Skilled Nursing Resource Utilization Group Classifications

The Resource Utilization Group Skilled Nursing Standard (RUG, or currently RUG-IV) classification system has eight major classification categories: Rehabilitation Plus Extensive Services, Rehabilitation, Extensive Services, Special Care High, Special Care Low, Clinically Complex, Behavioral Symptoms and Cognitive Performance Problems, and Reduced Physical Function (see Table 1). The categories, except for Extensive Services, are further divided by the intensity of the resident’s ADL needs. The Special Care High, Special Care Low, and Clinically Complex categories are also divided by the presence of depression. Finally, the Behavioral Symptoms and Cognitive Performance Problems and the Reduced Physical Function categories are divided by the provision of restorative nursing services.

A calculation worksheet was developed in order to provide clinical staff with a better understanding of how the RUG-IV classification system works. The worksheet translates the standard software code into plain language to assist staff in understanding the logic behind the classification system. A copy of the calculation worksheet for the RUG-IV classification system for nursing homes can be found at the end of this section.

Characteristics Associated With Major RUG-IV Category
 See CMS’s RAI Version 3.0 Manual CH 6: Medicare SNF PPS CHAPTER 6: MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM (SNF PPS)

Example of RUG Scores for a Post Acute / Sub Acute / SNF Population

RUG GroupRUG CodeDescription# of Medicare Days% of Medicare Days
RehabRUCUltra High Intensity (ADL 11-16)383.2 %
RehabRUBUltra High Intensity (ADL 6-10)21017.6 %
RehabRUAUltra High Intensity (ADL 0-5)34228.7 %
RehabRVCVery High Intensity (ADL 11-16)342.8 %
RehabRVBVery High Intensity (ADL 6-10)1038.6 %
RehabRVAVery High Intensity (ADL 0-5)17314.5 %
RehabRHCHigh Intensity (ADL 11-16)70.6 %
RehabRHBHigh Intensity (ADL 6-10)322.7 %
RehabRHAHigh Intensity (ADL 0-5)504.2 %
RehabRMCMedium Intensity (ADL 11-16)221.8 %
Rehab Plus ExtensiveRULUltra High Intensity (ADL 2-10)221.8 %
RehabRMBMedium Intensity (ADL 6-10)80.7 %
RehabRMAMedium Intensity (ADL 0-5)342.8 %
Extensive ServicesES1Isolation for active infectious disease (ADL 2-16)50.4 %
Special Care HighHD1Not Depressed (ADL 11-14)20.2 %
Special Care LowLD1Not Depressed (ADL 11-14)141.2 %
Special Care LowLC1Not Depressed (ADL 6-10)50.4 %
Special Care LowLB1Not Depressed (ADL 2-5)110.9 %
Clinically ComplexCD1Not Depressed (ADL 11-14)463.9 %
Clinically ComplexCC1Not Depressed (ADL 6-10)110.9 %
Reduced Physical FunctioningPB1Nursing Rehab 0 to 1 (ADL 2-5)100.8 %
Reduced Physical FunctioningPA1Nursing Rehab 0 to 1 (ADL 0-1)100.8 %
DefaultAAANo MDS assessment conducted or RUG-IV classification is invalid40.3 %

Rehabilitation Plus Extensive Services

Residents satisfying all of the following three conditions:
1.     Having a minimum activity of daily living (ADL) dependency score of 2 or more.
2.     Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.
3.     While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.

Rehabilitation

Special Care High

Residents receiving physical therapy, occupational therapy, and/or speech- language pathology services while a resident.

Residents satisfying the following two conditions:

Extensive Services

Residents satisfying the following two conditions:

1. Having a minimum ADL dependency score of 2 or more.

2. While a resident, receiving complex clinical care and have needs involving: tracheostomy care, ventilator/respirator, and/or infection isolation.

Having a minimum ADL dependency score of 2 or more.

Receiving complex clinical care or have serious medical conditions involving any one of the following:

—  comatose,

—  septicemia,

—  diabetes with insulin injections and insulin order changes,

—  quadriplegia with a higher minimum ADL dependence criterion (ADL score of 5 or more),

—  chronic obstructive pulmonary disease (COPD) with shortness of breath when lying flat,

—  fever with pneumonia, vomiting, weight loss, or tube feeding meeting intake requirement,

—  parenteral/IV feeding, or

—  respiratory therapy.

Special Care Low

Residents satisfying the following two conditions:

1. Having a minimum ADL dependency score of 2 or more.

2. Receiving complex clinical care or have serious medical conditions involving any of the following:

—  cerebral palsy with ADL dependency score of 5 or more,

—  multiple sclerosis with ADL dependency score of 5 or more,

—  Parkinson’s disease with ADL dependency score of 5 or more,

—  respiratory failure and oxygen therapy while a resident,

—  tube feeding meeting intake requirement,

—  ulcer treatment with two or more ulcers including venous ulcers, arterial ulcers or Stage II pressure ulcers,

—  ulcer treatment with any Stage III or IV pressure ulcer,

—  foot infections or wounds with application of dressing,

—  radiation therapy while a resident, or

—  dialysis while a resident.

Clinically Complex

Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following:

pneumonia,

hemiplegia with ADL dependency score of 5 or more,

surgical wounds or open lesions with treatment,

burns,

chemotherapy while a resident,

oxygen therapy while a resident,

IV medications while a resident, or

transfusions while a resident.

Behavioral Symptoms and Cognitive Performance

Residents satisfying the following two conditions:

1. Having a maximum ADL dependency score of 5 or less.

2. Having behavioral or cognitive performance symptoms, involving any of the following:

—  difficulty in repeating words, temporal orientation, or recall (score on the Brief Interview for Mental Status <=9),

—  difficulty in making self understood, short term memory, or decision making (score on the Cognitive Performance Scale >=3),

—  hallucinations,

—  delusions,

—  physical behavioral symptoms toward others,

—  verbal behavioral symptoms toward others,

—  other behavioral symptoms,

—  rejection of care, or

—  wandering.

Reduced Physical Function

Residents whose needs are primarily for support with activities of daily living and general supervision.

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Michael F. Arrigo

Michael Arrigo brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health IT, and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations who provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and medical billing, fraud damages, as well as electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, medical malpractice, insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software SA (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls IT audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and is published in Healthcare IT News.

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