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Why so many A's in our RUG-IV categories?

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Ask the payment expert
Ask the payment expert
Why are we seeing more A's in our RUG-IV categories?

Recently, when auditing charts and claims, we have been seeing this trend of an increase in A's, versus B's and C's. It is the new ADL summary methodology that is creating that issue. If you look at this issue, you will see that for the most part, a resident needs to have some “late loss” ADLs coded as Extensive Services or somewhere the resident needs two-person physical assistance in order to code above this level. This is going to create some difficulties with facility reimbursement.

A's are typically paid at a lower rate than B's or C's, depending on case mix methodology. My suggestion is that facilities need to re-educate their staff on the definitions for ADL coding. Although this coding has not changed, staff continue to have difficulty with the difference between limited and extensive assistance.

Should our facility have any X's or L's in our Rehab RUG levels since October?

If you did, you need to be verifying that the RUG levels are correct. In October, there were a lot of software issues with CMS and software vendors. Recently, we have found some facilities that incorrectly put residents into these categories even though they did not have any of the three Extensive Services qualifiers of Ventilator care in the facility, Tracheostomy care in the facility or Isolation due to an active infection.

Some software programs were coding IV medications either in the facility or in the hospital in this category. Even if this software is correct now, you need to go back to the beginning of October and recheck each of your validation reports to ensure you billed at the appropriate level and complete an adjusted bill if needed.

Please send your payment-related questions to Patricia Boyer at ltcnews@mcknights.com.

Please send your payment-related questions to
Patricia Boyer at ltcnews@mcknights.com.

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