Amended Attachment 4 Medicare Pricing Schedule with Instuctions.pdf

Medicare RUGS IV Pricing Schedule

LINE

ITEM

RUGS IV CATEGORY

DESCRIPTION

Medicare Base Rate

Percentage Discount

Medicare Per Diem Rate

1 RUX – Extensive Services criteria + RU Criteria – ADL 16-18

2 RUL – Extensive Services criteria + RU Criteria – ADL 7-15

3 RVX – Extensive Services criteria + RV Criteria – ADL 16-18

4 RVL - Extensive Services criteria + RV Criteria – ADL 7-15

5 RHX - Extensive Services criteria + Rehab High Criteria – ADL 13-

6 RHL- Extensive Services criteria + Rehab High Criteria – ADL 7-12

7 RMX - Extensive Services criteria + RM Criteria – ADL 15-18

8 RML - Extensive Services criteria + RM Criteria – ADL 7-15

9 RLX - Extensive Services criteria + RL Criteria – ADL 7-18

10 RUC – Special Rehab Ultra High –

ADL 16-18

11 RUB – Special Rehab Ultra High –

ADL 9-15

12 RUA – Special Rehab Ultra High –

ADL 1-8

13 RVC Special Rehab Very High –

ADL 16-18

14 RVB – Special Rehab Very High –

ADL 9-15

15 RVA – Special Rehab Very High –

ADL 1-8

16 RHC – Special Rehab High – ADL 13-18

17 RHB – Special Rehab High – ADL 8-12

18 RHA – Special Rehab High – ADL 1-7

19 RMC – Special Rehab Medium –

ADL 15-18

20 RMB – Special Rehab Medium –

ADL 8-14

Attachment 4: Medicare Pricing Schedule Instructions: If you currently have a contract with VISN 23 for this home, please use the current Medicare Base Rates from that contract and place those rates in the "Medicare Base Rate" column for each Line Item. If you do not have a contract for this home with VISN 23, please email todd.penkhus@va.gov for the current Medicare Base Rates.

Next, propose a discount rate in the "Percentage Discount" column for each Line Item.

Lastly, calculate the "Medicare Per Diem Rate column by reducing the "Medicare Base Rate" figure in each column by the applicable "Percentage Discount".

Please direct any questions to Todd Penkhus at todd.penkhus@va.gov.

21 RMA – Special Rehab Medium –

ADL 4-7

22 RLB Special Rehab Low – ADL 14-

23 RLA – Special Rehab Low – ADL 1-13

24 ES3 – Extensive Services – ADL 2-

25 ES2 – Extensive Services – ADL 2-

26 ES1 – Extensive Services – ADL 2-

27 HE2 – Special Care High – ADL 15-16

28 HE1 – Special Care High – ADL 15-16

29 HD2 – Special Care High – ADL 11-14

30 HD1 – Special Care High – ADL 11-14

31 HC2 – Special Care High – ADL 6-

32 HC1 – Special Care High – ADL 6-

33 HB2 – Special Care High – ADL 2-

34 HB1 – Special Care High – ADL 2-

35 LE2 – Special Care Low - ADL 15-

36 LE1 – Special Care Low – ADL 15-

37 LD2 – Special Care Low – ADL 11-

38 LD1 – Special Care Low – ADL 11-

39 LC2 – Special Care Low – ADL 6-

40 LC1 – Special Care Low – ADL 6-

41 LB2 – Special Care Low – ADL 2-5

42 LB1 – Special Care Low – ADL 2-5

43 CE2 – Clinically Complex – ADL 15-16

44 CE1 – Clinically Complex – ADL 15-16

45 CD2 – Clinically Complex – ADL 11-14

46 CD1 – Clinically Complex – ADL 11-14

47 CC2 – Clinically Complex – ADL 6-

48 CC1 – Clinically Complex – ADL 6-

49 CB2 – Clinically Complex – ADL 2-

50 CB1 – Clinically Complex – ADL 2-

51 CA2 – Clinically Complex – ADL 0-1

52 CA1 – Clinically Complex – ADL 0-1

53 BB2 – Behavior Symptoms – ADL 2-5

54 BB1 – Behavior Symptoms – ADL 2-5

55 BA2 – Behavior Symptoms – ADL 0-1

56 BA1 – Behavior Symptoms – ADL 0-1

57 PE2 – Physical Function Reduced

– ADL 15-16

58 PE1 – Physical Function Reduced

– ADL 15-16

59 PD2 – Physical Function Reduced

– ADL 11-14

60 PD1 – Physical Function Reduced

– ADL 11-14

61 PC2 – Physical Function Reduced

– ADL 6-10

62 PC1 – Physical Function Reduced

– ADL 6-10

63 PB2 – Physical Function Reduced

– ADL 2-5

64 PB1 – Physical Function Reduced

– ADL 2-5

65 PA2 – Physical Function Reduced

– ADL 0-1

66 PA1 – Physical Function Reduced

– ADL 0-1