Re: Nursing RUG with Therapy minutes on MDS

[Jenny Boring]

Title: AOL Email

Software companies program their products to calculate the RUGS based on the data specifications laid out by CMS. The Federal Medicare system uses version 5.12, 44 Grouper, index maximizing. So each RUG category has a case mix index value attached to it.  In an index maximizing system, the program will look and see which RUG categories a resident falls in, then assign the category with the highest case mix index. So if (hypothetically) a resident falls into both a rehab and extensive services category, the system will assign whichever category has the highest index, not the highest rate.   So for example : let's say RHC has a case mix index of 39.0, and a rate of 365.62,  and SE3 has a case mix index of 36.0 and a rate of 383.16. If a resident meets the criteria for both of these categories based on MDS items entered, a system that is index maximizing as specified for Medicare will look at both categories and pick the one with the higher case mix index. So in this instance, RHC would be chosen because the index value 39.0 is higher than 36.0. So the rate of reimbursement would be at 365.62.   It is not an arbitrary choice on the part of a correctly programmed software system. This is what is required. Below is a link to the manual RUG calculator tool provided by CMS. It can be useful if you are ever curious as to the logic of the RUG grouping provided by your software or otherwise.   http://www.cms.hhs.gov/medicaid/mds20/mds44ws2.pdf   Jenny Boring, R.N., B.A. Director, AANAC Board     ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Tuesday, January 27, 2004 10:46 PM Subject: Re: Nursing RUG with Therapy minutes on MDS I am not meaning it would be fraudulent, the minutes are still being done and are included on the UB-92, you still have to provide therapy since we have to provide all needed services, what i don't really understand, is why the software would make someone, who qualifies in a higher reimbursed RUG move to a lower Rehab RUG-is it only because of the CMI and the payment is based on that vs RUG payment?   Most cases this would only be the beginning of a part a stay and not done throughout the skilled stay.  I also do not understand if someone, geriatric, with a new fall at home and comes to us for Rehab and pain mgmt, how can they tolerate that much therapy to begin with?  Most are with acute pain and symptoms of Delirium at first and nursing should drive the MDS process not Rehab-which basically is done in many of the homes here in Alabama.  I did not mean to imply it was fraud-but i have heard of other homes doing this in the Southeast, and by omitting therapy minutes, the software could not automatically move you to a Rehab RUG.   I am i guess confused about this and wondered if anyone out there could help with my question. L.Morgan