Medicaid Testing New Rug Grouper

Last week, the Department of Medical Assistance Services (DMAS) announced via a communication included in each Medicaid-participating nursing facility’s GoFileRoom that it is evaluating a new version of the Resource Utilization Group (RUG).  The RUG-IV grouper was first available on October 1, 2010.  The Medicaid version of this grouper contains 48 RUG categories.  The evaluation of the Medicaid RUG-IV 48 group version is one component of work now underway to develop, and possibly implement, a new price-based Medicaid payment methodology in Virginia.

In order to test the new version of the grouper, DMAS will be adjusting the Minimum Data Set (MDS) requirements for Virginia nursing facilities.  Effective June 7, 2013, the RUG-IV, version 48 group will be included on the Virginia MDS data.

Once the Virginia MDS data is updated to include the alternate calculation of RUG-IV, version 48, the MDS software must be adjusted to calculate the RUG-IV version 48 group.  Nursing facilities or vendors that do not adjust the MDS software settings to allow the additional calculation will receive warning messages for MDS Items Z0250A and Z0250B.  These warning messages do not prevent the successful transmission of the MDS data.  Facilities or vendors may ignore these warning messages.

The addition of the alternate calculation for RUG-IV, version 48 will not impact the primary RUG-III, version 34 calculations.  DMAS will continue to use the RUG-III, version 34 group in the calculation of case mix scores for participating nursing facilities.

The 48 Medicaid RUG categories used in the RUG-IV grouper all fall into six major groupings. Within each grouping the assignment of a RUG category is typically based on the number of deficits in the activities of daily living associated with the patient. The documented presence of depression may also affect RUG grouping.

Extensive Services:
(such as ventilator, tracheostomy)
ES3, ES2, ES1

Special Care:
(such as multiple sclerosis, quadriplegia, cerebral palsy)
LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1, HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1

Clinically Complex:
(such as burns, coma, dialysis)
CE2, CE1, CD2, CD1, CC2, CC1, CB2, CB1, CA2, CA1

Behavioral Problems:
BB2, BB1, BA2, BA1

Reduced Physical Function:
PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1

Rehabilitation:
RAE, RAD, RAC, RAB, RAA

If you have any questions regarding the additional calculation, please contact Sandra Lee, Virginia Department of Health at Sandy.Lee@vdh.virginia.gov, Priscilla Bullard, Virginia Department of Health at Priscilla.Bullard@vdh.virginia.gov, or Carla Russell, DMAS at Carla.Russell@dmas.virginia.gov.