Clinical Management of RUG selection

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1 Clinical Management of RUG selection MATT SIVRET PT, CLT CHIEF CLINICAL OFFICER REHABCARE-DIVISION OF KINDREDHEALTHCARE

2 Objectives Identify the Clinical Rationale for Rehab RUG intensity Understand the Clinical significance of the ADL end split Know how documentation supports the clinical reasoning of the Rehab RUG selection

3 Identify the Clinical Rationale for Rehab RUG intensity Why is Clinical Rationale for Intensity, AKA RUG Utilization important? Clear identification of skilled patient need is foundation for supporting reimbursement CMS strives to ensure that patient need, rather than payment system incentives, are driving the provision of therapy services, says Dr. Shantanu Agrawal, Deputy Administrator for Program Integrity and Director of the Center for Program Integrity

4 National RUG Data LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

5

6 Clinical Rationale The therapy component of a Resource Utilization Group (RUG) level is based on a comprehensive, thorough evaluation and subsequent therapy treatment plan developed by the therapist for the individual patient. The therapy treatment plan should be a clinically driven, collaborative process that identifies the clinical/skilled needs of the patient. The therapy component of the RUG level is calculated each assessment by using the treatment time, days of therapy and appropriate frequency and intensity, necessary to achieve the goals in the treatment plan.

7 Clinical Rationale Who Determines the RUG level? The Patient

8 Clinical Rationale Thorough Initial Assessments are Key to Establishing foundation for Justification of services Diagnosis Functional Impairments Deficits Overall Strengths Interdisciplinary Process Rehab Disciplines (PT, OT, SLP) Nursing Social Services Dietary Physician Others

9 MDS Coding Requirements for therapy The physician orders the therapy Includes a statement of frequency, duration, and scope of treatment The services must be directly and specifically related to an active written treatment plan The services are required and provided by qualified personnel The services must be reasonable and necessary for treatment of the resident s condition.

10 Things not to include Services provided at the request of the resident or family that are not medically necessary When the performance of a maintenance program does not require the skills of a therapist Services Performed by an Aide The time spent investigating a refusal or trying to persuade the resident to participate in treatment Documentation time Non Skilled portions of Modality treatment

11 ADL Self Performance Algorithm LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

12

13 Coding Section G Who Codes Section G? What Supporting Documentation can be used? What do you want to capture?

14 Language Differences LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

15 Section GG New Section of MDS October 1, 2016 New Scoring Scale

16 Section GG LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

17 Documentation to Support Clinical Reasoning Specific Skilled Interventions needed Number of Interventions Patient Discharge Plans Prior Level of Function Objective Data Evidence Based Outcomes and treatment interventions Medical Necessity

18 Medical Necessity What are Medically Necessary Services?

19 Intensity How much Therapy is needed?

20 Questions? LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

21 References Medicare Skilled Nursing Facility (SNF) Transparency Data (CY2013) https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and- Reports/Medicare-Provider-Charge-Data/SNF.html CMS s RAI Version 3.0 Manual, 2015 CMS s RAI Version 3.0 Manual, Draft 2016 Medicare Benefits Policy Manual, Chapter 8

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