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.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been quoted in the Wall Street Journal, New York Times, and National Public Radio.

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