MDS Alert

Published on Thu Jan 26, 2006 PDF

New RUG offers formula for improved care and better payment.

Case management has always been the MDS nurse's bailiwick. And now you have more RUG room for Part A-stay patients with complex nursing needs who might benefit from a combo of restorative and low-intensity rehab.

"The new low rehab plus extensive services (RLX) provides an opportunity for SNFs to receive fair payment in caring for residents with clinically intensive needs who require low-intensity rehabilitation," says Cheryl Field, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA. "Under RUG-53, RLX pays more than SE1or SE2," she notes.

Identify Likely Candidates for the New RUG Category

The rehab low plus extensive services might be a good category for residents at admission who are too sick to tolerate much rehab but can benefit from low-intensity skilled therapy and restorative nursing, says Julie Thurn-Favilla, CRNAC, clinical consultant with LarsonAllen in Minneapolis.

Some of the potential restorative interventions for such patients, according to Thurn-Favilla, might include these services:

• Performing a continence assessment and implementing a toileting program or bladder retraining for a resident who's admitted to the SNF from the hospital with an indwelling catheter--or had one pulled right before the SNF admission, says Thurn-Favilla. The toileting or bladder program would have to meet the criteria spelled out by the RAI manual for coding it at H3a or H3b, she adds. (To review the criteria, go to www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20rai1202ch3.pdf, p. 3-125.)

• Focusing on transfer training, range of motion or ambulation coded in Section P3 to increase the person's endurance so he can tolerate more therapy.

• Working on communication for a stroke patient or someone who is on a ventilator.

The new RLX would be ideal for acutely ill people who are receiving IV antibiotics for an infected hip after a hip replacement and require some rehab and restorative nursing to progress toward their optimal rehab goal, says Jan Zacny, RN, a consultant with BKD Southern Missouri in Springfield, MO.

Another potential candidate for RLX: The "frequent flyers" who are hospitalized often for flare-ups of congestive heart failure or COPD who receive IV fluids, meds, suctioning, etc., in the hospital, says Zacny. "Those patients may need therapy and be good candidates for the new low or medium rehab category," she notes.

Inne Taylor, RN, says she could foresee residents admitted to the SNF from an acute cardiac rehabilitation inpatient stay being candidates for RLX. "In cases where the cardiac resident still has a lot of limitations and skilled nursing needs, his initial MDS assessment may categorize him into the RLX group," says Taylor, who is the MDS coordinator for Sunshine Terrace in Logan, UT. By the time the 14-day assessment is due, the same resident may be well enough for more extensive rehabilitation, adds Richard Penrod, a physical therapist with the nursing facility.

Capture Necessary Services

Providing rehab and restorative to a resident who had an IV in the hospital or facility is one thing--but capturing it on the MDS so the person groups into RLX is another. To do so, you have to set the assessment reference date to capture all of the required services, Field notes. Getting the resident into RLX on the 5-day assessment is relatively easy (review the requirements in the next article).

The patient may continue in the RLX category for the Medicare 14-day assessment if he still needs restorative and rehab and has the requisite ADL score. If so, select an assessment reference date to capture the IV medications or other hospital extensive service (or one provided in the facility) in the 14-day look-back period and an ADL score of at least 7. The assessment window for the 14-day MDS runs from days 11 to19 if you've completed the comprehensive assessment, says Zacny. "But keep in mind the RLX category requires six days of restorative nursing"

Another potential stumbling block: You can only code restorative nursing if it meets the RAI manual requirements for doing so. Zacny notes that many facilities actually provide nursing rehab but don't take the effort to meet the manual requirements, including documentation.

Review the requirements at www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20rai1202ch3.pdf (pp. 3-191 through 3-197).

Beware: If a medical reviewer finds a facility has been coding restorative on the MDS and billing Medicare for it--and the restorative doesn't meet the RAI manual guidelines--the payer can recoup the payment, warns Jane Belt, RN, MSN, CS, a consultant with Plante & Moran Swartz Group in Columbus, OH.