Understanding Virginia Medicaid Case Mix System. Example: Admi4ed regular Medicaid. Medicaid Rules. And you shall rise and show respect to the aged.

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1 Understanding Virginia Medicaid Case Mix System Virginia Medicaid Medicaid resident days are paid on a per diem rate Like Medicare A Billed each month with the HIPPS from the MDS controlling payment for the days in that month. Will only use OBRA assessments Virginia dual-eligible program also used this system. Judy Wilhide Brandt judy@judywilhide.com Rates vary facility to facility PA1 PA2 PB1 Direct Operating Cost (Case Mix Neutral) $83.18 $83.18 $83.18 RUG III, Grouper 34 Weight 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 $ $ $ Example: Admi4ed regular Medicaid Admission: 6/12/15 Admission MDS ARD: 6/19/14 Z0200 = SE201 MDS ARD 9/19/15 Z0200 = CB102 SE201 controls payment for: 6/12 9/18/15 CB102 controls payment beginning: 9/19/15 Link to your rates on JudyWilhide.com resources Example: Admi4ed Dual-Eligible: Medicare/Medicaid Admit: 6/15/14 Admission/5 Day MDS ARD: 6/19/14 Z0200 = RAD Medicare 6/15 7/20 Medicaid beginning 7/21 Bill Medicaid RAD 7/21 day before next OBRA ARD Medicaid Rules Payment is controlled by the last OBRA assessment done un;l the ARD of the next OBRA assessment Admission assessment controls payment from day 1. No State requirement on how close together OBRA assessments may be scheduled. Wilhide Consul;ng, Inc. (c) 1

2 Adm Tracker Admission OBRA Scheduling 366 days ARD to ARD Adm Tracker Admission SCSA Resets OBRA Clock! SCSA 366 days ARD to ARD 92 days ARD to ARD 92 days ARD to ARD Annual Annual Late Assessments If the OBRA ARD is set late, the nursing facility shall bill the default RUG code un;l the ARD of the next OBRA assessment. Annual may be late two ways: ARD > 92 days from last OBRA ARD > 366 days from last comprehensive Final Valida=on Report This is where the late warnings will appear Stays Less than 14 Days Two choices: Do early Admission assessment Bill default rate Medicaid RUG III, 34 grouper, version 5.20 Can do early quarterlies Must do Sig Change when clinical condi;on warrants Need to set ARD to maximize Medicaid RUG Wilhide Consul;ng, Inc. (c) 2

3 Basics RUG III-34 grouper Version 5.20 RUG assigned in Z0200 HIPPS Code Health Insurance Prospec=ve Payment System RAB 01 Z0250 is NOT used for ANY calcula;on. DMAS is running a different grouper in that box as part of an on-going study. Valida;on report warnings for Z0250 can be ignored. RUG Score Assessment Iden;fier Code HIPPS Code AI Code Any A0310A except 99 RAB May be combined with PPS RUG Score Case Mix Index Each RUG has its own CMI RUG CMI SE SE RAD 1.66 SE SSC 1.44 CC SSB 1.33 RUG III (Version 5.20) 34 Grouper Examples While a resident and While not a resident are both used to calculate RUG score. Extensive Service can pay more than more Rehab RUG III Grouper Wilhide Consul;ng, Inc. (c) 3

4 Bed Mobility, Toile;ng, Transfers Self Performance Support Score 0,1 or 7 Any number 1 2 Any number 3 3,4 or ,4 or Ea;ng: IV fluid NA 3 Qualifying NA 3 tube feeding 0,1, or 7 NA 1 2 NA 2 3,4 or 8 NA 3 Rehab Two ways to qualify: 5 treatment days of any combina;on of OT, PT or ST for at least 150 minutes Three treatment days of any combina;on of OT, PT or ST for at least 45 minutes and qualifying restora;ve nursing programs Dis;nct Calendar Days Not used RAD RAC RAB RAA 4-9 SE3 - Clinical Indicators 4-5 SE2 - Clinical Indicators 2-3 SE1 - Clinical Indicators 0-1 Extensive Services Score > 7 Extensive Services Subgroups: Service Count SE3 (4-5) SE2 (2-3) SE1 (0-1) Extensive Services Must meet one or more of the following services: In last 7 days, received parenteral or IV therapy In the last 14 days, received: IV medica@on Suc@oning Trach care Vent or respirator treatment Must have score at least 7 Lookback period includes prior to admit IV Fluid Other Extensive Services Qualifiers Wilhide Consul;ng, Inc. (c) 4

5 Extensive Services Count: 1. Parenteral/IV fluid 2. IV Med 3. Special Care 4. Clinically Complex 5. Impaired Cogni;on Score > 7 Extensive Services Diagram Qualifiers IV med IV fluid Trach Vent Suc;on IV Fluid IV Med Special Care Clinically Complex Impaired Cogni;on Services Count RUG SE3 SE2 SE1 Example IV Fluid RUG III Calcula;on does NOT use intake requirement Services Count Our Resident: Parenteral/IV Fluid X IV Med X Special Care X Clinically Complex X Impaired Cogni;on - Services Count = 4 RUG = SE3 Special Care Special Care Special Care Subgroups: (>7) SSC (17-18) SSB (15-16) SSA (7-14) Score at least 10 and: CP or MS or Quad Fever and 1 of the following: pneumonia dehydra;on vomi;ng weight loss tube feeding** Wilhide Consul;ng, Inc. (c) 5

6 Feeding Tube RUG III 34 V 5.20 Feeding tube and either At least 51% of calories by tube OR 26% to 50% calories by tube AND at least 501 cc fluid/day by tube Tube Feeding: Tube feeding DOES use intake requirement, but does NOT use during en;re 7 days Used for RUG IV Special Care, con;nued Had score of at least 7 and one of the following: Tube feeding* and aphasia Pressure ulcers and skin treatments St 3 or 4 PU and skin treatments Surgical wound or open lesion and 1+ treatment radia;on treatments 7 days of respiratory therapy Extensive Services w/ score <7 Used for RUG III 34 V 5.12 PrU Skin Treatments () Pressure reducing bed/chair (count as 1) Turning/reposi;oning Nutri;on or Hydra;on interven;on Pressure Ulcer Care Applica;on of nonsurgical dressings Applica;on of ointments/medica;ons other than to feet Surgical wound or open lesion and 1+ treatment Surgical wound care Applica;on of dressings Applica;on of ointments Wilhide Consul;ng, Inc. (c) 6

7 Clinically Complex Depressed Clinically Complex CA2 CB2 CC2 Not depressed 4-11 CA CB CC Clinically Complex Any one of the following: Coma and not awake and completely dependent Diabetes and injec;on 7 days and order changes days Not just INSULIN order changes Not just INSULIN injec;ons hemiplegia and score 10+ pneumonia sep;cemia dehydra;on Internal Bleeding Tube feeding* Clinically Complex Con;nued burns foot lesions or foot infec;on with applica;on of dressings to foot chemotherapy dialysis Oxygen therapy transfusions MD visits 1+ day and Rx change 4+ days MD visit days and Rx change days Special Care w/ sum < 7 Special Care: Qualifying Tube feeding with: Fever OR Aphasia Tube Feeding Recap Clinically Complex: Qualifying Tube feeding End Split: Criteria 10 or more on Mood Interview or Staff Assessment CC CC CB CB CA CA CPS: 3 or BIMS of 9 moderately impaired Impaired Cogni@on Score <= 10 Impaired Cogni;on 2 = Nursing 4-5 IA2 4-5 IA IB IB1 1 = Nursing 0-1 Wilhide Consul;ng, Inc. (c) 7

8 Nursing Restora;ve 2 or more qualifying nursing rehab services for at least 15 min on 6 of the past 7 days Scheduled toile@ng &/or bladder retraining Passive and/or ac@ve ROM Splint/Brace assistance Bed Mobility and/or gait training Transfer Training Dressing or Grooming Training Ea;ng or Swallowing Training Amputa;on or Prosthesis Care Communica;on Training Behavior Problems Score < 10 Behavior Problems 2 = Nursing 4-5 BA2 4-5 BA BB BB1 1 = Nursing 0-1 Behavior Problems Any one of the following behaviors occurred on 4 or more of the last 7 days: wandering verbal abuse physical abuse inappropriate behavior resists care Or, the resident experienced delusions and/or hallucina;ons at least once in the last 7 days. Reduced Physical Func;on S Reduced Physical Func;on Restora;ve Restora;ve 9-10 Restora;ve 6-8 Restora;ve 4-5 Restora;ve PE2 PD2 PC2 PB2 PA2 PE1 PD1 PC1 PB1 PA1 2 = Rest. Nsg 1= Rest. Nsg 0-1 Opera;onal Plan Opportuni;es MDS Schedule Score Rehab for Medicaid Residents 5 treatment days per week 3 treatment days + qualifying restora;ve Extensive Services: IV med, Fluid, Clysis Respiratory therapy 7days/week for 15 min Time on MAR/TAR Restora;ve Nursing interview Review two weeks prior to ARD: Score? Rehab in? Fluids/Meds? Restora;ve? Interview prior to ARD? Document Q shiw during this period Extra Quarterlies OBRA ;mely comple;on awareness Wilhide Consul;ng, Inc. (c) 8

9 Strategy Example Rehab: set Jan 10, 2015 RUG PD x 92 = 13, Has Part B OT beginning on Feb 6 for 30 min/ day. ARD set for Feb 10. RUG RAB OT con;nues for 3 weeks. Jan 10 Feb 9: Feb 10 for 92 days: 15, Strategy Example IV: set Jan 10, 2015 RUG PD x 92 = 13, Has IV fluid/med beginning Feb 6. ARD set for Feb 6. RUG SE Jan 10 Feb 6: Feb 6 for 92 days: 19, RUG IV 48 Grouper (1) Received 150 or more minutes and At least 5 dis;nct days of any combina;on of the 3 disciplines, OR (2) Received 45 or more minutes and At least 3 dis;nct days of any combina;on of the 3 disciplines and 2 or more restora;ve nursing programs received for 6 or more days, RAE Star;ng July 1, 2017 RAF Rehab RAC 6-10 RAB 2-5 RAA 0-1 JudyWilhide.com 52 Nursing Restora;ve: >=2 on 6 days in lookback Urinary and/or bowel training program* Passive and/or ac@ve ROM* While a resident Extensive Services > 2: Trach AND Vent ES3 Splint and/or brace assistance Bed Mobility and/or walking training* Transfer Training Dressing and/or Grooming Training Ea;ng and/or Swallowing Training Amputa;on/Prosthesis Care Training Communica;on Training Trach OR Vent Isola;on for Ac;ve Infec;ous Disease ES2 ES1 *Count as 1 for RUG purposes. JudyWilhide.com 53 JudyWilhide.com 54 Wilhide Consul;ng, Inc. (c) 9

10 Special Care High Special Care High: >= 2 End Split: >= 10 PHQ9/OV HE1 HE2 Comatose & 4/8 IV Fluid HD1 HC1 HB1 HD2 HC2 HB2 Sep;cemia Diabetes w/daily Insulin inj & Insulin Rx changes on > 2 days Quadriplegia & > 5 COPD & SOB lying flat Respiratory Therapy 7 days Fever & 1: Pneumonia Weight Loss Qualifying Feeding Tube all 7 days: >=51% calories 26-50% calories & 501cc fluid JudyWilhide.com 55 JudyWilhide.com 56 (Fever and ) IV Fluid Sec;on K: 7 day lookback Either count (Fever and ) Qualifying Tube Feeding Must have either: 26-50% AND 501cc OR 51% JudyWilhide.com 57 JudyWilhide.com 58 Special Care Low Special Care Low: >=2 End Split 10 PHQ9/OV LE1 LE2 Cerebral Palsy & > 5. Mul;ple Sclerosis & > LD1 LD2 Parkinson s Disease & > 5. Qualifying Tube Feeding (en;re 7 days) 6-10 LC1 LC2 Foot Infec;on, Diabe;c foot ulcer, or open lesions on foot w/ dressings to feet. Radia;on therapy while resident. 2-5 LB1 LB2 Respiratory Failure and Oxygen therapy while resident. Dialysis while resident. JudyWilhide.com 59 JudyWilhide.com 60 Wilhide Consul;ng, Inc. (c) 10

11 Special Care Low: >=2 End Split 10 PHQ9/OV >=2 St II PU & >=2 skin treatments >=1 St III, IV, or unstageable slough/ eschar PU & >=2 skin treatments >=2 venous/arterial ulcers & >=2 skin treatments 1 St II PU & 1 venous/arterial ulcer & >=2 skin treatments. Qualifying Skin Treatments Pressure relieving chair and/or bed * Turning/reposi;oning Nutri;on or hydra;on interven;on Ulcer care Applica;on of dressings (not to feet) Applica;on of ointments (not to feet) JudyWilhide.com 61 JudyWilhide.com 62 Clinically Complex CE1 CD1 CC1 CB1 CA1 CE2 CD2 CC2 CB2 CA2 JudyWilhide.com 63 Clinically Complex: Any Score End Split 10 PHQ9/OV Extensive Services, Special Care High or Low with an score of <2 Pneumonia Hemiplegia and score > 5 Surgical wounds or open lesions w/treatment Burns Chemotherapy while resident Oxygen therapy while resident IV Medica;ons while resident Transfusions while resident JudyWilhide.com 64 Behavioral Symptoms & Cogni;ve Performance Any 1 of the following: Behavioral Symptoms & Cogni;ve Performance <=5 Restora;ve Nursing End Split BIMS Score < 9 or CPS > 3 Physical or verbal behavioral symptoms directed to others* Other behavioral symptoms not directed to others* BB1 BA1 BB2 BA2 Rejec;on of Care* Wandering* Hallucina;ons Delusions JudyWilhide.com 65 *>=4 days JudyWilhide.com 66 Wilhide Consul;ng, Inc. (c) 11

12 Reduced Physical Func;on Transi;on: July 1, PE1 PD1 PC1 PB1 PA1 PE2 PD2 PC2 PB2 PA2 If there is an OBRA assessment with an ARD prior to July 1, 2017, the RUG III RUG in Z0200 will be used through the end of June and the RUG IV 48 grouper RUG will be used star;ng July 1, The RUG IV 48 grouper RUG is being calculated in Z0250. If your organiza;on did not load that grouper into Z0250 (and almost nobody did) you have to do this: JudyWilhide.com 67 This RUG must go on the July claim for Medicaid CONCLUSION Discussion/Questions JudyWilhide.com And you shall rise and show respect to the Wilhide Consul;ng, Inc. (c) 12