Mastering reimbursement under RUGs 53: four steps that start from the top.

We're all adjusting to life under RUGs (Resource Utilization Group) 53. After all, at first glance, major associations predicted a $10 per-day per-resident loss for every facility under the RUG refinements.

That hasn't come to pass for every nursing home. Nursing home leaders with a complete understanding of how the RUG payment categories interact with facility stability and resident outcomes aren't necessarily showing a loss. The payment categories actually bring an increase in payment rates for high acuity rehabilitation cases--but only if the facility is attuned to the details.

Mastering reimbursement under RUGs 53 is best understood through a series of actions. By following these examples, you can best situate your facility to appropriately maximize your benefits under the new payment process:

STEP ONE

Understand your options and the so-called "super" RUGs.

Learning about RUGs 53 is important for all facility employees, but many managers seem to have delegated this important step to the Minimum Data Set (MDS) coordinator without learning it themselves. That's not a good idea.

Frontline staff have a significant impact on the new RUGs--they are the people in your facility who document care delivery, including activities of daily living (ADL) performance on the MDS. But most nursing homes have difficulty with accurate ADL coding.

One of the reasons is that the management team isn't asking the right questions--or any questions at all. Test your awareness with the following questions:

* Have you discussed the documentation process for ADL scoring as it affects outcome measurement and payment groups? Examining a RUG report of your current census with ADL scores is a good place to start. Remember, to group into the highest RUG categories, an ADL score of 7 or higher is necessary.

* Does everyone know what qualifies as an extensive service--which group into the high level RUGs--and what does not?

* Is your MDS coordinator sensitive to MDS coding issues, and does he or she have the most recent updates to the Resident Assessment Instrument User's Manual?

* Is there backup documentation in residents' medical charts for MDS items that show the resident required extensive nursing services?

* Are there problems or inaccuracies with the information your facility receives from the hospital?

* Is your MDS coordinator aware of all of these problems, and does he or she follow up with you?

This sounds like a lot of detail--and it is. To make the new system work for you, you must regard the detail of coding and the timing of the assessment reference periods as tantamount.

Managers need to remember that the MDS process is not just a nursing process--it is an interdisciplinary process and has a significant effect on the overall operation of your facility.

STEP TWO

Determine the efficiency of your data collection.

In this industry, the regulatory and payment systems we work with are dependant on the electronic data submitted through the MDS and billing process. Internal electronic systems need to be efficient, not only to document the data for MDS transmissions and billing, but also to create a useful database. This database helps managers and members of the interdisciplinary team to track the care provided, outcomes, and payment process for each resident.

What kinds of reports should you look at?

* Status reports of your MDS process that detail the numbers and types of MDS documents in the system

* RUGs reports with assessment reference dates (ARD) and ADL scores

* Quality indicators/Quality measures, pretransmission ones being the best to use

* Rehab utilization reports that show minutes of therapy by discipline and by resident diagnosis groups

* Rehab services as related to ADL scores

* Other reports driven by changes in diagnostic groups, admission patterns, or quality assurance focus

Your MDS and payment database feed into your total operations. Your MDS software vendor should be able to provide reports that relate to building operations and resident service and outcome tracking.

Most importantly, your systems must be efficient--MDS staff should not be spending long periods of time on telephone help lines and troubleshooting. The system should match the acuity of the residents and needs of the facility.

Electronic records systems work well in some facilities, and the reporting capability of an electronic system is much larger and faster than a paper system. Real-time data reporting facilitates more immediate management interventions and evaluation of building performance, payment levels, and resident outcomes. Manual systems or paper charts can also be excellent tools with functional MDS data programs.

For these systems, data is not available until the MDS records are entered and closed, and, in some systems, until the MDS is validated by the state. Waiting for this does delay the data monitoring, but it can be a functional management platform if reports are generated and reviewed as soon as the data is available in the system.

Make sure your MDS software is efficient, and that it has excellent editing capabilities. You should be able to produce a variety of reports and interface with the fiscal database of the facility, and data entry should not require significant staff time. Then, ask yourself the following:

* Is my data system properly installed and my staff trained on how to use it?

* Do I know whom to contact (i.e., the vendor) when there are problems?

* Does my MDS coordinator know how efficient our data collection is? Is he or she aware of any software issues?

STEP THREE

Interdisciplinary training includes therapy.

Take a look at the rehab program in your facility and be certain that the members of the rehab team understand the definitions, timing, and documentation requirements of the new payment process.

Many skilled nursing facilities give inadequate information to their therapists about the new payment categories under RUGs 53. The therapist is a member of the team that is providing care to the resident, and the entire team must understand the goals and interventions the resident needs. Do your therapists know

* what procedures qualify as extensive rehabilitation?

* how ARDs affect reimbursement?

* the rules for using grace days?

I've found that interdisciplinary training on the RUGs and overall MDS process is valuable and promotes excellent interdepartmental communication, both written and informal.

The MDS process cannot and should not be totally driven by therapy, which can come as a surprise to some facilities. Review the policies of your rehab contractor to evaluate its coordination with the facility's documentation process. These should match the structure and requirements of the MDS process. Take a look at your rehab contractor's policies--you may be surprised to what you have agreed.

STEP FOUR

Know your ADLs.

Be aware of the documentation process in your facility that creates the scoring in MDS Section G1 for bed mobility, transfer, eating, and toilet use. If this seems like something you don't have to worry about, it's time to meet with your MDS coordinator and ask him or her how the codes get on to the form and whether the facility can improve the quality of coding in this area.

The answers may surprise you. The ADLs are the key to your database accuracy and proper RUG payment. Open the discussion, and make sure you can answer the following questions:

* How do ADL scores change when rehab is delivered?

* If the ADL score goes to a higher number during rehab, how do you explain that?

* If a resident comes into a facility with ADL scores of 4-6, why are you providing rehab at all?

* How are resident outcomes documented in the database?

ADLs are difficult to code accurately, and they involve frontline staff education, performance standards for documentation, and an understanding of the MDS process by all the staff of the facility. But if you can get ADLs right, you're on the ball with one of the most important of all reimbursement variables.

by Leah Klusch, RN

Leah Klusch is the executive director of Alliance (OH) Training Center, and a nurse educator and operational consultant who brings more than 40 years of experience to her work. She can be reached at The Alliance Training Center, at 330/821-7616.