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RESOURCE UTILIZATION GROUP,VERSION IV48-GROUP USER GUIDEMississippi Division of MedicaidMyers and Stauffer LC

CONTENTS1 OVERVIEW3INTRODUCTION . 3PURPOSE . 3SCOPE . 3Hierarchical Classification: . 4Index Maximizing Classification: . 42 ADL CALCULATION SCORE5INTRODUCTION . 53 RUG-IV 48-GROUP CALCULATION GUIDE7EXTENSIVE SERVICES . 7REHABILITATION . 8SPECIAL CARE HIGH . 10SPECIAL CARE LOW . 13CLINICALLY COMPLEX . 17BEHAVIORAL SYMPTOMS AND COGNITIVE PERFORMANCE . 20REDUCED PHYSICAL FUNCTION . 234 GLOSSARY/DEFINITIONS26COMMON TERMS AND ABBREVIATIONS . 26Resource Utilization Group, RUG-IV 48-Groupii

1 OVERVIEWINTRODUCTIONThe Division of Medicaid (DOM) contracted with Myers and Stauffer LC todevelop and design a web portal for Mississippi’s Medicaid nursing facilities.PURPOSEThe purpose of this calculation guide for the 48-Group model is toprovide a step-by-step instructional guide to manually determine theappropriate RUG-IV classification based on the responses from an MDS3.0 assessment. This guide takes the standard grouper logic and puts itinto a readable format.SCOPEIn the RUG-IV 48-Group model, compared to the RUG-IV 66 (Medicare)group model, the Rehabilitation groups have been collapsed from 23 to 5groups and the different levels of rehabilitation service are onlydistinguishable by the ADL range. The simplified Rehabilitationclassification in the 48-Group model is better suited for long-term careresidents, which classify on the basis of nursing care need only. In the48-group model, the Extensive Services groups have the highest level ofneed. For this reason, the Extensive Services groups are placed first inthe hierarchy.There are two basic approaches to RUG-IV Classification: (1)Hierarchical Classification and (2) Index Maximizing Classification.This guide, developed for training purposes, is presented in thehierarchical methodology. Instructions for adapting this guide to theindex maximizing approach are included below (see “Index MaximizingClassification”).Resource Utilization Group, RUG-IV 48-Group3

Hierarchical Classification:Hierarchical classification is used in some payment systems, in staffing analysis,and in many research projects. In the hierarchical approach, start at the top ofthe groups (Extensive Services) and work down through the RUG-IV model; theassigned classification is the first group for which the assessment meetsqualifiers. In other words, start with Extensive Services and work down throughthe groups in hierarchical order: Extensive Services, Rehabilitation, Special CareHigh, Special Care Low, Clinically Complex, Behavioral Symptoms and CognitivePerformance, and Reduced Physical Function. When you find the first of the 48individual RUG-IV groups for which the assessment qualifies, assign that groupas the RUG-IV classification.If the assessment qualifies in the Extensive Services group and a Special CareHigh group, always choose the Extensive Services classification because it ishigher in the hierarchy. Likewise, if the assessment qualifies for Special CareLow and Clinically Complex, choose Special Care Low. In hierarchicalclassification, always pick the group nearest the top of the model.Index Maximizing Classification:The index maximizing classification approach is used in the Medicare PPS andmany Medicaid payment systems. There is a designated Case Mix Index (CMI),a numeric value that represents the relative resource utilization associated witheach of the 48 RUG-IV classifications. For index maximizing, first determine allof the RUG-IV groups for which the assessment qualifies. Then, from thequalifying groups, choose the RUG-IV group that has the highest CMI.While the following guide illustrates the hierarchical classification method, it canbe adapted for index maximizing. For index maximizing, evaluate allclassification groups rather than assigning the assessment to the first qualifyinggroup. In the index maximizing approach, again start at the top of the model, andthen work down through all of the RUG-IV classification groups. When all 48groups are evaluated, determine the qualifying group with the highest CMI. Thisgroup is the index-maximized classification for the assessment.For Case Mix purposes the CMI set F01 is used for index maximizingclassification with logic version 1.03 of the RUG-IV grouper.Resource Utilization Group, RUG-IV 48-Group4

2 ADL CALCULATION SCOREINTRODUCTIONThe Activities of Daily Living (ADL) score is a component of thecalculation for the placement in all RUG-IV groups. The ADLscore is based upon the four “late loss” ADLs (bed mobility,transfer, toilet use, and eating). This score indicates the level orfunctional assistance of support required by the resident and is avital component of the classification process.Step #1:To calculate the ADL score use the following chart for bed mobility (G0110A), transfer (G0110B), andtoilet use (G0110I) and record the ADL score for each:Self-PerformanceColumn 1 AndSupport ProvidedColumn 2 ADLScore -, 0, 1, 7 or 8and-, 0, 1, 2, 3 or 80Bed Mobility 2and-, 0, 1, 2, 3 or 81Transfer 3and-, 0, 1 or 22Toilet Use 4and-, 0, 1 or 233 or 4and34Record ScoreStep #2:To calculate the ADL score for Eating (G0110H), use the following chart and record the ADL score foreating:Self-PerformanceColumn 1 AndSupport ProvidedColumn 2 -, 0, 1, 2, 7 or 8and-, 0, 1 or 80-, 0, 1, 2, 7 or 8and2 or 323 or 4and-, 0 or 123and2 or 334and2 or 34Resource Utilization Group, RUG-IV 48-GroupADLScore Record ScoreEating 5

Step #3:Sum the scores for Bed Mobility, Transfer, Toilet Use and Eating to determine the total ADL score. Thetotal ADL score ranges from 0 through 16; a score of 0 represents independence whereas a score of 16represents total dependence.Record Total ADL ScoreThe other ADLs are also very important, but the research indicates that the late loss ADLs predictresource use most accurately. The early loss ADLs do not significantly change the classificationhierarchy or add to the prediction of resource use.Resource Utilization Group, RUG-IV 48-Group6

3 RUG-IV 48-GROUPCALCULATION GUIDEEXTENSIVE ach AND VentES3ES3 3.000Trach OR VentES2ES2 2.230ES1ES1 2.2202-16IsolationDetermine whether the assessment is coded for at least one of the following conditions or services:Extensive Services Conditions or ServicesO0100E, 2Tracheostomy care (while a resident)O0100F, 2Ventilator or respirator (while a resident)O0100M, 2Infection isolation (while a resident)Step #1:A. If the assessment is not coded with one of the above conditions or services, skip to Category II,Rehabilitation.B. If the assessment is coded with at least one of the above conditions or services, and the ADL score is0 or 1, skip to Category V, Clinically Complex (CA1 or CA2), Step #2.C. If the assessment is coded with at least one of the above conditions or services, and the ADL score is2 or more, the assessment classifies as Extensive Services; proceed to Step #2.Step #2:The final classification for Extensive Services is based on the following chart:Extensive Service Conditions or Services (while a resident)A. Tracheostomy care and ventilator/respiratorB. Tracheostomy care or ventilator/respiratorC. Infection isolation without tracheostomy care and withoutventilator/respiratorRUG-IV ClassES3ES2ES1CMI3.0002.2302.220Extensive Services ClassificationResource Utilization Group, RUG-IV 48-Group7

sRAERAE 1.650RADRAD 1.580RACRAC 1.360RABRAB 1.100RAARAA 0.8206-10ADL2-50-1Rehabilitation classification is any combination of the disciplines of licensed speech-language pathology,occupational therapy or physical therapy services. Restorative Nursing programs are also considered forthe low intensity therapy level.Determine whether the assessment is coded for therapy minutes and days:O0400 TherapiesO0400A - Speech-Language Pathology and Audiology ServicesO0400A, 1Individual MinutesO0400A, 2Concurrent MinutesO0400A, 3Group MinutesO0400A, 4DaysO0400B - Occupational TherapyO0400B, 1Individual MinutesO0400B, 2Concurrent MinutesO0400B, 3Group MinutesO0400B, 4DaysO0400C - Physical TherapyO0400C, 1O0400C, 2O0400C, 3O0400C, 4Individual MinutesConcurrent MinutesGroup MinutesDaysO0420Distinct Calendar Days of TherapyStep #1:A. If the assessment is not coded for therapy minutes and days, skip to Category III, Special CareHigh.B. If the assessment is coded for therapy minutes and days, calculate and sum the total therapyminutes. If the total sum of therapy minutes is less than 45 minutes, the resident does notclassify in the Rehabilitation Category; skip to Category III, Special Care High.C. If the assessment is coded for therapy minutes and days, and the total sum of therapy minutes isequal to or greater than 45 minutes, use the following criteria to determine the RehabilitationClassification.Resource Utilization Group, RUG-IV 48-Group8

Step #1 C continued:(1) Received 150 or more minutes andAt least 5 distinct days of any combination of the 3 disciplines, proceed to Step #3.OR(2) Received 45 or more minutes andAt least 3 distinct days of any combination of the 3 disciplines and2 or more restorative nursing programs received for 6 or more days,proceed to Step #2.Step #2:Determine Restorative Nursing Program Count.Count the number of restorative nursing programs provided for 6 or more days:Restorative Nursing ProgramsH0200CH0500Current toileting program or trial#Bowel toileting program#O0500AO0500BRange of motion (passive)#Range of motion (active)#O0500CO0500DO0500FSplint or brace assistanceBed mobility#Walking#O0500ETransferO0500GDressing and/or groomingO0500HEating and/or swallowingO0500IAmputation/Prosthesis careO0500JCommunication# For RUG classification count as one program even if both providedRecord Restorative Nursing Program Count:Proceed to Step #3.Step #3:The final classification for Rehabilitation is based on the following chart:ADL Score15 - 1611 - 146 - 102- 50- 1RUG-IV habilitation ClassificationResource Utilization Group, RUG-IV 48-Group9

SPECIAL CARE dDepressedHE1YesNoHD1HC2HC1HB2HB1HE2 1.880HE1 220Determine if the assessment is coded for one of the following conditions or services:Special Care High Conditions or ServicesB0100Comatose with ADL Self-Performance dependencycoded 4 or 8 for all late loss ADLsI2100SepticemiaDiabetes Mellitus (DM) with both of the following:Insulin injections for all 7 daysInsulin order changes on 2 or more daysQuadriplegia with ADL score of 5 or J1550BK0300, 1 or 2K0510B, 1 or 2K0510A, 1 or 2O0400D, 2Chronic Obstructive Pulmonary Disease (COPD) withShortness of breath when lying flatFever with one of the following:PneumoniaVomitingWeight LossFeeding Tube with requirements*Parenteral/IV FeedingRespiratory Therapy for all 7 days*Tube feeding requirements:(1) Proportion of total calories received through parenteral or tube feeding(K0710A3) is 51% or more of total calories during entire periodOR(2) Proportion of total calories received through parenteral or tube feeding(K0710A3) is 26% to 50% of total calories and average fluid intake perday (K0710B3) is 501 cc or more during entire periodStep 1:A. If the assessment does not have one of these conditions or services coded, skip to Category IV,Special Care Low.B. If the assessment does have one of these conditions or services coded and the ADL score is 0 or 1,the assessment classifies as Clinically Complex; skip to Category V, Clinically Complex (CA1 orCA2), Step #2.C. If the assessment does have one of these conditions or services coded and the ADL score is 2 ormore (with the exception of Comatose which requires total dependency and Quadriplegia whichrequires an ADL score of 5 or higher), the assessment classifies as Special Care High; proceed toStep #2.Resource Utilization Group, RUG-IV 48-Group10