatose with ADL Self-Performance dependency coded
4 or 8 for all late loss ADLs
I2100 Septicemia
I2900
N0350A
N0350B
Diabetes Mellitus (DM) with both of the following:
~Insulin injections for all 7 days
~Insulin order changes on 2 or more days
I5100 Quadriplegia with ADL score of 5 or higher
I6200 J1100C Chronic Obstructive Pulmonary Disease (COPD) with
~Shortness of breath when lying flat (Assess COPD
residents for ability to breathe while lying flat during
assessment period)
J1550A
I2000
J1550B
K0300, 1 or 2
K0510B, 1 or 2
Fever with one of the following:
~Pneumonia
~Vomiting
~Weight Loss
~Feeding Tube with requirements*
1-while not a resident
2-while a resident
K0510A, 1 or 2 Parenteral/IV Feeding
1-while not a resident
2-while a resident
O0400D, 2 Respiratory Therapy for all 7 days
Tube Feeding Requirements
*Tube feeding requirements:
(1)Proportion of total calories received through parenteral or tube feeding (K0710A3) is 51% or more of total calories during entire period. OR
(1)Proportion of total calories received through parenteral
or tube feeding (K0710A3) is 26% to 50% of total calories
and average fluid intake per day (K0710B3) is 501 cc or
more during entire period.
Reimbursement Example:
PE1 $ 255.11
HE2 339.63
Daily Improvement: 84.52
Quarterly Improvement: 7,776
Annual Improvement: $ 30,850
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EC
IAL H
IGH
Category III: Special Care High (continued)
Resident Interview Resident Mood Symptom Frequency
Staff
Assessment
D0200A, 2 Little interest or pleasure in doing things D0500A, 2
D0200B, 2 Feeling (or appearing) down, depressed, or hopeless
D0500B, 2
D0200C, 2 Trouble falling or staying asleep, or sleeping too much
D0500C, 2
D0200D, 2 Feeling tired or having little energy D0500D, 2
D0200E, 2 Poor appetite or overeating D0500E, 2
D0200F, 2 Feeling bad about yourself – or that you are a failure or have let
yourself or your family down D0500F, 2
D0200G, 2 Trouble concentrating on things, such as reading or watching TV
D0500G, 2
D0200H, 2
Moving or speaking slowly that others have noticed or being fidgety or
restless; moving around a lot more than usual D0500H, 2
D0200I, 2 Thoughts better off dead or hurting self D0500I, 2
NA Being short-tempered, easily annoyed D0500J, 2
D0300
Total Severity Score
These items are used to calculate a Total Severity Score; Item D0300
for the resident interview and Item D0600 for the staff assessment. D0600
The assessment indicates depression for RUG-IV classification if:
A.The Total Severity Score PHQ-9© (D0300), which includes items D0200A-I (Resident Interview), is greater than or equal to 10 but not 99. OR B.The Total Severity Score PHQ-9-OV© (D0600), which includes items D0500A-J (Staff Assessment), is greater than or equal to 10.
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L-SP
EC
IAL H
IGH
Category III: Special Care High (continued)
ADL Score Depressed RUG-IV Class CMI
15 - 16 Yes HE2 1.88
15 - 16 No HE1 1.47
11 - 14 Yes HD2 1.69
11 - 14 No HD1 1.33
6 - 10 Yes HC2 1.57
6 - 10 No HC1 1.23
2 - 5 Yes HB2 1.55
2 - 5 No HB1 1.22
The final classification for Special Care High is based on the following:
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L-SP
EC
IAL C
AR
E L
OW
Category IV: Special Care Low
Determine if the assessment is coded for one of the following conditions or services:
Special Care Low Conditions or Services
I4400 Cerebral Palsy with ADL score of 5 or higher
I5200 Multiple Sclerosis (MS) with ADL score of 5 or higher
I5300 Parkinson’s Disease with ADL score of 5 or higher
I6300
O0100C, 2
Respiratory Failure with
~Oxygen therapy (while a resident)
K0510B, 1 or 2 Feeding tube with requirements*
M0300B, 1 Two or more Stage 2 pressure ulcers with ~Two or more selected skin treatments**
M0300C, 1 One Stage 3 pressure ulcer with two or more selected skin treatments**
M0300D, 1 One Stage 4 pressure ulcer with two or more selected skin treatments**
M0300F, 1 One Unstageable-slough and/or eschar with ~Two or more selected skin treatments**
M1030 Two or more Venous/Arterial ulcers with ~Two or more selected skin treatments**
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L-SP
EC
IAL C
AR
E L
OW
Category IV: Special Care Low (continued)
Special Care Low Conditions or Services
M0300B, 1 M1030 One Stage 2 pressure ulcer and One Venous/Arterial ulcer with
~Two or more selected skin treatments**
M1040A M1200I Infection of the foot with
~Application of dressing to feet
M1040B M1200I Diabetic foot ulcer with
~Application of dressing to feet
M1040C M1200I Other open lesion on the foot with ~Application of dressing to feet
O0100B, 2 Radiation treatment (while a resident)
O0100J, 2 Dialysis treatment (while a resident)
*Tube feeding requirements:
(1)Proportion of total calories received through parenteral or tube feeding (K0710A3) is 51% or more of total calories during entire period.
OR
(1)Proportion of total calories received through parenteral or tube feeding (K0710A3) is 26% to 50% of total calories and
average fluid intake (K0710B3) is 501 cc or more during entire period.
**Selected Skin Treatments for Special Care Low
Pressure reducing device for chair# Pressure reducing device for bed# (count as one treatment even if both are
provided)
Turning/repositioning program
Nutrition or hydration intervention to manage skin problems
Pressure ulcer care
Application of non-surgical dressing (other than to feet)
Application of ointment/medication (other than to feet)
# For RUG classification count as one treatment even if both are provided
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L-SP
EC
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E L
OW
Category IV: Special Care Low (continued)
The assessment indicates depression for RUG-IV classification if:
A. The Total Severity Score PHQ-9© (D0300), which includes items D0200A-I (Resident Interview), is greater than or equal to 10 but not 99.
OR B. The Total Severity Score PHQ-9-OV© (D0600), which includes items D0500A-J (Staff Assessment), is greater than or equal to 10.
Resident is considered depressed: Yes ______ No _______
The final classification for Special Care Low is based on the following:
ADL Score Depressed RUG-IV Class CMI
15 - 16 Yes LE2 1.61
15 - 16 No LE1 1.26
11 - 14 Yes LD2 1.54
11 - 14 No LD1 1.21
6 - 10 Yes LC2 1.30
6 - 10 No LC1 1.02
2 - 5 Yes LB2 1.21
2 - 5 No LB1 0.95
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Category IV: Special Care Low (continued)
Resident
Interview Resident Mood Symptom Frequency
Staff
Assessment
D0200A, 2 Little interest or pleasure in doing things D0500A, 2
D0200B, 2 Feeling (or appearing) down, depressed, or hopeless D0500B, 2
D0200C, 2 Trouble falling or staying asleep, or sleeping too much D0500C, 2
D0200D, 2 Feeling tired or having little energy D0500D, 2
D0200E, 2 Poor appetite or overeating D0500E, 2
D0200F, 2 Feeling bad about yourself – or that you are a failure or
have let yourself or your family down D0500F, 2
D0200G, 2 Trouble concentrating on things D0500G, 2
D0200H, 2 Moving or speaking slowly or being fidgety or restless D0500H, 2
D0200I, 2 Thoughts better off dead or hurting self D0500I, 2
NA Being short-tempered, easily annoyed D0500J, 2
D0300
Total Severity Score
These items are used to calculate a Total Severity Score;
Item D0300 for the resident interview and Item D0600 for
the staff assessment.
D0600
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Category IV: Special Care Low (continued)
If the assessment does have one of these conditions or services coded and the ADL score is 2 or more (with the exception of Cerebral Palsy, Multiple Sclerosis and Parkinson’s Disease which requires an ADL score of 5 or higher), the assessment classifies as Special Care Low;
Signs and symptoms of depression are used as a third-level split for the Special Care Low category. Assessments indicating signs and symptoms of depression are identified by the Resident Mood Interview (PHQ-9©) or the Staff Assessment of Resident Mood (PHQ-9-OV©) for symptom frequency. Instructions for completing the PHQ-9© are in the RAI Manual (Chapter 3, Section D).
The following MDS items comprise the Resident Mood Interview PHQ-9© and Staff Assessment of Resident Mood (PHQ-9-OV©):
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LLY C
OM
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X
Category V: Clinically Complex
*Selected Skin Treatments for Clinically Complex
I2000 Pneumonia
I4900 Hemiplegia or Hemiparesis with ADL score of 5 or higher
M1040D Open lesion other than ulcers, rashes, cuts with ~Any selected skin treatment*
M1040E Surgical wound with any selected skin treatment*
M1040F Burn (2nd to 3rd degree)
O0100A, 2 Chemotherapy (while a resident)
O0100C, 2 Oxygen therapy (while a resident)
O0100H, 2 IV medication (while a resident)
O0100I, 2 Transfusion (while a resident)
*Selected Skin Treatments for Clinically Complex
M1200F Surgical wound care
M1200G Application of non-surgical dressing (other than to feet)
M1200H Applications of ointment/medication (other than to feet)
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Category V: Clinically Complex (continued)
Signs and symptoms of depression are used as a third-level split for the
Special Care Low category. Assessments indicating signs and symptoms
of depression are identified by the Resident Mood Interview (PHQ-9©) or
the Staff Assessment of Resident Mood (PHQ-9-OV©) for symptom
frequency. Instructions for completing the PHQ-9© are in the RAI
Manual (Chapter 3, Section D).
Oxygen with signs and symptoms of depression captured.
Reimbursement Example:
PD1 $ 242.01
CD2 $ 269.39
Daily Improvement: 27.38
Quarterly Improvement: 2,519
Annual Improvement: $ 9,994
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Category V: Clinically Complex (continued)
The following MDS items comprise the Resident Mood Interview PHQ-9© and Staff Assessment of Resident Mood (PHQ-9-OV©):
Resident
Interview Resident Mood Symptom Frequency
Staff
Assessment
D0200A, 2 Little interest or pleasure in doing things D0500A, 2
D0200B, 2 Feeling (or appearing) down, depressed, or hopeless D0500B, 2
D0200C, 2 Trouble falling or staying asleep, or sleeping too much D0500C, 2
D0200D, 2 Feeling tired or having little energy D0500D, 2
D0200E, 2 Poor appetite or overeating D0500E, 2
D0200F, 2 Feeling bad about yourself – or that you are a failure or
have let yourself or your family down D0500F, 2
D0200G, 2 Trouble concentrating on things D0500G, 2
D0200H, 2 Moving or speaking slowly or being fidgety or restless D0500H, 2
D0200I, 2 Thoughts better off dead or hurting self D0500I, 2
NA Being short-tempered, easily annoyed D0500J, 2
D0300
Total Severity Score
These items are used to calculate a Total Severity Score;
Item D0300 for the resident interview and Item D0600
for the staff assessment.
D0600
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Category V: Clinically Complex (continued)
Step #3:
The final classification for Clinically Complex is based on the following chart:
ADL Score Depressed RUG-IV Class CMI
15 - 16 Yes CE2 1.39
15 - 16 No CE1 1.25
11 - 14 Yes CD2 1.29
11 - 14 No CD1 1.15
6 - 10 Yes CC2 1.08
6 - 10 No CC1 0.96
2 - 5 Yes CB2 0.95
2 - 5 No CB1 0.85
0 - 1 Yes CA2 0.73
0 - 1 No CA1 0.65
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Category VI: Behavioral and Cognitive
Classification in this category is based on the impaired cognitive performance or the presence of certain behavioral symptoms. Use the following instructions in this order:
Step #1:
A.If the ADL score is greater than 5, skip to Category VII, Reduced Physical Function.
B.If the ADL score is 5 or less, proceed to Step #2.
Step #2:
A.If the resident interview using the Brief Interview for Mental Status (BIMS) was not conducted (indicated by a value of “0” for Item C0100), skip to Step #3.
If the resident interview using the Brief Interview for Mental Status (BIMS) was conducted, determine the resident’s cognitive status based on the following:
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Category VI: Behavioral and Cognitive (continued)
Brief Interview for Mental Status (BIMS) Items
C0200 - Repetition of three words
C0300 - Temporal Orientation
C0300A
C0300B
C0300C
Able to report correct year
Able to report correct month
Able to report correct day of the week
C0400 - Recall
C0400A
C0400B
C0400C
Able to recall “sock”
Able to recall “blue”
Able to recall “bed”
C0500
BIMS Summary Score
The BIMS Summary Score, a range of 0-15, indicates cognitive level of performance. A score of 15 indicates the resident is
cognitively intact while a score of 0 indicates severe cognitive impairment. If the interview is not successful, then the
BIMS Summary Score will equal 99.
A. For RUG-IV classification, if the Summary Score is less than or equal to 9, he/she is considered cognitively impaired and the assessment classifies in the Behavioral Symptoms and Cognitive Performance category; skip to Step #5.
B. If the Summary Score is greater than 9, but not 99, skip to Step #4.
C. If the Summary Score is 99 (resident interview not successful) or the Summary Score is blank (resident interview not attempted and skipped) or the Summary Score has a dash value (not assessed), proceed to Step #3.
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Category VI: Behavioral and Cognitive (continued)
Step #3:
If the resident chooses not to participate in the BIMS interview or if four or more items were coded 0 because he/she chose not to answer or gave nonsensical response, the cognitive impairment level will be determined based upon the staff assessment rather than resident interview.
Cognitive Performance Scale (CPS) - Staff Assessment
B0100 Comatose with ADL Self-Performance dependency code of 4 or 8 for all late loss ADLs
OR
C1000=3 Severely impaired cognitive skills
OR
Two or more of the following impairment indicators:
B0700>0
C0700=1
C1000>0
Makes Self Understood (problem being understood)
Short-Term Memory (problem)
Cognitive Skills for Daily Decision Making (problem)
AND
One or both of the following severe impairment indicators:
B0700>=2 C1000>=2 Makes Self Understood (severe problem being understood) Cognitive Skills for Daily Decision Making (severe problem)
A. If the assessment does not satisfy any of the above criteria, then he/she is not considered cognitively impaired, skip to Step #4.
B. If the assessment does satisfy one of the above criteria for being cognitively impaired, then he/she is considered cognitively impaired and the assessment classifies in Behavioral Symptoms and Cognitive Performance; skip to Step #5.
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Category VI: Behavioral and Cognitive (continued)
Step #4:
Determine whether the assessment is coded for one of the following behavioral symptoms that occurred four to seven days during the observation period:
Behavioral Symptoms
E0100A Hallucinations
E0100B Delusions
E0200A, 2 or 3 Physical behavioral symptoms directed toward others
E0200B, 2 or 3 Verbal behavioral symptoms directed toward others
E0200C, 2 or 3 Other behavioral symptoms not directed toward others
E0800, 2 or 3 Rejection of Care
E0900, 2 or 3 Wandering
A. If the assessment does not have one of these behaviors coded, skip to Category VII, Reduced Physical Function.
B. If the assessment does have one of these behaviors coded, the assessment classifies as Behavioral Symptoms and Cognitive Performance; proceed to Step #5.
Step #5: The final step in determining the Behavioral Symptoms and Cognitive Performance classification is the Restorative Nursing Program Count.
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Category VI: Behavioral and Cognitive (continued)
Count the number of restorative nursing programs provided 6 or more days:
Restorative Nursing Programs
H0200C H0500 Current toileting program or trial# Bowel toileting program#
O0500A
O0500B
Range of motion (passive)# Range of motion (active)#
O0500C Splint or brace assistance
O0500D O0500F Bed mobility# Walking#
O0500E Transfer
O0500G Dressing and/or grooming
O0500H Eating and/or swallowing
O0500I Amputation/Prosthesis care
O0500J Communication
# For RUG classification count as one program even if both provided
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Category VI: Behavioral and Cognitive (continued)
Step #6:
The final classification for Behavioral Symptoms and Cognitive Performance is based on the following:
ADL Score Restorative Nursing RUG-IV Class CMI
2 - 5 2 or more programs BB2 0.81
2 - 5 0 or 1 program BB1 0.75
0 - 1 2 or more programs BA2 0.58
0 - 1 0 or 1 program BA1 0.53
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Category VII: Reduced Physical Function
Assessments that do not meet the conditions of any of the previous categories, including those assessments that met the criteria for the Behavioral Symptoms and Cognitive Performance category but have an ADL score greater than 5, are classified in this category;
Determine Restorative Nursing Program Count
Count the number of restorative nursing programs provided for 6 or more days:
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Category VII: Reduced Physical Function (continued)
Restorative Nursing Programs
H0200C H0500 Current toileting program or trial# Bowel toileting program#
O0500A
O0500B
Range of motion (passive)# Range of motion (active)#
O0500C Splint or brace assistance
O0500D O0500F Bed mobility# Walking#
O0500E Transfer
O0500G Dressing and/or grooming
O0500H Eating and/or swallowing
O0500I Amputation/Prosthesis care
O0500J Communication
# For RUG classification count as one program even if both provided
Step #3:
The final classification for Reduced Physical Function is based on the following:
ADL Score Restorative Nursing RUG-IV Class CMI
15 - 16 2 or more programs PE2 1.25
15 - 16 0 or 1 program PE1 1.17
11 - 14 2 or more programs PD2 1.15
11 - 14 0 or 1 program PD1 1.06
6 - 10 2 or more programs PC2 0.91
6 - 10 0 or 1 program PC1 0.85
2 - 5 2 or more programs PB2 0.70
2 - 5 0 or 1 program PB1 0.65
0 - 1 2 or more programs PA2 0.49
0 - 1 0 or 1 program PA1 0.45
Inactive/Expired BC1 0.43
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Category VII: Reduced Physical Function (continued)
Inactive/Expired Assessment Definition:
For purposes of Medicaid reimbursement only, each assessment shall be considered active for up to 92 days. Active days are measured between two consecutive assessments using the ARD dates of both assessments. If no new assessment is completed, transmitted and accepted, the period beginning day 93 is considered an inactive or expired assessment period.
The days following an expired assessment (starting the 93rd day) will be assigned the delinquent RUG classification of BC1 with a CMI of 0.43.
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Restorative Nursing – Tips for Success RAI Requirements
Under nursing supervision
Addressed in Plan of Care and clinical record with measurable objectives and interventions
Evidence of periodic evaluation by a nurse in the clinical record
Each restorative nursing service is delivered at least 15 minutes in a 24 hour period.
Personnel performing restorative care are trained in restorative techniques.
Can be provided by CNAs, Activities, Facility Staff, etc. who are trained in restorative care.
Additional Considerations for Restorative Nursing
At least 2 restorative activities (Note: these pairs are counted as “1”)
Active / Passive ROM
Bed mobility / walking
6 out of 7 days
Group restorative care
At least 4:1 resident / staff ratio
Each resident receives credit for total treatment time
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Restorative Nursing - Structure
Who is in charge of Restorative Nursing?
Designate a person and/or position
Who supervises Restorative Nursing?
24 hours a day
7 days a week
Who performs restorative nursing services?
Restorative Nursing Assistant (RNA)
Certified Nursing Assistant (CNA)
A combination of both RNA and CNA
How are other departments involved?
Activities with exercise or grooming groups?
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As with any MDS coding, ensure that supporting documentation in lookback period will support the RUG score billed.
Corresponding Nursing documentation in the medical record for the type of RUG billed.
MDS coded correctly for reason for assessment.
Appropriate diagnosis codes on UB-04, have any new Dx been added that may need to be made a primary?
MDSs within billing period have ARDs set within required timelines (no late assessments).
MDSs transmitted timely and in repository prior to billing the RUG.
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Strategies for Medicaid CMI Success
Form team to oversee transition to 48-Grouper
Active Therapy Referral Program
Rehab not what it used to be but still good
Restorative Nursing Program (must collaborate with therapy team) – increased reimbursement opportunity
Review at risk residents for acuities
MDS schedule to disciplines well ahead of the MDS schedule
Target the Low CMIs (0.45-0.91) to monitor for acuities
O2 orders – check the prn orders for usage
Capture nebulizer treatment minutes
Provide training for licensed nurses for RT
Physician Order Logs
Insulin dependent diabetics
Insulin order changes
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Strategies for Medicaid CMI Success (continued)
Skin Conditions (QMs)
Stage 1 ulcers will not enter in RUG score
2 or more State II ulcers
Stage 3,4 or unstageable due to slough or eschar
2 or more venous/arterial ulcers
Stage II plus one venous/arterial ulcer
Fever as per RAI Manual
Pneumonia, vomiting, weight loss, feeding tube
Monitor physician insulin orders and 24-hour reports for changes in condition or clinical services
Review RUG-IV 48-grouper reports
Rehab – Medicare Part-B caseload – If 5 x week for 5 days and 150 or > mins, or 3 x week with 2 RNA programs, 6 out of 7 days for 15 or > minutes per day
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Strategies for Medicaid CMI Success (continued)
Strategically setting the optimal ARD
Anytime resident leaves for hospital/ER, request documentation (not admitted or out less than 24 hours)
Must have an active CMI work group that holds weekly meetings to review CMI
MDS staff
Rehab (very, very important)
Nursing Admin (DON, ADON, etc.)
Administration
Assess COPD residents for ability to breathe while lying flat during assessment periods
Diagnosis of Parkinson’s Disease with medication (Definitive DX)
Capture isolation as appropriate
Documentation of respiratory therapy services and maintenance of staff training records
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Strategies for Medicaid CMI Success (continued)
Review hospital records
In-house services
IV/Parenteral fluids or feedings in 7-day look back
Services in house
Respiratory failure with Oxygen
Radiation therapy, Dialysis, Transfusions
Chemotherapy
Oxygen
IV medications
Tracheostomy care, ventilator/respirator
Isolation
Make sure you are being reimbursed for services you are rendering. Document well.
Measure, Measure, Measure, for success!!!!
