¶ … Medicare RUG-53 that went into effect on January 1, 2006. This change added several new groups to rehabilitation coverage that increased the number to 23 groups that will pay for those services. It covers the changes in RUG-53, including no more Medicare add-ons and "wage indices" for many providers. There are several changes that affect Medicare recipients as well. The purpose of the changes is to overall pay more for medical services that are often bundled with rehabilitation services. Most of the changes modify the RUG-44 plan.

The article goes into detail about how rehabilitation services are measured and what qualifies for the RUG-53 benefits. It also tells health care providers how to correctly assess MDS data to make sure their reimbursements are correct and they do not lose revenue. Making sure this financial data is correct also cuts down on financial audits.

It also notes how to deal with clinical inconsistencies in coding medical data that might result in loss of revenue or denial of claims. For example, it discusses the problem of patients who do not get adequate nutrition, but do not have IV's or feeding tubes, and how to deal with situations such as these.

It notes that these nine new categories only apply to "MDS assessments that meet the criteria for the rehabilitation category and the Extensive Services category" (Field and Kazmer, 2006). These cases must also have an ADL rating of 7 or higher to qualify, and it talks about grouper software that facilities can use to assess whether these criteria are met or not. The article notes that a good case mix of patients can help a facility become a "winner" with RUG-53. Finally, it lists several processes facilities should utilize to make sure cases have the right qualifications. These include timing the Assessment Reference Date, obtaining all medical records, and following RAI guidelines in coding. All of these things should help assure RUG-53 works for all facilities.

References

Field, C and Kazmer, J. Be a winner in Medicare RUG-53. Nursing Homes. Cleveland: Jun 2006 Vol.55, Iss. 6-page 58 4 pages.