This Centers for Medicare and Medicaid Services (CMS) final rule updates the fiscal year (FY) 2011 payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNF). The final rule for FY 2011 was released with the final rule for 2010, due to the anticipation of a new refinement, effective Oct. 1, 2010.
The final rule for 2011 uses results from the ongoing analysis of the nursing home staff time measurement data collected in the Staff Time and Resource Intensity Verification (STRIVE) project. It implements a new Resource Utilization Groups (RUG) classification system, RUG-IV, that will use the updated Minimum Data Set 3.0 resident assessment for case-mix classification. A proposed rule for FY 2011 with an updated market basket will be released in May of 2010.
Getting Started: Understanding Payment Rates for RUG-IV
With the implementation of the new RUG-IV system in fiscal year 2011, many skilled nursing facilities need more detailed information on how to correctly interpret the various changes to the new classification system as they assess payment for 2011. The documents below provide comprehensive educational material to help nursing homes translate these changes into payment for RUG-IV.
Reference Material for Assessing RUG-IV Payment in 2011
- Getting Started: Understanding RUG-IV
Understanding RUG-IV provides an overview of the payment rates for each RUG group as it relates to the new RUG-IV payment classification system. This resource is the first step in understanding how to correctly estimate payments based on how residents will classify into the RUG groups with the elimination of the exception for the “lookback” period, estimated therapy, and concurrent therapy. The reference material listed below is additional material needed for understanding changes to RUG IV, and will be mentioned within this document, as well as provided separately as download files below.
It is important to note, however, that this exercise does not include information on how to classify residents into the different RUG IV groups based on the new MDS 3.0 resident assessment, which is something all nursing facilities will have to learn before the implementation of the MDS 3.0 by Oct. 1, 2010. In addition to other training, all these materials should be reviewed with your clinical staff prior to using the rate calculation tool.
- RUG-IV Audio Conferences
- Understand and Prepare for the New RUG-IV Rules: This audio conference will enable aging services providers to assess potential changes in Medicare payments for their organizations under the new classification system based on the elimination of the exception rules for the “lookback” period, estimated therapy, and concurrent therapy. The focus of this audio conference will be on the new RUG-IV refinement and how payments will change.
- Big Changes in Therapy Coding and Payment: Some of the most significant changes in RUG-IV are the elimination of Section T and a new requirement to track and report different modes of therapies. This audio conference will present the major changes related to therapy services and provide steps on how to plan for them.
- Proposed and Modified Characteristics by RUG Category
This table provides information on the modification of each Resource Utilization Group as they relate to the proposed 2011 refinement.
- RUG-III and RUG-IV Comparison Charts
This chart provides information on the proposed refinement to each Resource Utilization Group set to occur in Oct. 1, 2011. It shows the differences in classification between RUG-III (53 RUGs) and the proposed RUGs-IV (66 RUGs).
- RUGs Tree
This file is a tree diagram that shows all separate RUGs and rates as proposed for RUGs IV.
- A Guide to Help You Start A Conversation With Your Therapy Contractor
As SNFs transition to a new Medicare Part A payment system effective Oct 1, one major change is how concurrent therapy will be coded and paid. This file provides SNFs with a checklist of points that can help facilities start a conversation with their therapy companies to find out how the new RUGs IV will affect your therapy costs.
RUG Rate Calculation Tools
Other RUG-IV Resources and Training Material from CMS
MDS 3.0
- Resident Assessment Instrument (RAI) Manual: The RAI helps nursing home staff gather definitive information on a resident’s strengths and needs, which is addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident’s status. This zip file contains chapters 1-6. Each section in chapter 3 is contained in a separate PDF file (e.g., Section C: Cognitive Patterns). Appendices A through G, and H are also listed.
- MDS 3.0 Frequently Asked Questions
- Other Resources Specific to MDS 3.0: :Resource table with all assessment types required under OBRA; Section O flow chart to determine whether vaccination is recommended; Section Q general and referral resources;and GO110 flow chart to help staff determine resident level of ADLs.
- MDS 3.0 RAI Manual and Updates and Training Material: Contains files with MS PowerPoint slides and other resources to help prepare and train for the MDS 3.0.
- MDS 2.0 to MDS 3.0 Transition Timeline (updated May 25, 2010).
Contact: Iara Woody, (202) 508-9429.