Training - October 2015 STATE OF MISSISSIPPI DIVISION OF MEDICAID RUG 48-CLASSIFICATION MODEL AND MORE

Transcription

1 STATE OF MISSISSIPPI DIVISION OF MEDICAID RUG 48-CLASSIFICATION MODEL AND MORE 1 2 1

2 3 4 2

3 5 BINDER TAB 1 PRESENTATION SLIDES 6 3

4 BINDER TAB 2 RUG-IV CLASSIFICATION MODEL 48-GROUPS 7 ACTIVITIES OF DAILY LIVING RUG-IV CLASSIFICATION MODEL 8 4

5 ACTIVITIES OF DAILY LIVING (ADLS) Calculation of ADL score: Late loss ADLs: Bed Mobility Transfer Toileting Eating 9 STEP #1 - CALCULATION OF ADL SCORE Calculate the ADL score for bed mobility (G0110A), transfer (G0110B) and toilet use (G0110I) referring to the chart below The eating ADL score will be calculated in Step #2 Self Performance Column 1 = Support Provided Column 2 = ADL Score = Record Score Below -, 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 or 4 And

6 STEP #2 - CALCULATION OF ADL SCORE Calculate the ADL score for eating (G0110H) referring to the chart below Self Performance Column 1 = Support Provided Column 2 = ADL Score = Record Score Below -, 0, 1, 2, 7 or 8 And -, 0, 1 or 8 0 Eating = -, 0, 1, 2, 7 or 8 And 2 or or 4 And -, 0, or And 2 or And 2 or STEP #3 - CALCULATION OF ADL SCORE Sum the scores for Bed Mobility, Transfer, Toilet Use and Eating to determine the total ADL score The total ADL score ranges from 0 through 16 A score of 0 represents independence whereas a score of 16 represents total dependence TOTAL ADL SCORE 12 6

7 EXAMPLE ONE: SECTION G G0110 Column 1 2 A BED MOBILITY How resident moves to and from lying position, turns side to side, and positions body while in bed 0 0 B TRANSFER How resident moves between surfaces to/from: bed, chair, wheelchair, standing position (EXCLUDE to/from bath/toilet) 2 2 I TOILET USE How resident uses the toilet room (or commode, bedpan, urinal); transfer on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes 2 3 H EATING How resident eats and drinks (regardless of skill). Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition) EXAMPLE ONE: ADL SCORE CALCULATION ADL Score Calculation Transmitted Values Column 1 Column 2 ADL Score (G0110A) Bed Mobility 0-0 = (G0110B) Transfer 2-2 = (G0110I) Toilet Use 2-3 = (G0110H) Eating 1-1 = TOTAL SCORE =

8 EXAMPLE TWO: SECTION G G0110 Column 1 2 A BED MOBILITY How resident moves to and from lying position, turns side to side, and positions body while in bed 3 3 B TRANSFER How resident moves between surfaces to/from: bed, chair, wheelchair, standing position (EXCLUDE to/from bath/toilet) 4 2 I TOILET USE How resident uses the toilet room (or commode, bedpan, urinal); transfer on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes 4 3 H EATING How resident eats and drinks (regardless of skill). Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition) EXAMPLE TWO: ADL SCORE CALCULATION ADL Score Calculation Transmitted Values Column 1 Column 2 (G0110A) Bed Mobility 3-3 = (G0110B) Transfer 4-2 = (G0110I) Toilet Use 4-3 = (G0110H) Eating 3-2 = TOTAL SCORE = ADL Score

9 ACTIVITIES OF DAILY LIVING (ADL) ADL Self-Performance Measures what the resident actually did (not what he/she might be capable of doing) according to a performance-based scale ADL Support Provided Measures the most support provided, even if that level only occurred on Since each section uses its own scale, it is recommended that Self-Performance column be completed first then the Support Provided column 17 ACTIVITIES OF DAILY LIVING (ADL) ASSISTANCE (G0110) Code based on level of assistance when using special adaptive devices Do not include assistance provided by individuals hired (compensated or not) outside of the facility s management/administration Hospice staff Nursing/CNA students Family members Self-performance and support provided may vary day to day, shift to shift, within shifts, 24 hours a day 18 9

10 ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 3 or More Times: Code 0 = Independent, no help or staff oversight at any time Code 1 = Supervision, oversight, encouragement, or cueing Code 2 = Limited assistance: Resident highly involved in activity Staff provide guided maneuvering of limbs or other nonweight-bearing assistance: Guided maneuvering vs. weight-bearing is determined by who is supporting the weight of the resident s extremity or body 19 ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 3 or More Times: Code 3 = Extensive assistance: Resident involved in part of activity Staff provide weight-bearing support, OR Full staff performance part but not all of the time Code 4 = Total dependence: Full staff performance every time during entire 7- day period No participation by resident for any aspect of ADL activity 20 10

11 ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 2 or Fewer Times: Code 7 = Activity occurred only once or twice Code 8 = Activity did not occur: Activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period For additional guidance please watch: CMS youtube video for Section G: 21 ACTIVITIES OF DAILY LIVING RULE OF 3 11

12 INSTRUCTIONS FOR THE RULE OF 3 The Rule of 3 is a method to help determine the appropriate ADL Self-Performance code Staff must fully understand: ADL components Self-Performance coding level definitions The Rule of 3 To properly apply the Rule of 3: Note which activities occurred How many times What type of support was required What level of support was required Over the 7-day observation period 23 INSTRUCTIONS FOR THE RULE OF 3 The Rule of 3 steps must be used in sequential order Use the first instruction encountered that meets the coding scenario Exceptions for the Rule of 3: Code 0, Code 4, and Code 8 as the definition for these coding levels are finite and cannot be entered on the MDS unless it is the level that occurred every time the ADL occurred Code 7 as this code only applies if the activity occurred only 1 or 2 times 24 12

13 INSTRUCTIONS FOR THE RULE OF 3 Rule of 3: 1. When activity occurs 3 times at any one level, code that level. 2. When an activity occurs 3 or more times at multiple levels, code the most dependent level. 3. When an activity occurs 3 or more times and at multiple levels, but not 3 times at any one level, apply the following: a) Convert episodes of full staff performance to weightbearing assistance. b) When there are 3 or more episodes of a combination of full staff performance, and weight-bearing assistance code extensive assistance (3). NOTE: Do not proceed to c below if b applies. c) When there are 3 or more episodes of a combination of full staff performance, weight-bearing assistance, and/or nonweight-bearing assistance, code limited assistance (2). 25 INSTRUCTIONS FOR THE RULE OF 3 If none of the above are met, code Supervision (1): *This box in the algorithm corresponds to a, b, and c under the third Rule above The instruction in this box only applies when the third Rule applies, i.e., an activity occurs 3 times and at multiple levels, but not 3 times at any one level (e.g., 2 times non-weight bearing, 2 times weight bearing) If the coding scenario does not meet the third Rule, do not apply a, b, and c of the third Rule. Code (1) Supervision 26 13

14 ADL EXERCISES EXAMPLE #1 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 1 Applicable Rule of 3 #1. Applies because the activity occurred 3 times as Independent but 0 is an exception so can t be used #2. Does not apply #3. Does not apply because the activity DID occur at least 3 times at 0 SO... If none of the above are met, code Supervision (1) 28 14

15 EXAMPLE #2 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 2 Applicable Rule of 3 #3. When an activity occurs 3 or more times and at multiple levels, but not 3 times at any one level, apply the following: c. When there are 3 or more episodes of a combination of full staff performance, weight-bearing assistance, and/or non-weightbearing assistance, code limited assistance (2) 29 EXAMPLE #3 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 3 Applicable Rule of 3 #2. When an activity occurs 3 or more times at multiple levels, code the most dependent level that occurred 3 or more times NOTE: Instructions for coding Extensive Assistance (3) from RAI Manual Chapter 3, page G-5: if resident performed part of the activity over the last 7 days and help of the following type was provided three or more times: Weight-bearing support OR Full staff performance of activity three or more times during part but not all of the last 7 days 30 15

16 EXAMPLE #4 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 1 Applicable Rule of 3 #1. Applies because the activity occurred 3 times as Independent but 0 is an exception so can t be used #2. Does not apply #3. Does not apply because the activity DID occur at least 3 times at 0 SO... If none of the above are met, code Supervision (1) 31 EXAMPLE #5 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 7 Exceptions for the Rule of 3: Code 7 as this code only applies if the activity occurred only 1 or 2 times 32 16

17 EXAMPLE #6 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 2 Applicable Rule of 3 #2. When an activity occurs 3 or more times at multiple levels, code the most dependent level 33 EXAMPLE #7 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 3 Applicable Rule of 3 #3. When an activity occurs 3 or more times and at multiple levels, but not 3 times at any one level, apply the following: b. When there is a combination of full staff performance and weight-bearing assistance that total 3 or more times code extensive assist (3) 34 17

18 EXAMPLE #8 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 1 Applicable Rule of 3 #1. Applies because the activity occurred 3 times as Independent but 0 is an exception so can t be used #2. Does not apply #3. Does not apply because the activity DID occur at least 3 times at 0 SO... If none of the above are met, code Supervision (1) 35 EXAMPLE #9 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 2 Applicable Rule of 3 #3. When an activity occurs 3 or more times and at multiple levels, but not 3 times at any one level, apply the following: c. When there is a combination of full staff performance/ weightbearing assistance, and/or non-weight-bearing assistance that total three or more times, code limited assistance (2) 36 18

19 EXAMPLE #10 HOW WOULD YOU CODE SELF-PERFORMANCE? Code of 1 Applicable Rule of 3 #1. Applies because the activity occurred 3 times as Independent but 0 is an exception so can t be used #2. Does not apply #3. Does not apply because the activity DID occur at least 3 times at 0 SO... If none of the above are met, code Supervision (1)

20 RUG-IV CLASSIFICATION MODEL 48-GROUPER 39 RUG-IV, 48-Group Classification Model 20

21 Training - October 2015 RUG-IV CLASSIFICATION SYSTEM Index Maximizing Classification: Classifies in the group with the highest Case Mix Index (CMI) Even if RUG group is lower on the tree Used in Medicare PPS Used in Mississippi case mix Hierarchical Classification: Start at the top and work down First group for which the resident qualifies Primarily for training or research purposes Non-Therapy Classification: All the RUG items are used except the rehabilitation items (O0400A-C) 41 RUG-IV CLASSIFICATION SYSTEM Example of index maximizing: A resident meets criteria for both RAB and HB1 RAB = CMI HB1 = CMI Hierarchy RAB at Index Maximizing HB1 at

22 RUG-IV CLASSIFICATION SYSTEM Seven major resident classification group splits include: ADL split Depression Indicator split Restorative Nursing split 43 CATEGORY I: EXTENSIVE SERVICES ADL Score Range =

23 STEP #1 Determine whether the assessment is coded for at least one of the following conditions or services: Extensive Services Conditions or Services O0100E, 2 O0100F, 2 O0100M, 2 Tracheostomy care (while a resident) Ventilator or respirator (while a resident) Infection isolation (while a resident) 45 STEP #1 (CONTINUED) A. If the assessment is not coded with one of the above conditions or services, skip to Category II, Rehabilitation. B. If the assessment is coded with at least one of the above conditions or services, and the ADL score is 0 or 1, skip to Category V, Clinically Complex (CA1 or CA2), Step #2 C. 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 Services; proceed to Step #

24 STEP #2 The final classification for Extensive Services is based on the following: Extensive Service Conditions or Services RUG-IV Class CMI 48 Alzheimer s CMI Tracheostomy care* AND Ventilator/respirator* Tracheostomy care* OR Ventilator/respirator* Infection isolation* without tracheostomy care* without ventilator/respirator* ES ES ES *While a resident 47 CATEGORY II: REHABILITATION ADL Score Range = 0-16 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 48 24

25 If only we had spell check... I saw your patient today, who is still under our car for physical therapy. 49 STEP #1 If the assessment is coded for therapy minutes and days, calculate and sum the total therapy minutes O0400 Therapies O0400A - Speech-Language Pathology and Audiology Services O0400A, 1,2,3 O0400A, 4 O0400B - Occupational Therapy O0400B, 1,2,3 O0400B, 4 O0400C - Physical Therapy O0400C, 1,2,3 O0400C, 4 Individual, Concurrent and Group Minutes Therapy Days Individual, Concurrent and Group Minutes Therapy Days Individual, Concurrent and Group Minutes Therapy Days If the total combined minutes are less than 45 minutes, Skip to Category III, Special Care High 50 25

26 STEP #2 If the assessment is coded for therapy minutes and days, and the total sum of therapy minutes is equal to or greater than 45 minutes, use the following criteria to determine the Rehabilitation Classification: Criteria #1 150 minutes or more AND At least 5 distinct days of any combination of ST, OT, PT OR Criteria #2 45 minutes or more AND At least 3 distinct days of any combination of ST, OT, PT AND 2 or more restorative nursing programs - 6 or more days 51 H0200C H0500 O0500A O0500B O0500C O0500D O0500F O0500E O0500G O0500H O0500I O0500J STEP #2 (CONTINUED) Determine Restorative Nursing Program Count: Restorative Nursing Programs Current toileting program or trial # Bowel toileting program # Range of motion (passive) # Range of motion (active) # Splint or brace assistance Bed mobility # Walking # Transfer Dressing and/or grooming Eating and/or swallowing Amputation/Prosthesis care Communication # For RUG classification count as one program even if both provided 52 26

27 * Ancient Egyptians used metal tubes for catheters as early as 3000BC? And that other objects used as catheters included: Straw Rolled up palm leaves Gold, silver, brass, copper, lead tubes 53 STEP #3 ADL Score Range RUG Class CMI 48 Alzheimer s CMI RAE RAD RAC RAB RAA

28 CATEGORY III: SPECIAL CARE HIGH ADL Score Range = CATEGORY III: SPECIAL CARE HIGH Determine if the assessment is coded for one of the following conditions or services: Special Care High Conditions or Services B0100 Comatose with ADL Self-Performance dependency coded 4 or 8 for all late loss ADLs I2100 I2900 N0350A N0350B I5100 I6200 J1100C Septicemia Diabetes Mellitus (DM) with both of the following: Insulin injections for all 7 days Insulin order changes on 2 or more days Quadriplegia with ADL score of 5 or higher Chronic Obstructive Pulmonary Disease (COPD) with Shortness of breath when lying flat *Tube feeding intake 51% calories or 26-50% calories and 501cc fluid during entire period 56 28

29 CATEGORY III: SPECIAL CARE HIGH Determine if the assessment is coded for one of the following conditions or services: Special Care High Conditions or Services J1550A I2000 J1550B K0300, 1 or 2 K0510B, 1 or 2 K0510A, 1 or 2 O0400D, 2 Fever with one of the following: Pneumonia Vomiting Weight Loss Feeding Tube with requirements* Parenteral/IV Feeding Respiratory Therapy for all 7 days *Tube feeding intake 51% calories or 26-50% calories and 501cc fluid during entire period 57 STEP #1 A. If the assessment does not have one of these conditions or services coded, skip to Category IV, Special Care Low. B. If the assessment does have one of these conditions or services coded and the ADL score is 0 or 1, the assessment classifies as Clinically Complex; skip to Category V, Clinically Complex (CA1 or CA2), Step #2. C. If the assessment does have one of these conditions or services coded and the ADL score is 2 or more (with the exception of Comatose which requires total dependency and Quadriplegia which requires an ADL score of 5 or higher), the assessment classifies as Special Care High; proceed to Step #

30 STEP #2 The following MDS items comprise the Resident Mood Interview PHQ-9 and Staff Assessment of Resident Mood (PHQ-9-OV ): Resident Staff Resident Mood Symptom Frequency Interview Assessment D0200A, 2 Little interest or pleasure in doing things D0500A, 2 D0200B, 2 Feeling (or appearing) down, depressed, or D0500B, 2 hopeless D0200C, 2 Trouble falling or staying asleep, or sleeping too D0500C, 2 much 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 59 STEP #2 (CONTINUED) The following MDS items comprise the Resident Mood Interview PHQ-9 and Staff Assessment of Resident Mood (PHQ-9-OV ): Resident Staff Resident Mood Symptom Frequency Interview Assessment D0200G, 2 Trouble concentrating on things, such as reading or D0500G, 2 watching TV D0200H, 2 Moving or speaking slowly that others have noticed or D0500H, 2 being fidgety or restless; moving around a lot more than usual 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. D

31 STEP #2 (CONTINUED) Resident is considered Depressed for RUG Classification if: 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 The Total Severity Score PHQ-9-OV (D0600) which includes items D0500A-J (Staff Assessment) is greater than or equal to STEP #3 ADL Score Range Depressed RUG Class CMI 48 Alzheimer s CMI Yes HE No HE Yes HD No HD Yes HC No HC Yes HB No HB

32 CATEGORY IV: SPECIAL CARE LOW ADL Score Range = CATEGORY V: SPECIAL CARE LOW Determine if the assessment is coded for one of the following conditions or services: I4400 I5200 I5300 I6300 O0100C, 2 K0510B, 1 or 2 M0300B, 1 M0300C, 1 M0300D, 1 M0300F, 1 M1030 Special Care Low Conditions or Services Cerebral Palsy with ADL score of 5 or higher Multiple Sclerosis with ADL score of 5 or higher Parkinson s Disease with ADL score of 5 or higher Respiratory Failure with Oxygen therapy (while a resident) Feeding tube with requirements* Two or more Stage 2 pressure ulcers with two or more selected skin treatments** Stage 3 pressure ulcer with two or more selected skin treatments** Stage 4 pressure ulcer with two or more selected skin treatments** Unstageable-Slough and/or eschar with two or more selected skin treatments** Two or more Venous/Arterial ulcers with two or more selected skin treatments** *Tube feeding intake 51% calories OR 26-50% calories and 501cc fluid during entire period 64 32

33 CATEGORY V: SPECIAL CARE LOW (CONTINUED) Determine if the assessment is coded for one of the following conditions or services: M0300B, 1 M1030 M1040A M1200I M1040B M1200I M1040C M1200I O0100B, 2 O0100J, 2 Special Care Low Conditions or Services One Stage 2 pressure ulcer and One Venous/Arterial ulcer with two or more selected skin treatments** Infection of the foot with Application of dressing to feet Diabetic foot ulcer with Application of dressing to feet Other open lesion on the foot with Application of dressing to feet Radiation treatment (while a resident) Dialysis treatment (while a resident) 65 CATEGORY V: SPECIAL CARE LOW (CONTINUED) M1200A M1200B M1200C M1200D M1200E M1200G M1200H **Selected Skin Treatments for Special Care Low Pressure reducing device for chair # Pressure reducing device for bed # 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 66 33

34 STEP #1 If the assessment does not have one of these conditions or services coded, skip to Category V, Clinically Complex. If the assessment does have one of these conditions or services coded and the ADL score is 0 or 1, the assessment classifies as Clinically Complex; skip to Category V, Clinically Complex (CA1 or CA2), Step #2. If the assessment does have one of these conditions or services coded and the ADL score is 2 or more (with the exception of CP, MS and Parkinson s Disease which require an ADL score of 5 or higher), the assessment classifies as Special Care Low; proceed to Step #2. 67 STEP #2 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,

35 STEP #2 The following MDS items comprise the Resident Mood Interview PHQ-9 and Staff Assessment of Resident Mood (PHQ-9-OV ): Resident Interview D0200G, 2 Resident Mood Symptom Frequency Staff Assessment 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 D0500H, 2 than usual 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. D STEP #2 (CONTINUED) Resident is considered Depressed for RUG Classification if: 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 The Total Severity Score PHQ-9-OV (D0600) which includes items D0500A-J (Staff Assessment) is greater than or equal to

36 STEP #3 ADL Score Range Depressed RUG Class CMI 48 Alzheimer s CMI Yes LE No LE Yes LD No LD Yes LC No LC Yes LB No LB CATEGORY V: CLINICALLY COMPLEX Extensive Services with ADL score of 0 or 1 Special Care High with ADL score of 0 or 1 Special Care Low with ADL score of 0 or 1 ADL Score Range =

37 CATEGORY V: CLINICALLY COMPLEX Determine if the assessment is coded for one of the following conditions or services: I2000 I4900 M1040D M1040E M1040F O0100A, 2 O0100C, 2 O0100H, 2 O0100I, 2 Clinically Complex Conditions or Services Pneumonia Hemiplegia or Hemiparesis with ADL score of 5 or higher Open lesion other than ulcers, rashes, cuts with any selected skin treatment* Surgical wound with any selected skin treatment* Burn Chemotherapy (while a resident) Oxygen therapy (while a resident) IV medication (while a resident) Transfusion (while a resident) 73 CATEGORY VI: CLINICALLY COMPLEX *Selected Skin Treatments for Clinically Complex M1200F M1200G M1200H Surgical wound care Application of non-surgical dressing (other than to feet) Applications of ointment/medication (other than to feet) 74 37

38 STEP #1 A. If the assessment does not have one of these conditions or services coded, skip to Category VI, Behavioral Symptoms and Cognitive Performance. B. If the assessment does have one of these conditions or services coded, the assessment classifies as Clinically Complex; proceed to Step #2. 75 STEP #2 Resident is considered Depressed for RUG Classification if: 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 The Total Severity Score PHQ-9-OV (D0600) which includes items D0500A-J (Staff Assessment) is greater than or equal to

39 STEP #3 ADL Score Range Depressed RUG Class CMI 48 Alzheimer s CMI Yes CE No CE Yes CD No CD Yes CC No CC Yes CB No CB Yes CA No CA CATEGORY VI: BEHAVIORAL SYMPTOMS AND COGNITIVE PERFORMANCE ADL score range = 0-5 Restorative Nursing Services 78 39

40 CATEGORY VI: BEHAVIORAL SYMPTOMS AND COGNITIVE PERFORMANCE ADL Score Range = 0-5: If 6 or more, classifies into Reduced Physical Function Cognitive Performance determined by: Brief Interview for Mental Status (BIMS) if interview was completed. If not, then; Cognitive Performance Scale (CPS) items if the BIMS interview was not completed If resident doesn t qualify via Cognitive Performance, then evaluate Behavioral Symptoms items 79 STEP #1 BIMS - Brief Interview for Mental Status C0200 C0300 C0400 C0500 Repetition of three words Temporal Orientation Recall BIMS score 0-15 Score <= 9 is cognitively impaired Score >= 10 is cognitively intact 80 40

41 STEP #1 (CONTINUED) A. If the ADL score is greater than 5, proceed to Category VII, Reduced Physical Function. B. If the BIMS score (C0500) is <=9; the assessment is cognitively impaired for RUG purposes. C. If one or more BIMS items are missing, then a BIMS score is not calculated. Instead a Cognitive Performance Score (CPS) is calculated, proceed to Step #2. 81 STEP #2 CPS Cognitive Performance Score Staff assessment for mental status Determine if the assessment meets at least one of the Impaired Cognition conditions according to the RUG-IV Cognitive Performance Score (CPS) below: B0100 B0700 C0700 C1000 Comatose Makes self understood Short term memory problem Cognitive skills for daily decision making 82 41

42 STEP #2 (CONTINUED) A. B0100 Coma and completely ADL dependent B. C1000 Severely impaired daily decision making If not, then: 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 C0700 = 1 C1000 > 0 Problem making self understood Short term memory problem Cognitive skills for daily decision making AND 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 83 STEP #1 If the ADL score is greater than 5, proceed to Category VII, Reduced Physical Function. Determine if the assessment is coded for at least one of the following: E0100A E0100B E0200A 2 or 3 E0200B 2 or 3 E0200C 2 or 3 E or 3 E or 3 Hallucinations Delusions Physical behavioral symptoms Verbal behavioral symptoms Other behavioral symptoms Rejection of care Wandering 84 42

43 STEP #2 If no match, proceed to Category VII, Reduced Physical Function. If there is a match, proceed to Step #3. 85 STEP #3 - DETERMINE RESTORATIVE NURSING SERVICES COUNT Count the number of Restorative Nursing Services provided each for: At least 15 minutes Each administered for 6 or more days Includes any urinary toileting or bowel toileting program 86 43

44 JUST FOR FUN! She stated that she had been constipated for most of her life, until she got a divorce. 87 STEP #4 ADL Score Range Restorative Nursing RUG Class CMI 48 Alzheimer s CMI or more BB or 1 BB or more BA or 1 BA

45 CATEGORY VII: REDUCED PHYSICAL FUNCTION ADL score range = 0-16 Assessments that do not meet the conditions of any of the previous categories Assessments meeting criteria for Behavioral Symptoms and Cognitive Performance but have an ADL score of greater than 5 Restorative Nursing Services 89 STEP #1 - DETERMINE RESTORATIVE NURSING SERVICES COUNT Count the number of Restorative Nursing Services provided each for: At least 15 minutes Each administered for 6 or more days Includes any urinary toileting or bowel toileting program 90 45

46 CATEGORY VII: REDUCED PHYSICAL FUNCTION ADL Score Range Restorative Nursing RUG Class CMI 48 Alzheimer s CMI or more PE or 1 PE or more PD or 1 PD or more PC or 1 PC or more PB or 1 PB or more PA or 1 PA BINDER TAB 3 RUG-IV SUPPORTIVE DOCUMENTATION REQUIREMENTS 92 46

47 Supportive Documentation Requirements YOU CHANGED MY CATEGORY! Current trends in category changes during Case Mix audits 93 Supportive Documentation Requirements OBJECTIVES To gain a better understanding of documentation requirements to: Support RUG categories Avoid category changes 94 47

48 Supportive Documentation Requirements REASONS FOR CHANGES Insufficient documentation in the clinical record Coding errors Lack of care planning Time frame errors 95 Supportive Documentation Requirements HOW TO AVOID RUG CHANGES Follow and refer to the Mississippi Division of Medicaid Case Mix Documentation Requirements along with the RAI manual Clear, concise, interdisciplinary documentation Efficient communication within the Interdisciplinary team 96 48

49 Supportive Documentation Requirements SECTION C: COGNITIVE PATTERNS C0200 Repetition of Three Words (BIMS) ~Behavioral Symptoms and Cognitive Performance Does require: Validation of completion of item C0200 on or before the ARD date (may be dated up to two (2) days after the ARD under limited circumstances). An exact description of the resident s responses. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. 97 Supportive Documentation Requirements SECTION C: COGNITIVE PATTERNS C0300 A,B,C Temporal Orientation (BIMS) ~Behavioral Symptoms and Cognitive Performance Does require: Validation of completion of item C0300 A,B,C on or before the ARD date (may be dated up to two (2) days after the ARD under limited circumstances). An exact description of the resident s responses. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care

50 Supportive Documentation Requirements SECTION C: COGNITIVE PATTERNS C0700 Short-Term Memory (CPS) Staff interview ~Behavioral Symptoms and Cognitive Performance Does require: Documentation to determine functional capacity to remember recent events and assess the mental state of residents who cannot be interviewed. Documentation in the clinical record with example(s) describing the lack of follow through on a direction given 5 (five) minutes earlier within the observation period. Example(s) must reference the 5 (five) minute time frame. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. 99 Supportive Documentation Requirements SECTION C: COGNITIVE PATTERNS C1000 Cognitive Skills for Daily Decision Making (CPS) Staff Interview ~Behavioral Symptoms and Cognitive Performance Does require: Documentation in the clinical record within the observation period of example(s) demonstrating degree of compromised decision-making about tasks of everyday living. Does include: Choosing clothing. Knowing when to go to meals. Using environmental cues to organize and plan. Documentation of seeking information from others to plan the day. Supervision or assistance required to make decisions. Cognitive performance must also be consistent with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. Does NOT include: Resident s decision to exercise his/her right to decline treatment or recommendations by staff

51 Supportive Documentation Requirements SECTION D: MOOD D0200 Resident Mood Interview (PHQ-9 ) ~Special Care High ~Special Care Low ~Clinically Complex Documentation in the clinical record within the time frame must have an exact description of the resident s responses to the occurrence and symptom frequency. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and mood/behavior records. Have a plan of care in place with specific interventions addressing each mood symptom(s) coded. D0200A-I, Column 2 Resident Mood Interview Symptom Frequency Does require: Validation of completion of items D0200 A-I on or before the ARD (may be dated up to two (2) days after the ARD under limited circumstances). Evidence of resident mood interview (PHQ- 9 ) in the medical record within the observation period. Items coded to record symptom occurrence and frequency of mood symptoms. 101 Supportive Documentation Requirements SECTION D: MOOD D0500 Staff Assessment of Resident Mood (PHQ- 9-OV ) ~Special Care High ~Special Care Low ~Clinically Complex Does require: Example(s) that demonstrates the resident s mood (specific to each D0500A-J item). Evidence of daily documentation supporting frequency of mood. An exact description of resident s responses, staff observations and symptom frequency. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and mood/behavior records. Have a plan of care in place with specific interventions addressing each mood symptom(s) coded

52 Supportive Documentation Requirements SECTION I: ACTIVE DIAGNOSES Active Diagnosis Definition: A physician documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days that has a direct relationship to the resident s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death within the 7-day look back period. Does require: Physician documented diagnosis in the 60-day look back period. Documentation supporting active diagnosis in the 7-day look back period. Documentation related to necessary care, monitoring, interventions, symptoms, or risks relative to the diagnosis. Documentation must also be consistent with radiological reports, laboratory reports, positive study, test or procedures, physician orders, progress notes, interdisciplinary notes, treatment records, mood/behavior records and the plan of care. 103 Supportive Documentation Requirements SECTION I: ACTIVE DIAGNOSES Active Diagnosis Definition: A physician documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days that has a direct relationship to the resident s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death within the 7-day look back period. Does include: Functional limitations loss of range of motion, contractures, muscle weakness, fatigue, decreased ability to perform ADLs, paresis or paralysis. Nursing monitoring nursing monitoring includes clinical monitoring by a licensed nurse (e.g., serial blood pressure evaluations, medication management, etc.). Does NOT include: Conditions that have been resolved, that do not affect the resident s current status or do not drive the resident s plan of care within the 7-day look back period; these would be considered inactive diagnoses

53 Supportive Documentation Requirements SECTION I: ACTIVE DIAGNOSES I6200 Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Chronic Lung Disease ~Special Care High Asthma: A physical condition that makes it difficult for someone to breathe. A chronic lung disorder that is marked by recurring episodes of airway obstruction (as from bronchospasm) manifested by labored breathing accompanied especially by wheezing and coughing and by a sense of constriction in the chest, and that is triggered by hyperactivity to various stimuli (as allergens or rapid change in air temperature). Chronic Obstructive Pulmonary Disease and/or Chronic Lung Disease: Pulmonary disease (as emphysema or chronic bronchitis) that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation-abbreviation COPD. 105 Supportive Documentation Requirements SECTION I: ACTIVE DIAGNOSES I5300 Parkinson s Disease Respiratory Failure ~Special Care Low Parkinson s Disease: A chronic progressive neurological disease chiefly of later life that linked to decreased dopamine production in the substantia nigra and is marked especially by tremor of resting muscles, rigidity, slowness of movement, impaired balance, and shuffling gait - called also paralysis agitans, Parkinson s, Parkinson s syndrome. A condition where not enough oxygen passes from the lungs into the blood. Respiratory Failure may also occur if the lungs can t properly remove carbon dioxide from the blood

54 Supportive Documentation Requirements SECTION J: HEALTH CONDITIONS J1100C Shortness of Breath (dyspnea) when lying flat ~Special Care High Shortness of Breath: Difficulty in drawing sufficient breath; labored breathing. Dyspnea: Difficult or labored respiration. Does require: Documentation of shortness of breath or trouble breathing when lying flat. A care plan with individualized interventions and evidence the interventions have been monitored and modified as appropriate. Consistency with physician orders, progress notes, interdisciplinary notes, treatment records and plan of care. Does include: Avoidance of lying flat because of shortness of breath. 107 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0510A (code 1 or 2) Parenteral / IV Feeding ~Special Care High Does require: Nutrition and hydration received by the resident in the last 7 days either at the nursing home, at the hospital as an outpatient or an inpatient, administered for nutrition or hydration. Documentation in the clinical record must reflect that alternative nutritional approaches are monitored to validate effectiveness. Care planning must include periodic reevaluation of the appropriateness of the approach. Does include: Document fluids received by the nursing home resident after admission/ entry or reentry to the facility. Introduction of a nutritive substance into the body by means other than the intestinal tract (e.g., subcutaneous, intravenous). IV fluids or hyperalimentation, including TPN, administered continuously or intermittently. Documentation in the clinical record of physician s order, time, type, amount, and rate of administration. IV at KVO (keep vein open) rate. IV fluids contained in IV piggyback. Hypodermoclysis and sub-q ports in hydration therapy. IV fluids administered for the purpose of prevention of dehydration if specifically documented for nutrition or hydration

55 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0510A (code 1 or 2) Parenteral / IV Feeding ~Special Care High Does NOT include: Additives, such as electrolytes & insulin that are added to TPN or IV fluids. IV medications. IV fluids used to reconstitute and/or dilute meds. IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay. IV fluids administered solely as flushes. IV fluids administered in conjunction with chemotherapy or dialysis. 109 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0510B (code 1 or 2) Feeding Tube ~Special Care High ~Special Care Low Does require: Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system in the last 7 (seven) days after admission/entry or reentry to the facility. Does include: (not limited to) NG tubes, gastrostomy tubes, J-tubes, tubes. Documentation consistent with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. Documentation in the clinical record to include time, type, amount and rate of administration. Documentation in the clinical record to reflect that alternative nutritional approaches are monitored to validate effectiveness. Care planning to include periodic reevaluation of the appropriateness of the approach

56 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0710A3 Proportion of Total Calories the Resident Received Through Parenteral or Tube Feeding During Entire 7 days ~Special Care High ~Special Care Low Does require: Documentation to support the proportion of calories actually received (not just what is ordered), for nutrition or hydration through parenteral or tube feeding during the entire 7- day observation period after admission /entry or reentry to the facility. Documentation in the clinical record to include intake records to determine actual caloric intake through parenteral or tube feeding routes. Documentation to be consistent with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. Oral intake must be documented. Proportion of calories received through artificial routes to be monitored with periodic reassessment to ensure adequate nutrition and hydration. 111 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0710A3 Proportion of Total Calories the Resident Received Through Parenteral or Tube Feeding During Entire 7 days ~Special Care High ~Special Care Low For residents receiving both oral nutrition and tube feeding, documentation must demonstrate how the facility calculated the % of calorie intake the tube feeding provided and must include: Calories tube feeding provided within observation period. Calories oral feeding provided within observation period. Percent of total calories provided by tube feeding

57 Supportive Documentation Requirements SECTION K: SWALLOWING/NUTRITIONAL K0710B3 Average Fluid Intake Per Day by IV or Tube Feeding. During Entire 7 days ~Special Care High ~Special Care Low Does require: Documentation to support average fluid intake per day by IV and/or tube feeding during the entire 7-day observation period after admission/entry or reentry to the facility. Documentation in the clinical record to include intake records to determine actual fluid intake through parenteral or tube feeding routes. Fluid intake received through artificial routes to be monitored with periodic reassessment to ensure adequate nutrition and/or hydration. Documentation to be consistent with physician orders, progress notes, interdisciplinary notes, treatment records and the plan of care. Documentation must demonstrate how the facility calculated the average fluid intake the tube feeding provided and must include: 1. Adding the total amount of fluid received each day by IV or tube feedings only. 2. Divide the week s total fluid intake by 7 (or look back period if less than seven days) to calculate the average of fluid intake per day (Divide by 7 (or look back period if less than seven days) even if the resident did not receive IV fluids or tube feeding on each of the 7 days). 113 Supportive Documentation Requirements SECTION M: SURGICAL WOUNDS M1040E Surgical Wound ~Clinically Complex Does require: Detailed current description of the surgical wound including location and appearance. Does include: Any healing or non-healing, open or closed surgical incisions, skin grafts or drainage sites on any part of the body. Pressure ulcers that are surgically repaired with grafts and flap procedures. Does NOT include: Healed surgical sites and healed stomas. Lacerations that require suturing or butterfly closure. PICC sites, central line sites, peripheral IV sites. Pressure ulcers that have been surgically debrided

58 Supportive Documentation Requirements SECTION N: MEDICATIONS N0350A Injections N0350B Days of Orders for Insulin ~Special Care High ~Special Care High Documentation to include the number of days that insulin injections were received for the last 7 (seven) days. Documentation must be consistent with physician orders, treatment/medication administration records and the plan of care. Does include: Subcutaneous insulin pumps, the number of days the resident actually required a subcutaneous injection to restart the pump. Documentation to include the number of days that the resident insulin orders changed for the last 7 (seven) days. Does include: Sliding scale order that is new, discontinued or is the first sliding scale order. Does NOT include: A day simply because a different dose of insulin is administered based on an existing sliding scale order. 115 Supportive Documentation Requirements SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS O0100M, 2 Isolation or Quarantine for active infectious disease I can t come outside; I m highly contagious! ~Extensive Services Documentation supporting active infectious disease, i.e., symptomatic and/or have a positive test and are in the contagious stage. Does require: Documentation of need for transmission-based precautions and strict isolation alone in separate room. Documentation of highly transmissible or epidemiologically significant pathogens acquired by physical contact, airborne or droplet transmission. Consistent with physician orders, progress notes, lab, Interdisciplinary notes, and plan of care Does NOT include: Standard precautions. History of infectious disease. Urinary tract infections. Encapsulated pneumonia. Wound infections. Cohorting with roommate

59 Supportive Documentation Requirements SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS O0100A, 2 Chemotherapy ~Clinically Complex Administration of any type of chemotherapy agent (anticancer drug) given by any route for the sole purpose of cancer treatment. Does require: A description that includes the name of the drug, amount given, route and time must be documented in the clinical record within the observation period. Monitoring of the side effects associated with the chemotherapy and the plan of care. Does NOT include: Chemotherapy agent given for reasons other than treatment of cancer (e.g. Megace for appetite stimulation). 117 Supportive Documentation Requirements SECTION 0: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS O0100C, 2 Oxygen Therapy ~Special Care Low ~Clinically Complex Administration of oxygen continuously or intermittently via mask, cannula, etc., delivered to relieve hypoxia in last 14 days. Does include: Resident places or removes his/her own oxygen mask, cannula. Oxygen when used in BiPAP/CPAP. Must include the method of administration, time and amount of oxygen administered within the observation period. Does NOT include: Hyperbaric oxygen for wound therapy

60 Supportive Documentation Requirements SECTION 0: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS O0500A-J Restorative Nursing Program Days ~Rehabilitation ~Behavioral Symptoms and Cognitive Performance ~Reduced Physical Function Restorative nursing program refers to nursing interventions that promote the resident s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Does require: Evidence of actual minutes on a daily/shift/occurrence for each activity provided within a 24-hour period. Initials/signature(s) on a daily/shift occurrence to support the total minutes of restorative nursing activity/activities provided. 119 BINDER TAB 4 CASE MIX MASTER ROSTER REPORT USER GUIDE

61 Roster Report INTRODUCTION TO CASE MIX MASTER ROSTER REPORT USER GUIDE The Division of Medicaid (DOM) contracted with Myers and Stauffer LC to transition to RUG-IV, resume the processing of Roster Reports, develop an electronic case mix review system and develop a portal system for the collection of bed hold dates for Mississippi s Medicaid nursing facilities The transition began with rates effective January 1, 2015 A portion of the rate is adjusted quarterly based on the case mix of the residents in each facility, meaning the measure of the intensity of care and services used by similar residents 121 Roster Report INTRODUCTION TO CASE MIX MASTER ROSTER REPORT USER GUIDE The source of the case mix rate element is the Minimum Data Set (MDS) which is transmitted electronically to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System The Case Mix Master Roster Report User Guide describes the process in which these MDS assessments are used to develop the case mix index used in the reimbursement rate