Resource Utilization Group (Rug) Residential Care Services For Injured Workers {F245-392-000}

Mail to: Department of Labor & Industries Health Services Analysis PO Box 44322 Olympia, WA 98504-4322 RUG (Resource Utilization Group) Residential Care Services for Injured Workers (In place of MDS 3.0 beginning Oct 1, 2010) This form does not apply to self insurers Claim Number If any section does not apply, leave blank and go to next section Provider Name Provider Number Assessor's name Step #1 1. Independent or supervision only. 2. Limited assistance. 3. Extensive assistance or total dependence, setup or 1 person assisted 4. Extensive assistance or total dependence and 2 people assisted 1. Independent or supervision 2. Limited assistance 3. Parental/IV or total dependence or tube feeding with 26% to 75% calorie intake Enter numeric score Bed mobility: Transfer: Toilet use: Step #2 Eating: Total ADL Score Step #3 RUG Calculation Category 1 (of 6) ­ Rehabilitation ­ RUG Hierarchical Classification Rehab Ultra High - 720 minutes expected or actual therapy per week minimum AND one discipline 5 days/week AND a 2nd discipline 3 days/week. Bill REHAB ULTRA HIGH Using Code 8880H Rehab Very High ­ 500 to 719 minutes total therapy per week AND 1 discipline 5 days/week. Bill REHAB VERY HIGH Using Code 8881H Rehab High ­ 325 to 499 minutes total therapy per week AND 1 discipline 5 days/week. Bill REHAB HIGH Using Code 8882H Rehab Medium ­ 150 to 324 minutes total therapy per week on any combination of 3 disciplines. Bill REHAB MEDIUM Using Code 8883H Evaluate Category 2: Extensive Services BEFORE assigning REHAB LOW Rehab Low ­ 48 to 149 minutes total therapy per week AND at least 3 days of any combination of 3 disciplines. Bill REHAB LOW Using Code 8884H Category 2 (of 6) ­ Extensive Services ­ RUG Hierarchical Classification Extensive Services ­ Tracheostomy care OR Ventilator or respirator OR Isolation for active infectious disease AND ADL score greater than or equal to 2. Bill EXTENSIVE SERVICES Using Code 8885H Place X in correct box Place X in correct box F245-392-000 rug services for injured workers (In place of MDS 3.0 beginning Oct 1, 2010) 10-2010 American LegalNet, Inc. www.FormsWorkFlow.com RUG CALCULATION CONTINUED If any section does not apply, leave blank and go to next section Provider Name Provider Number Assessor's name Claim Number Place X in correct box Category 3 (of 6) ­ Special Care ­ RUG Hierarchical Classification Special Care High Comatose and completely ADL dependent; OR Septicemia; OR Diabetes with daily injections requiring physician order changes on 2 or more days; OR Quadriplegia and ADL score greater than or equal to 5; OR Chronic obstructive pulmonary disease and shortness of breath when lying flat; OR Fever with pneumonia, or vomiting, or weight loss, or feeding tube; OR Parenteral/IV feedings; OR Respiratory therapy for 7 days Bill SPECIAL CARE HIGH Using Code 8886H Special Care Low Cerebral palsy and ADL score greater than or equal to 5; OR Multiple sclerosis and ADL score greater than or equal to 5; OR Parkinson's disease and ADL score greater than or equal to 5; OR Respiratory failure and oxygen therapy while a resident; OR Feeding tube; OR Ulcers (2 or more venous/arterial ulcers; or 1 stage II pressure ulcer and 1 venous/arterial ulcer) with 2 or more skin treatments; OR Radiation therapy while a resident; OR Dialysis while a resident Bill SPECIAL CARE LOW Using Code 8887H Category 4 (of 6) ­ Clinically Complex ­ RUG Hierarchical Classification Clinically Complex Pneumonia; OR Hemiplegia and ADL score greater than or equal to 5; OR Surgical wounds or open lesions with treatment; OR Burns; OR Chemotherapy while a resident; OR Oxygen therapy while a resident; OR IV medications while a resident; OR Transfusions while a resident Place X in correct box Bill SPECIAL CLINICALLY COMPLEX Using Code 8888H Category 5 (of 6) ­ Behavioral Symptoms and Cognitive Performance RUG Hierarchical Classification Behavioral Symptoms and Cognitive Performance Hallucinations or delusions; OR Residents displaying any of the following on 4 or more days over the last 7 days: · Physical or verbal behavioral symptoms toward others; · Rejection of care; · Wandering; Place X in correct box · Other behavioral symptoms Bill BEHAVIORAL SYSTOMS AND COGNITIVE PERFORMANCE Using Code 8889H Category 6 (of 6) ­ Reduced Physical Function ­ RUG Hierarchical Classification Place X in correct box Reduced Physical Function Restorative nursing services: OR Urinary and/or bowel training program; OR Passive and/or active ROM; OR Splint and/or brace assistance; OR Bed mobility and/or walking training; OR Transfer training; OR Dressing and/or grooming training; OR Eating and/or swallowing training; OR Amputation/prosthesis care training; OR Communication traing; OR Residents not qualifying for other categories Bill REDUCED PHYSICAL FUNCTION Using Code 8890H F245-392-000 rug services for injured workers (In place of MDS 3.0 beginning Oct 1, 2010) 10-2010 American LegalNet, Inc. www.FormsWorkFlow.com Please complete and FAX this page to the Department of Labor & Industries Obtain FAX number from Claims Unit ONC or by calling the Claims Unit at (360) 902-5013 MAIL pages 1, 2 and 3 of this form to the address below Department of Labor & Industries Health Services Analysis PO box 44322 Olympia, WA 98504-4322 Provider Name Provider Number RUG (Resource Utilization Group) Residential Care Services for Injured Workers (In place of MDS 3.0 beginning Oct 1, 2010) This form does not apply to self insurers Assessor's name Claim Number PLACE AN "X' IN APPROPRIATE BOX TO INDICATE ACTION TAKEN: Initial (first) RUG assessment for the L&I Injured worker New RUG assessment An L&I Occupational Nurse Consultant (ONC) has authorized a new RUG assessment INITIAL RUG ASSESSMENT Initial RUG Category assessed (6 categories possible) Initial RUG code assessment Initial RUG payment rates (see L&I RUG fee schedule at): http://www.lni.wa.gov/ClaimsIns/Providers/Billing/FeeSched/2010/default.asp, "Residential Facility Rates" Initial RUG billing code (see L&I RUG fee schedule at): http://www.lni.wa.gov/ClaimsIns/Providers/Billing/FeeSched/2010/default.asp, "Residential Facility Rates" NEW RUG ASSESSMENT Current RUG category assessed Current RUG code assessed Current RUG payment rate Current RUG billing code New RUG payment rate (see L&I RUG fee schedule at): http://www.lni.wa.gov/ClaimsIns/Providers/Billing/FeeSched/2010/default.asp, "Residential Facility Rates" New RUG billing code (see L&I RUG fee schedule at): http://www