MDS Alert

Published on Mon Jan 22, 2007 PDF

Directions: Read the following case example, which includes enough information to answer these questions:

1. Would the resident qualify for a Medicare Part A stay?

2. If so, what RUG-53 class would he fall into?

3. Based on the resident's information and diagnoses, what additional information might you look for in order to see if the resident might qualify for a higher-paying RUG?

Case example: Mr. Thomas is an 82-year-old male discharged from the hospital today following a five-day stay for fever and dehydration. He meets all of the technical requirements for Part A coverage, including a three-day hospital stay and days left in the benefit period. Mr. Thomas lives with his elderly wife and has been her caretaker for the past two years. He has lost 12 pounds in the past two weeks and is not drinking very well. ADL information from the hospital indicates he'd have an ADL score of at least "7" after initial admission to the SNF. His diagnoses are dehydration, malnutrition, COPD and hypertension.

See if you know the score.

Question 1. Would the resident qualify for SNF care?

Answer: Yes, Mr. Thomas would qualify for skilled coverage for fever and dehydration.

Question 2. What RUG would he fall into?

Answer: The information provided would put him in the Special Care RUGs classification. He also lived at home taking care of his wife, so he will need therapy to bring him to his prior level of functioning. This could put him in a Rehab RUGs class.

Question 3. Based on the resident's information and diagnoses, what additional information might you look for in order to see if the resident might qualify for a higher paying RUG?

Answer: The MDS team would need to review the resident's hospital record for any missing information for the lookback, which would most likely show IV fluids for the dehydration, as well as IV medications.

If the resident had IV fluids and/or IV meds -- and an ADL score of at least 7 -- he might qualify for rehab plus extensive services. The classification could be from Rehab Very High to Rehab Medium depending on his need and ability to tolerate the therapy as well as the date of the last IV medication or fluids.

The final RUG would most likely be RVL. It could also be RML depending on therapy's evaluation and the lookback information.

Source: Diana Johnson, RN, clinical consultant, Health Dimensions Group, Minneapolis, MN, presentation at the October 2006 American Association of Nurse Assessment Coordinators