D09_VA_CNH_RUG_IV_Hierarchy.docx
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- CNH IDC NMVAHCS State Wide Federal contract opportunity
- Solicitation number
- 36C25819Q0002
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36C25819Q0002 D09 VA CNH RUG IV Hierarchy.docx
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VA CNH RUG IV Hierarchy Level of Care determinations are based on CMS case mix Resource Utilization Groups (RUGs-IV) case-mix, the industry standard. See CFR 42 Parts 411 and 489. A case-mix system categorizes patients into groups according to their level of care needs. RUGs-IV, like other case-mix systems, defines patients for clinical and reimbursement purposes. Additional information on RUGs-IV use for VA purposes can be acquired from the Contracting Officer in concert with the appropriate VA community health official.
| RUG-IV Group |
| RUG-IV Case-mix Classifications |
| RUG-IV Description of services |
Respite Care
This level of care is designed to provide short-term, time limited (not to exceed 14 days per episode and 30 days per calendar year) services for veterans with chronic illness not in need of acute care services and who are not better accounted for in the RUG case mix. This is designed to provide temporary relief to the primary care giver to help the veteran continue residing in their primary residence. It is designed to accommodate referrals with minimum care needs. Referrals with more complex care needs would be accommodated under the RUG case mix classification system.
| Reduced Physical Function |
| PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1 |
| Residents whose needs are primarily for support with activities of daily living and general supervision. Calculations identify residents who are receiving restorative nursing services as recorded on the MDS and include: urinary and/or bowel training program, passive and/or active range of motion, amputation/prosthesis, training, splint or brace assistance, dressing or grooming training, eating or swallowing training, transfer training, bed mobility and/or walking training, communication training. |
| Behavioral Symptoms & Cognitive Performance |
| BB2, BB1, BA2, BA1 |
| Residents satisfying the following two conditions: Having a maximum ADL dependency score of 5 or less. Having behavioral or cognitive performance symptoms, involving any of the following: difficulty in repeating words, temporal orientation, or recall (score on the Brief Interview for Mental Status <=9), difficulty in making self understood, short term memory, or decision making (score on the Cognitive Performance Scale >=3), hallucinations, delusions, physical behavioral symptoms toward others, verbal behavioral symptoms toward others, other behavioral symptoms, rejection of care, or wandering. |
| Clinically Complex |
| CE2, CE1, CD1 |
CC2, CC1, CB2, CB1, CA2, CA1
Residents receiving complex clinical care or have conditions requiring skilled nursing management, interventions or treatments involving any of the following: pneumonia, hemiplegia with ADL dependency score of 5 or more, surgical wounds or open lesions with treatment, burns, chemotherapy while a resident, oxygen therapy while a resident, IV medications while a resident, or transfusions while a resident.
| Special Care Low | |
| LE2, LE1, LD2, LD1, LC2, LC1, LB2, LB1 | |
| Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any of the following: | cerebral palsy with ADL dependency score of 5 or more, multiple sclerosis with ADL dependency score of 5 or more, Parkinson’s disease with ADL dependency score of 5 or more, respiratory failure and oxygen therapy while a resident, tube feeding meeting intake requirement, ulcer treatment with two or more ulcers including venous ulcers, arterial ulcers or Stage II pressure ulcers, ulcer treatment with any Stage III or IV pressure ulcer, foot infections or wounds with application of dressing, radiation therapy while a resident, or dialysis while a resident. |
| Special Care High |
| HE2, HE1, HD2, HD1, HC2, HC1, HB2, HB1 |
| Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. Receiving complex clinical care or have serious medical conditions involving any one of the following: comatose, septicemia, diabetes with insulin injections and insulin order changes, quadriplegia with a higher minimum ADL dependence criterion (ADL score of 5 or more), chronic obstructive pulmonary disease (COPD) with shortness of breath when lying flat, fever with pneumonia, vomiting, weight loss, or tube feeding meeting intake requirement, parenteral/IV feeding, or respiratory therapy. |
| Extensive Services |
| ES3, ES2, ES1 |
| Residents satisfying the following two conditions: Having a minimum ADL dependency score of 2 or more. While a resident, receiving complex clinical care and have needs involving: tracheostomy care, ventilator/respirator, and/or infection isolation. |
| Rehabilitation |
| RUC, RUB, RUA |
RVC, RVB, RVA
RHC, RHB, RHA
RMC, RHB, RHA,
RLB, RLA
Residents receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident.
| Rehabilitation plus Extensive Services |
| RUX, RUL, RSV, RVL, RHX, RHL |
RMS, RML
RLS
Residents satisfying all of the following three conditions: Having a minimum activity of daily living (ADL) dependency score of 2 or more. Receiving physical therapy, occupational therapy, and/or speech-language pathology services while a resident. While a resident, receiving complex clinical care and have needs involving tracheostomy care, ventilator/respirator, and/or infection isolation.
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