RUG-III V ERSION 5.20 CALCULATION WORKSH E E T 34 GROUP MOD E L F OR MDS 3.0

Transcription

1 RUG-III V ERSION 5.20 CALCULATION WORKSH E E T 34 GROUP MOD E L F OR MDS 3.0 This RUG-III Version 5.20 calculation worksheet is a step-by-step walk through to manually determine the appropriate RUG-III classification based on the information from an MDS 3.0 assessment. The worksheet takes the computer programming and puts it into words. We have carefully reviewed the worksheet to insure that it represents the standard logic. This worksheet is for the 34 group RUG-III Version 5.20 model. In the 34 group model the Rehabilitation groups have been collapsed to 4 groups and different levels of rehabilitation service are not distinguished. The simplified Rehabilitation classification in the 34 group model is better suited to long-term care programs, which often classify on the basis of nursing care needs only. Medicaid long-term care programs in many States are examples. In the 34 group model, the Extensive Services groups have the highest level of nursing care needs, while the Rehabilitation groups have the next highest level of need. For this reason, the order of the Rehabilitation and Extensive Services groups are reversed in the 34 group model, with the Extensive Services groups first. H I E R A R C H I C A L V E RSUS IND E X M A X I M I Z IN G There are two basic approaches to RUG-III classification: [1] hierarchical classification and [2] index maximizing classification. The present worksheet is focused on the hierarchical approach but can be adapted to the index maximizing approach. Hierarchical Classification. The present worksheet employs the hierarchical classification method. Hierarchical classification is used in some payment systems, in staffing analysis, and in many research projects. In the hierarchical approach, you start at the top and work down through the RUG-III model, and the classification is the first group for which the resident qualifies. In other words, start with the Extensive groups at the top of the RUG-III model. Then you work your way down through the groups in hierarchical order: Extensive Services, Rehabilitation, Special Care, Clinically Complex, Impaired Cognition, Behavior Problems, and Reduced Physical Functions. When you find the first of the 34 individual RUG-III groups for which the resident qualified, then assign that group as the RUG-III classification and you are finished. If the resident would qualify in one of the Extensive Services groups and also in a Rehabilitation group, always choose the Extensive Services classification, since it is higher in the hierarchy. Likewise, if the resident qualifies for Special Care and Clinically Complex, always choose Special Care. In hierarchical classification, always pick the group nearer the top of the model. Index Maximizing Classification. Index maximizing classification is used in Medicare PPS and most Medicaid payment systems. For a specific payment system, there will be a designated Case Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 1 of 18

2 RUG-III V ERSION 5.20 CALCULATION WORKSH E E T 34 GROUP MOD E L F OR MDS 3.0 Mix Index [CMI] for each RUG-III group. The first step in index maximizing is to determine all of the RUG-III groups for which the resident qualifies. Then from the qualifying groups you choose the RUG-III group that has the highest case mix index. Index maximizing classification is simply choosing the group with the highest index. While the present worksheet illustrates the hierarchical classification method, it can be adapted for index maximizing. To index maximize, you would evaluate all classification groups rather than assigning the resident to the first qualifying group. In the index maximizing approach, you again start at the beginning of the worksheet. You then work down through all of the 34 RUG-III classification groups, ignoring instructions to skip groups and noting each group for which the resident qualifies. When you finish, record the CMI for each of these groups. Select the group with the highest CMI. This group is the index maximized classification for the resident. If the resident would qualify in one of the Extensive Services groups and a Rehabilitation group choose the RUG-III classification with the higher CMI. Likewise, if the resident qualifies for Special Care and Clinically Complex, again choose the RUG-III classification with the higher CMI. Always select the classification with the highest CMI. Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 2 of 18

3 F OR MDS 3.0 -III category. It is a very important component of the classification process. ST EP #1 To calculate the ADL core use the following chart for G0100A{1&2} bed mobility, G0110B{1&2} transfer, and G0110I{1&2} toilet use. Enter the ADL scores to the right. Column 1 Column 2 ADL score = SCORE -, 0, 1, or 7 and (any number) = 1 Bed Mobility 2 and (any number) = 3 Transfer 3, 4, or 8 and -, 0, 1 or 2 = 4 Toilet Use 3, 4, or 8 and 3 or 8 = 5 ST EP #2 If K0500A [parenteral/iv] is checked, the eating ADL score is 3. If K0500B [feeding tube] is checked and EITHER [1] K0700A is 50% or more calories OR [2] K0700A is 26% to 50% calories and K0700B is 501cc or more per day fluid enteral intake, then the eating ADL score is 3. Enter the A D L eating score [G0110H {1}] below and total the A D L score. If not, go to Step #3. ST EP #3 If neither K0700A nor K0700B [with appropriate intake] are checked, evaluate the chart below for G0110H [eating self-performance]. Enter the score to the right and total the ADL score. This is the RUG-III T O T A L A D L SC O R E. [The total ADL score range possibilities are 4 through 18.] Column 1 Eating ADL Score SCORE -, 0, 1, or 7 = 1 Eating 2 = 2 3, 4, or 8 = 3 T O T A L RU G-III A D L SC O R E Other ADLs are also very important, but the researchers have determined that the late loss ADLs were more predictive of resource use. They determined that allowing for the early loss ADLs did not significantly change the classification hierarchy or add to the variance explanation. Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 3 of 18

4 CAT E GORY I: E XT E NSIV E SERVIC ES The classification groups in this hierarchy are based on various services provided. Use the following instructions to begin the calculation: ST EP #1 Is the resident coded for receiving one or more of the following extensive services? K0500A O0100H{1or2} O0100D{1or 2} O0100E {1or2} O0100F {1or2} Parenteral / IV IV medication Suctioning Tracheostomy care Ventilator or respirator If the resident does not receive one of the above, skip to Category II now. ST EP #2 If at least one of the above treatments is coded then examine the total RUG-III ADL score. a. If the total RUG-III ADL score is 7 or more, then the resident classifies as Extensive Services. Move to Step #3. b., skip to Category II now to determine if the resident will qualify for a Rehabilitation group. If the resident does not qualify for Rehabilitation then they will automatically qualify for Special Care [SSA }. ST EP #3 Determine the At this step, if Parenteral/IV is checked, include a count of 1 to the Extensive Services Count. If IV Medication is checked, include a count of 1 to the Extensive Services Count. Suctioning, Tracheostomy Care, and Ventilator or Respirator contributes a count of 0 to the Extensive Services Count. Parenteral / IV checked Suctioning is checked Tracheostomy care is checked Ventilator / Respirator is checked IV Medication is checked = 1 count = 0 count = 0 count = 0 count = 1 count Extensive Services Count Possible range at this step is 0-2 Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 4 of 18

5 CAT E GORY I: E XT E NSIV E SERVIC ES ST EP #4 To complete the Extensive Services Count: To complete the scoring for the Extensive Services Category, and Extensive Services Count is completed by evaluating the criteria for Special Care, Clinically Complex and Impaired Cognition. The final classification into SE1, SE2, or SE3 will be completed after all criteria have been evaluated. A. Go to Category III, Special Care. If the assessment meets one* or more of the Special Care criteria, assign a count of 1; [assign a count of 0, if no criteria are met in this category]. B. Go to Category IV, Clinically Complex. If the assessment meets one* or more of the Clinically Complex criteria, assign a count of 1; [assign a count of 0, if no criteria are met in this category]. C. Go to Category V, Impaired Cognition. If assessment meets one* or more of the Impaired Cognition criteria, assign a count of 1; [assign a count of 0, if no criteria are met in this category]. *Even if the assessment meets more than one criterion in a category, it only receives an Extensive Services count of 1. ST EP #5 Sum the Extensive Services Count[s] in all four categories below: Category I. Extensive Services Count - Extensive Service [0, 1, 2] Category III. Extensive Services Count - Special Care [0,1] Category IV. Extensive Services Count - Clinically Complex [0, 1] Category V. Extensive Services Count - Impaired Cognition [0, 1] Total Extensive Services Count [0 5] ST EP #6 Determine the final Extensive Services classification using the Total Extensive Services Count. Total Extensive Services Count Extensive Services Classification 4 or 5 SE3 2 or 3 SE2 0 or 1 SE1 Final Extensive Services Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 5 of 18

6 CAT E GORY II: RE H ABILITATION Rehabilitation therapy is any combination of the disciplines of physical, occupational, or speech therapy. This information is found in Section O0400{A,B,C}. Nursing rehabilitation is also considered for the low intensity classification level. It consists of providing active or passive range of motion, splint/brace assistance, training in transfer, training in dressing/grooming, training in eating/swallowing, training in bed mobility or walking, training in communication, amputation/prosthesis care, any scheduled toileting program, and bladder retraining program. This information is found in Section O0500{A-J}, H0200{C}, and H0500 of the MDS Version 3.0. ST EP #1 Sum the therapy minutes in Section O0400{A,B,C}. If the total number of therapy minutes is less than 45 minutes, the resident does not classify in the Rehabilitation Category. Skip to Category III now. ST EP #2 If the total number of therapy minutes is equal to or greater than 45 minutes, use the following to complete the Rehabilitation Classification. Rehabilitation C riteria [Section O0400{A,B,C}] In the last 7 days: Received 150 or more minutes A ND At least 5 days of any combination of the 3 disciplines O R Alternative Rehabilitation C riteria [Section 00400{A,B,C} and H0200{C} and H0500} In the last 7 days: Received 45 or more minutes At least 3 days of any combination of the 3 disciplines 2 or more nursing rehabilitation services* received for at least 15 minutes each with each administered for 6 or more days Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 6 of 18

7 CAT E GORY II: RE H ABILITATION * Nursing Rehabilitation Services H0200{C}, H0500** Urinary or bowel toileting programs O0500{A,B}** Passive and/or action ROM O0500{C} Splint or brace assistance O0500{D,F }** Bed mobility and/or walking training O0500{E} Transfer training O0500{G} Dressing and/or grooming training O0500{H} Eating and/or swallowing training O0500{I} Amputation/Prosthesis care O0500{J} Communication training **Count as one service even if both provided RUG-III ADL Score RU G-III Class RAD RAC RAB 4 9 RAA Final Rehabilitation Classification If the resident does not classify in the Rehabilitation Category, skip to Category III. Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 7 of 18

8 CAT E GORY III: SPE CIAL CARE The classification groups in this hierarchy are based on certain resident conditions. Note: Residents receiving extensive services but with an A D L score of 6 or less also qualify in this hierarchy. ST EP #1 Determine if the assessment is coded for at least one of the following special care conditions: M DS 3.0 Items M DS Descriptions I4400 Cerebral palsy, with an ADL score >=10 I5100 Quadriplegia, with an ADL score >=10 I5200 Multiple sclerosis, with and ADL score >=10 J1550A and at least one Fever and at least one of the following of the following: I2000 Pneumonia J1550B Vomiting J1550C Dehydration K0300 {1&2} Weight loss K0500B Feeding tube* K0500B and I4300 Feeding tube* and aphasia M0300A and M1030 Number of Stage I pressure ulcers and Number of venous and arterial ulcers 2 or more ulcers with 2 or more skin treatments** M0300B1 Stage II 2 or more ulcers with 2 or more skin treatments** M0300C1 Stage III 2 or more ulcers with 2 or more skin treatments** M0300D1 and M0300F1 Stage IV 2 or more ulcers with 2 or more skin treatments** [See crosswalk below] # Any stage III or IV pressure ulcer with 2 or more skin treatments** M1040D Open lesions with 1 or more skin treatment*** M1040E Surgical wounds with 1 or more skin treatment*** O0100B 1 or 2 Radiation treatment O0400D 2 Respiratory therapy provided for 7 days #Since there is no equivalent on the MDS 3.0 for highest pressure ulcer, the RUG-III crosswalk will apply M0300C1, M0300D1, and M0300F1 when any one is greater than or equal to 1. Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 8 of 18

9 CAT E GORY III: SPE CIAL CARE *F eeding tube classification must include either: MDS 3.0 MDS Descriptions [1] K0700A 51% or more calories OR [2] K0700A 26% to 50% calories AND fluids are 501 cc. or more per day K0700B enteral fluid intake in the last 7 days ** 2 or more Skin Treatments: MDS 3.0 MDS Descriptions M1200A# Pressure relieving device/chair M1200B# Pressure relieving device/bed M1200C Turning/repositioning program M1200D Nutrition or hydration intervention to manage skin problems M1200E Ulcer care M1200G Application of dressing [not to fee]) M1200H Application of ointments/medications[not to fee]) # Count as one treatment even if both provided *** 1 or more Skin Treatments: MDS 3.0 MDS Descriptions M1200F Surgical wound care M1200G Application of dressings (not to feet) M1200H Application of ointments/medication s (not to feet) A. To continue the scoring for the Extensive Services Category, evaluate the criteria for Category III. Extensive Services County-Special Care {0,1} B. If the assessment does not meet one of the above Special Care criteria, go to Category IV, Clinically Complex. C. If the assessment meets one or more of the criteria in the Special Care Category and the ADL Score is 6 or less, the assessment classifies in the Clinically Complex Category [CA]. To complete the Clinically Complex classification, go to Category IV, Clinically Complex, Step #2, to determine the presence[ca2] or absence [CA1] of mood symptoms. D. If neither B nor C above applies, classify the assessment by proceeding to Step #2. Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 9 of 18

10 CAT E GORY III: SPE CIAL CARE ST EP #2 If the ADL Score is 7 or more and the assessment meets one or more criteria, record the appropriate Special Care classification based on the ADL score. ADL Score Special Care Classification SSC SSB 7 14 SSA Final Special Care Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 10 of 18

11 CAT E GORY IV: CLINICALLY COMPL E X The classification groups in this category are based on certain resident conditions. Use the following instructions: ST EP #1 Determine if the assessment is coded for at least one of the following: M DS 3.0 M DS Descriptions B0100 Coma and completely ADL dependent [G0110A, G0110B, G0110H, G01101=4 or 8] I2000 Pneumonia I2100 Septicemia I2900, N0300, O0700 Diabetes mellitus A ND Injection = 7 days and Physician Order Changes >=2 days I4900 Hemiplegia/hemiparesis with an ADL score >=10 J1550C Dehydration J1550D Internal bleeding K0500B Feeding tube * M1040A, M1200I Infection of the foot with application of dressings M1040B&C, M1200I Diabetic foot ulcer/open lesions on the foot with application of dressings M1040F Burns O0100A 1 and 2 Chemotherapy OP0100C 1 and 2 Oxygen therapy O0100J 1 and 2 Dialysis O0100I 1 and 2 Transfusions O0600, O0700 Physician Examinations/Physician Order Changes in the last 14 days: Examinations >=1 day and Order Changes >=4 days O R Examinations >=2 days and Order Changes >=2 days * F eeding tube classification must include either: MDS 3.0 MDS Descriptions [1] K0700A 51% or more calories OR [2] K0700A 26% to 50% calories AND fluids are 501cc or more per day enteral K0700B Fluid intake in the last 7 days A. To continue the scoring for the Extensive Services Category, evaluate the criteria for Category IV. Extensive Services Count-Clinically Complex {0,1} B. If the assessment does not meet one of the above criteria, to go Category V, Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 11 of 18

12 CAT E GORY IV: CLINICALLY COMPL E X Impaired Cognition. C. If there is a match, proceed to Step #2 to evaluate for mood symptoms. ST EP #2 Evaluate for signs of mood symptoms Signs of mood symptoms are used as a third level split for the Clinically Complex Category as follows: Criteria 1 When D0100=NO, and when the resident is rarely/never understood [B0700=3] do not conduct Resident Mood Interview. Proceed to criteria 2. M DS 3.0 M DS Definition D0500A2 Little interest or pleasure in doing things D0500B2 Feeling or appearing down, depressed, or hopeless D0500C2 Trouble falling or staying asleep, or sleeping too much D0500D2 Feeling tired or having little energy D0500E2 Poor appetite or overeating D0500F2 Indicating that s/he feels bas about self, is a failure, or has let self or family down D0500G2 Trouble concentrating on things, such as reading the newspaper or watching TV D0500H2 D0500I2 D0500J2 Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that s/he have been moving around a lot more than usual worth living, wishes for death, or attempts to harm self Being short tempered, easily annoyed Once completed, sum the values in the symptom frequency column. The score is considered valid if no more than two items are incomplete. If the score at D0600 is 10 or greater, the resident is considered depressed. ST EP #3 Record the appropriate Clinically Complex classification based on both the ADL score and the severity score at D0300 or D0600. ADL Score Mood Symptoms Clinically Complex Classification YES CC NO CC YES CB NO CB YES CA NO CA1 Final Clinically Complex Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 12 of 18

13 CAT E GORY V: IMPAIRE D COGNITION The classification groups in this category are based on certain resident conditions. Note that certain conditions require special considerations. Use the following instructions: ST EP #1 go to Category VII, Reduced Physical Functions. ST EP #2 Criteria 1 Resident interview for mental status If all BIMS [Brief Interview for Mental Status] items are completed, then a BIMS score is calculated. If one of more BIMS items is missing, then a BIMS score is not calculated. Instead a Cognitive Performance Score [SPC] is calculated. Proceed to Criteria 2. A resident with a BIMS score less than or equal to 9 is considered cognitively impaired. A resident with a BIMS score of 10 or greater is not considered to be cognitively impaired. M DS 3.0 M DS Description C0200 Repetition of three words C0300 Temporal Orientation C0400 Recall C0500 BIMS score 0-15 Score <=9 is cognitively impaired Score >=10 is cognitively intact Criteria 2 Staff assessment for mental status Determine if the assessment meets at least one of the Impaired Cognition conditions according to the RUG-III Cognitive Performance Score [CPS] below: M DS 3.0 B0100 M0700 C0700 C1000 M DS Description Comatose Makes self understood Short term memory problem Cognitive skills for daily decision making A. B0100 Coma and completely ADL dependent O R B. C1000 Severely impaired daily decision making [C1000=3] O R C. C0700, C1000, B0700 These three items are assessed with none being blank or unknown: Two or more of the following impairment indicators are present: B0700>0 Problem making self understood C0700=1 Short term memory problem C1000>0 Cognitive skills for daily decision making A ND Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 13 of 18

14 CAT E GORY V: IMPAIRE D COGNITION One or more of the following severe impairment indicators are present: B0700>=2 Severe problem making self understood C1000>=2 Severely impaired decision making skills ST EP #3 A. To complete the scoring for the Extensive Services Category, continue the Extensive Services Count by evaluating the criteria for Impaired Cognition by adding a score of for one or more criteria matches: Category V. Extensive Services Count-Impaired Cognition {0,1} This concludes the Extensive Services Count evaluation. Total Extensive Services Count Extensive Services Classification 4 or 5 SE3 2 or 3 SE2 0 or 1 SE1 B. If the assessment does not meet one of the above Impaired Cognition criteria, go to Category VI, Behavior Problems. C. If there is a BIMS score <=9 in criteria 1 or a match in criteria 2, proceed to Step #4. ST EP #4 Determine Nursing Rehabilitation Services Count Count the number of Restorative Nursing Services* received each for at least 15 minutes, each administered for 6 or more days and including any scheduled toileting plan or bladder retraining program. Record the total count below: M DS 3.0 Items M DS Description H0200C, H0500** Urinary or bowel toileting programs O0500A** Passive ROM O0500B** Active ROM O0500C Splint or brace assistance O0500D** Bed mobility O0500E Transfer O0500F** Walking O0500G Dressing and/or grooming O0500H Eating and/or swallowing O0500I Amputation/prosthesis care O0500J Communication **Count as one service (H0200C & H0500; O0500A & B; O0500D & F) even if both are provided Total Nursing Rehabilitation Services Provided Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 14 of 18

15 CAT E GORY V: IMPAIRE D COGNITION ST EP #5 Record the appropriate Impaired Cognition classification by using the total ADL Score and the Nursing Rehabilitation Services Count. Nursing Rehabilitation ADL Score Services Count or more services IB or 1 service IB or more services IA or 1 service IA1 Impaired Cognition Classification Final Impaired Cognition Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 15 of 18

16 CAT E GORY VI: B E H AVIOR PROBL E MS The classification groups in this category are based on certain resident conditions. Note that certain conditions require special coding. Use the following instructions: ST EP #1 er than 10, go to Category VII, Reduced Physical Functions. ST EP #2 At least one of the following conditions must be met: M DS 3.0 M DS Description E0100A Hallucinations E0100B Delusions E0200A Physical behavioral symptoms (coded 2 or 3) E0200B Verbal behavioral symptoms (coded 2 or 3) E0200C Other behavioral symptoms (coded 2 or 3) E0800 Rejection of care (coded 2 or 3) E0900 Wandering (coded 2 or 3) ST EP #3 If the assessment does not meet one of the above Behavior Problems criteria, go to Category VII, Reduced Physical Functions. ST EP #4 Determine Nursing Rehabilitation Services Count If at least one of the conditions is met in Step #2, proceed to the determination of the restorative nursing count. Count the number of Restorative Nursing Services* received each for at least 15 minutes, each administered for 6 or more days and including any scheduled toileting plan or bladder retraining program. Record the total count below: M DS 3.0 Items M DS Descriptions H0200C, H0500 ** Urinary bowel toileting programs O0500A ** Passive ROM O0500B Active ROM O0500C Splint or brace assistance O0500D ** Bed mobility O0500E Transfer O0500F ** Walking O0500G Dressing and/or grooming O0500H Eating and/or swallowing O0500I Amputation/prosthesis care O0500J Communication ** Count as one service [H0200C & H0500; O0500A & B; O0500D & F] even if both provided Total Nursing Rehabilitation Services Provided Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 16 of 18

17 CAT E GORY VI: B E H AVIOR PROBL E MS ST EP #5 Select the final RUG-III classification by using the total ADL score and the Nursing Rehabilitation Services Count. ADL Score Nursing Rehabilitation Services Count Behavior Problems Classification or more services BB or 1 service BB or more services BA or 1 service BA1 Final Behavior Problems Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 17 of 18

18 CAT E GORY VII: RE DUC E D PHYSICAL F UNCTIONS ST EP #1 Resident who do not meet the conditions of any of the previous categories, including those who would meet the criteria for the impaired Cognition or Behavior Problems categories but have a RUG-III ADL score greater than 10, are placed in this category. ST EP #2 Determine the Nursing Rehabilitation Services Count Count the number of the following services provided for 15 or more minutes a day for 6 or more of the last 7 days: M DS 3.0 M DS Descriptions H0200C, H0500 ** Urinary or bowel toileting programs O0500A ** Passive ROM O0500B ** Active ROM O0500C Splint or brace assistance O0500D ** Bed mobility O0500E Transfer O0500F ** Walking O0500G Dressing and/or grooming O0500H Eating and/or swallowing O0500I Amputation/prosthesis care O0500J Communication **Count as one service [H0200C & H0500; O0500A & B; O0500D & F] even if both are provided Total Restorative Nursing Services Provided ST EP #3 Select the RUG-III classification by using the total ADL score and the Restorative Nursing Services Count. Nursing Rehabilitation ADL Score Services Count or more services PE or 1 service PE or more services PD or 1 service PD or more services PC or 1 service PC or more services PB or 1 service PB or more services PA or 1 service PA1 Reduced Physical F unction Classification Final Reduced Physical Function Classification Version 5.20 [34 groups] Prepared by Myers and Stauffer LC Page 18 of 18