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UnderstandingVirginiaMedicaidCaseMixSystem
Virginia Medicaid • Medicaidresidentdaysarepaidonaperdiemrate
• LikeMedicareA• BilledeachmonthwiththeHIPPSfromtheMDScontrollingpaymentforthedaysinthatmonth.
• WillonlyuseOBRAassessments• Virginiadual-eligibleprogramalsousedthissystem.
Ratesvaryfacilitytofacility
PA1 PA2 PB1 Direct Operating Cost (Case Mix Neutral) $83.18 $83.18 $83.18
RUG III, Grouper 34 Weight 0.59 0.62 0.63 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 $138.28 $140.77 $141.60
LinktoyourratesonJudyWilhide.com“resources”
Example: Admi4ed regular Medicaid
• Admission:6/12/15• AdmissionMDSARD:6/19/14Z0200=SE201• QuarterlyMDSARD9/19/15Z0200=CB102• SE201controlspaymentfor:
• 6/12–9/18/15• CB102controlspaymentbeginning:
• 9/19/15
Example: Admi4ed Dual-Eligible: Medicare/Medicaid
• Admit:6/15/14• Admission/5DayMDSARD:6/19/14Z0200=RAD
• Medicare6/15–7/20• Medicaidbeginning7/21• BillMedicaidRAD7/21–daybeforenextOBRAARD
Medicaid Rules
• PaymentiscontrolledbythelastOBRAassessmentdoneun;ltheARDofthenextOBRAassessment
• Admissionassessmentcontrolspaymentfromday1.
• NoStaterequirementonhowclosetogetherOBRAassessmentsmaybescheduled.
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OBRAScheduling
Admission
Quarterly
Quarterly
Quarterly
Annual
92daysARDtoARD
366daysARDtoARD
AdmTracker
SCSAResetsOBRAClock!
92daysARDtoARD
366daysARDtoARD
Admission
Quarterly
SCSA
Quarterly
Quarterly
Quarterly
Annual
AdmTracker
LateAssessments
• IftheOBRAARDissetlate,thenursingfacilityshallbillthedefaultRUGcodeun;ltheARDofthenextOBRAassessment.
• Annualmaybelatetwoways:– ARD>92daysfromlastOBRA– ARD>366daysfromlastcomprehensive
Final Valida=on Report
Thisiswherethelatewarningswill
appear
StaysLessthan14Days
• Twochoices:– DoearlyAdmissionassessment– Billdefaultrate
• MedicaidRUGIII,34grouper,version5.20
• Candoearlyquarterlies• MustdoSigChangewhenclinicalcondi;onwarrants
• NeedtosetARDtomaximizeMedicaidRUG
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Basics
• RUGIII-34grouperVersion5.20• RUGassignedinZ0200
Z0250isNOTusedforANYcalcula;on.DMASisrunningadifferentgrouperinthatboxaspartofanon-goingstudy.Valida;onreportwarningsfor
Z0250canbeignored.
HIPPS Code Health Insurance Prospec=ve Payment System
RAB
RUGScore
01
AssessmentIden;fierCode
AnyA0310Aexcept“99”
MaybecombinedwithPPS
AICode
HIPPS Code
RAB02
RUGScore CaseMixIndex
1.24
EachRUGhasitsownCMI
RUG III (Version 5.20) 34 Grouper Examples
RUG CMISE3 2.10SE2 1.79RAD 1.66SE1 1.54SSC 1.44CC2 1.42SSB 1.33
RUGIIIGrouper
• “Whilearesident”and“Whilenotaresident”arebothusedtocalculateRUGscore.– ExtensiveServicecanpaymorethanmoreRehab
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ADL SelfPerformance
Support ADLScore
BedMobility,Toile;ng,Transfers
0,1or7 Anynumber 12 Anynumber 33,4or8 2 43,4or8 3 5
Ea;ng: IVfluid NA 3Qualifyingtubefeeding
NA 3
0,1,or7 NA 12 NA 23,4or8 NA 3
Rehab
RAD 17-18RAC 14-16RAB 10-13RAA 4-9
• Twowaystoqualify:– 5treatmentdaysofanycombina;onofOT,PTorSTforatleast150minutes
– Threetreatmentdaysofanycombina;onofOT,PTorSTforatleast45minutesand2+qualifyingrestora;venursingprograms
“Dis;nctC
alendar
Days”No
tused
ExtensiveServicesSubgroups:• SE3-ClinicalIndicators4-5• SE2-ClinicalIndicators2-3• SE1-ClinicalIndicators0-1
ExtensiveServices
ServiceCount
SE3(4-5)
SE2(2-3)
SE1(0-1)
ADLScore>7
ExtensiveServices• Mustmeetoneormoreofthefollowingservices:
– Inlast7days,receivedparenteralorIVtherapy
– Inthelast14days,received:• IVmedica@on• Suc@oning• Trachcare• Ventorrespiratortreatment
• MusthaveADLscoreatleast7• Lookbackperiodincludespriortoadmit
IVFluid
OtherExtensiveServicesQualifiers
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ExtensiveServicesCount:
5.ImpairedCogni;on
4.ClinicallyComplex
3.SpecialCare
2.IVMed
1.Parenteral/IVfluidExtensiveServicesDiagram
• ADLScore
>7
• IVmed• IVfluid• Trach• Vent• Suc;on
Qualifiers• IVFluid• IVMed• SpecialCare
• ClinicallyComplex
• ImpairedCogni;on
ServicesCount
• SE3• SE2• SE1
RUG
ServicesCount OurResident:Parenteral/IVFluid XIVMed XSpecialCare XClinicallyComplex XImpairedCogni;on -
ServicesCount=4RUG=SE3
ExampleIVFluidRUGIIICalcula;ondoesNOTuseintakerequirement
SpecialCareSubgroups:
SpecialCare ADL(>7)
SSC(17-18)
SSB(15-16)
SSA(7-14)
SpecialCare
• ADLScoreatleast10and:– CPorMSorQuad
• Feverand1ofthefollowing:– pneumonia– dehydra;on– vomi;ng– weightloss– tubefeeding**
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TubeFeeding:
• Feedingtubeandeither– Atleast51%ofcaloriesbytubeOR– 26%to50%caloriesbytubeANDatleast501ccfluid/daybytube
FeedingTubeRUGIII34V5.20
UsedforRUGIV
UsedforRUGIII34V5.12
TubefeedingDOESuseintakerequirement,butdoesNOTuse“duringen;re7days”
SpecialCare,con;nued• HadADLscoreofatleast7andoneofthefollowing:– Tubefeeding*andaphasia– 2+Pressureulcersand2+skintreatments– St3or4PUand2+skintreatments– Surgicalwoundoropenlesionand1+treatment– radia;ontreatments– 7daysofrespiratorytherapy– ExtensiveServicesw/ADLscore<7
PrUSkinTreatments(2+)
• Pressurereducingbed/chair(countas1)• Turning/reposi;oning• Nutri;onorHydra;oninterven;on• PressureUlcerCare• Applica;onofnonsurgicaldressings• Applica;onofointments/medica;onsotherthantofeet
Surgicalwoundoropenlesionand1+treatment
• Surgicalwoundcare• Applica;onofdressings• Applica;onofointments
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ClinicallyComplex
ClinicallyComplex
ADL CA2 CC2
CC1CB1CA1ADL
CB2
Notdepressed
Depressed
4-11
4-11
12-16 17-18
17-1812-16
ClinicallyComplex• Anyoneofthefollowing:
– ComaandnotawakeandcompletelyADLdependent– Diabetesandinjec;on7daysandorderchanges2+days
• NotjustINSULINorderchanges• NotjustINSULINinjec;ons
– hemiplegiaandADLscore10+– pneumonia– sep;cemia– dehydra;on– InternalBleeding– Tubefeeding*
ClinicallyComplexCon;nued
– burns– footlesionsorfootinfec;onwithapplica;onofdressingstofoot
– chemotherapy– dialysis– Oxygentherapy– transfusions– MDvisits1+dayandRxchange4+days– MDvisit2+daysandRxchange2+days– SpecialCarew/ADLsum<7
TubeFeedingRecap
• SpecialCare:– QualifyingTubefeedingwith:
• FeverOR• Aphasia
• ClinicallyComplex:– QualifyingTubefeeding
EndSplit:SignsofDepressionCriteria
10ormoreonMoodIntervieworStaffAssessment
CC2 1.42CC1 1.25CB2 1.15CB1 1.07CA2 1.06CA1 0.95
ImpairedCogni;on
ImpairedCogni@on
ADL 4-5IA2
6-10IB1
4-5IA1ADL
6-10IB2
1=Restora@veNursing0-1
2=Restora@veNursing2+
ADLScore<=10
CPS:3orBIMSof9“moderatelyimpaired”
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NursingRestora;ve• 2ormorequalifyingnursingrehabservicesforatleast15
minon6ofthepast7days– Scheduledtoile@ng&/orbladderretraining– Passiveand/orac@veROM– Splint/Braceassistance– BedMobilityand/orgaittraining– TransferTraining– DressingorGroomingTraining– Ea;ngorSwallowingTraining– Amputa;onorProsthesisCare– Communica;onTraining
BehaviorProblems
BehaviorProblems
ADL 4-5BA2
6-10BB1
4-5BA1ADL
6-10BB2
1=Restora@veNursing0-1
2=Restora@veNursing2+
ADLScore<10
BehaviorProblems• Anyoneofthefollowingbehaviorsoccurredon4ormoreofthelast7days:– wandering– verbalabuse– physicalabuse– inappropriatebehavior– resistscare
• Or,theresidentexperienceddelusionsand/orhallucina;onsatleastonceinthelast7days.
ReducedPhysicalFunc;on
ReducedPhysicalFunc;on
Restora;vePE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
ADLS
Restora;ve
Restora;ve
Restora;ve
Restora;ve
ADL16-18
ADL11-15
ADL9-10
ADL6-8
ADL4-52=Rest.Nsg2+1=Rest.Nsg0-1
Opera;onalPlanOpportuni;es
• ADLScore• RehabforMedicaidResidents
– 5treatmentdaysperweek– 3treatmentdays+qualifyingrestora;ve
• ExtensiveServices:– IVmed,Fluid,Clysis
• Respiratorytherapy7days/weekfor15min– TimeonMAR/TAR
• Restora;veNursing• Depressioninterview
MDSSchedule
• ReviewtwoweekspriortoARD:– ADLScore?– Rehabin?– Fluids/Meds?– Restora;ve?– InterviewpriortoARD?– DocumentQshiwduringthisperiod
• ExtraQuarterlies• OBRA;melycomple;onawareness
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StrategyExampleRehab:• QuarterlysetJan10,2015RUGPD1144.43• 144.43x92=13,287.56• HasPartBOTbeginningonFeb6for30min/day.ARDsetforFeb10.RUGRAB171.19.OTcon;nuesfor3weeks.
• Jan10–Feb9:5488.34• Feb10for92days:15,749.48
StrategyExampleIV:
• QuarterlysetJan10,2015RUGPD1144.43• 144.43x92=13,287.56• HasIVfluid/medbeginningFeb6.ARDsetforFeb6.RUGSE2213.24.
• Jan10–Feb6:8232.51• Feb6for92days:19,618.08
RUGIV48Grouper
Star;ngJuly1,2017
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0-1RAA
RAB
11-14
2-5
Rehab RAC
RAF
15-16
6-10
RAE
(1) Received150ormoreminutesandAtleast5dis;nctdaysofanycombina;onofthe3disciplines,OR(2) Received45ormoreminutesandAtleast3dis;nctdaysofanycombina;onofthe3disciplinesand2ormorerestora;venursingprogramsreceivedfor6ormoredays,
NursingRestora;ve:>=2on6daysinlookback
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Urinaryand/orboweltrainingprogram*
Passiveand/orac@veROM*
Splintand/orbraceassistance
BedMobilityand/orwalkingtraining*
TransferTraining
Dressingand/orGroomingTraining
Ea;ngand/orSwallowingTraining
Amputa;on/ProsthesisCareTraining
Communica;onTraining
*Countas1forRUGpurposes.
ExtensiveServices–ADL>2:
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ES3
Isola;onforAc;veInfec;ousDisease
TrachORVent
TrachANDVent
ES1
ES2
Whilearesident
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SpecialCareHigh
HC2SignsofDepression
HC1ADL6-10
HB2SignsofDepression
HB1ADL2-5
HD2SignsofDepression
HD1ADL11-14
SignsofDepression HE2
HE1ADL15-16
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SpecialCareHigh:ADL>=2DepressionEndSplit:>=10PHQ9/OV
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Comatose&ADL4/8
Sep;cemia
Diabetesw/dailyInsulininj&InsulinRxchangeson>2days
Quadriplegia&ADL>5
COPD&SOBlyingflat
IVFluid
RespiratoryTherapy7days
Fever&1:
• Pneumonia• WeightLoss• QualifyingFeedingTubeall7days:• >=51%calories• 26-50%calories&501ccfluid
(Feverand)IVFluid
• Sec;onK:7daylookback
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Eithercount
(Feverand)QualifyingTubeFeeding
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Musthaveeither:26-50%AND501cc
OR51%
LD2SignsofDepression
LD1ADL11-14
LE2SignsofDepression
LE1ADL15-16
LC2SignsofDepression
LC1ADL6-10
LB2SignsofDepression
LB1ADL2-5
SpecialCareLow
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SpecialCareLow:ADL>=2DepressionEndSplit–10PHQ9/OV
CerebralPalsy&ADL>5.
Mul;pleSclerosis&ADL>5.
Parkinson’sDisease&ADL>5.
QualifyingTubeFeeding(en;re7days)
FootInfec;on,Diabe;cfootulcer,oropenlesionsonfootw/dressingstofeet.
Radia;ontherapywhileresident.
RespiratoryFailureandOxygentherapywhileresident.
Dialysiswhileresident.
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SpecialCareLow:ADL>=2DepressionEndSplit–10PHQ9/OV
>=2StIIPU&>=2skintreatments
>=1StIII,IV,orunstageableslough/escharPU&>=2skintreatments
>=2venous/arterialulcers&>=2skintreatments
1StIIPU&1venous/arterialulcer&>=2skintreatments.
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Qualifying“SkinTreatments”
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Pressurerelievingchairand/orbed*
Turning/reposi;oning
Nutri;onorhydra;oninterven;on
Ulcercare
Applica;onofdressings(nottofeet)
Applica;onofointments(nottofeet)
CE2SignsofDepression
CE1ADL15-16
ClinicallyComplex
CC2SignsofDepression
CC1ADL6-10
CD2SignsofDepression
CD1ADL11-14
CB2SignsofDepression
CB1ADL2-5
CA2SignsofDepression
CA1ADL0-1
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ClinicallyComplex:AnyADLScoreDepressionEndSplit10PHQ9/OV
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ExtensiveServices,SpecialCareHighorLowwithanADLscoreof<2
Pneumonia
HemiplegiaandADLscore>5
Surgicalwoundsoropenlesionsw/treatment
Burns
Chemotherapywhileresident
Oxygentherapywhileresident
IVMedica;onswhileresident
Transfusionswhileresident
BB22+
Restora@veBB1ADL2-5
BA22+
Restora@veBA1ADL0-1
BehavioralSymptoms&Cogni;vePerformance
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BehavioralSymptoms&Cogni;vePerformanceADL<=5
Restora;veNursingEndSplit
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Delusions
Hallucina;ons
Wandering*
Rejec;onofCare*
Otherbehavioralsymptomsnotdirectedtoothers*
Physicalorverbalbehavioralsymptomsdirectedtoothers*
BIMSScore<9orCPS>3
*>=4days
Any1ofthefollowing:
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PE22+
Restora@vePE1ADL15-16
ReducedPhysicalFunc;on
PC22+
Restora@vePC1ADL6-10
PD22+
Restora@vePD1ADL11-14
PB22+
Restora@vePB1ADL2-5
PA22+
Restora@vePA1ADL0-1
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Transi;on:July1,2017
• IfthereisanOBRAassessmentwithanARDpriortoJuly1,2017,theRUGIIIRUGinZ0200willbeusedthroughtheendofJuneandtheRUGIV48grouperRUGwillbeusedstar;ngJuly1,2016.
• TheRUGIV48grouperRUGisbeingcalculatedinZ0250.Ifyourorganiza;ondidnotloadthatgrouperintoZ0250(andalmostnobodydid)youhavetodothis:
ThisRUGmustgoontheJulyclaimforMedicaid
JudyWilhide.com [email protected] 909-800-9124 www.facebook/wilhideconsulting Twitter: @wilhidemds
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CONCLUSION Discussion/Questions
And you shall rise and show respect to the aged.