The MDS 3.0-RUG-IV partnership

At a glance…

Some basic changes to the MDS in version 3.0 resulted in very significant alterations in the method for calculating the RUG-IV category. One of the most significant changes is the elimination of Section T.

Implementation of the next generation of the Minimum Data Set (MDS), known as the MDS 3.0, on October 1, 2010, will have a ripple effect on nearly every aspect of nursing home operations, including the survey process, quality indicators and quality measures, and the Part A payment system. As the federal government continues its work to transition these processes from MDS 2.0 to MDS 3.0, the integration with RUG-IV, successor to RUG-III, the case mix classification system used for nursing home Part A payment, is already near completion.

The final version of the MDS 3.0 item set made its debut on the Centers for Medicare & Medicaid Services (CMS) Web site in October, and portions of the instruction manual for the MDS 3.0 were posted just before Thanksgiving. The remainder is expected to be released before the end of this year. Because the daily payment rate is calculated from response options selected for a resident for the payment-related items on the MDS, some basic changes to the MDS in version 3.0 resulted in very significant alterations in the method for calculating the RUG-IV category.

One of the most significant changes is the elimination of Section T. Because therapy does not necessarily start on the day of admission, the MDS 2.0 and the RUG-III system include a provision for capturing therapy services that are scheduled to occur but have not yet been provided in order to calculate a RUG level that better reflects the intensity of care the resident would actually receive. Through items T1b, T1c, and T1d on the five-day assessment, providers project the amount of therapy a resident is expected to receive through day 15 of the Medicare stay based on the therapy treatment plan. This is eliminated with MDS 3.0 and RUG-IV.

Instead, effective October 1, 2010, according to the PPS Final Rule for fiscal year 2010, the following changes will occur:

  • An optional Start of Therapy Other Medicare Required Assessment (SOT OMRA) will be available. The Assessment Reference Date (ARD), which is the end of the observation period for the assessment, will be day five, six, or seven, with the first day of therapy counting as day one. Payment at the rehabilitation RUG calculated from this OMRA will start on day one of therapy.

    This assessment may be completed when therapy starts between regularly scheduled assessments. It also may be completed when therapy started within the regular assessment window in situations in which not enough therapy was delivered for a rehabilitation RUG to be calculated. For example, for the five-day assessment, if therapy began on day five and the facility chose day seven for the ARD, only three days of therapy would be captured. In that case, the facility would have the option of doing a SOT OMRA with an ARD of day five, six, or seven after the start of therapy (day nine, 10, or 11 of the Part A stay in this example) to capture more days of therapy. To facilitate this, the MDS 3.0 includes therapy items in which to record the therapy start date.

  • To address the concern that these voluntary additional assessments will increase provider burden, CMS said it plans to provide an abbreviated OMRA for SOT OMRAs when they are not combined with other assessments. This assessment will include only the items needed for this type of assessment: Required demographic information, therapy items, restorative therapy and bladder and bowel training items, and Extensive Services items. This abbreviated form will have fewer items than the optional Medicare PPS Assessment Form (MPAF), which will continue to be available under


    Another change in the MDS requirements with MDS 3.0, according to the Final Rule, is an overhaul of the OMRA required when therapy ends and the resident will continue to receive Part A services for skilled nursing. With MDS 3.0, this assessment is called the End of Therapy (EOT) OMRA.

  • Instead of setting the ARD eight to 10 days after the last therapy treatment, with MDS 3.0 and RUG-IV the ARD will have to be set one to three days from the last day therapy was provided. Payment at the nontherapy RUG level would begin the day after therapy services end. Day 1 would correspond to the first day following the cessation of therapy services on which therapy services would normally be provided. For example, if the last therapy treatment is delivered on Friday in a facility which does not provide therapy on weekends, day one would be Monday, the first day on which therapy services normally would be provided. To facilitate this OMRA, the MDS 3.0 includes therapy items in which to record the therapy end date.

  • The therapy RUG would be billed for the days in the payment block that therapy was delivered; the nontherapy RUG would be billed for the covered days after therapy ended. The MDS 3.0 calculates both of these RUGs, when applicable, in item Z0100, Medicare Part A billing.

MDS 3.0 and RUG-IV have created a new category of assessment called the Medicare Short Stay Assessment. This assessment provides for calculation of a rehabilitation RUG for residents discharged on or before day eight who received less than five days of therapy. In this case, the average daily minutes actually provided will be calculated from the MDS. RUG categories will be assigned:

  • Average daily therapy minutes between 30-64 minutes = Rehabilitation Medium category (RMx)

  • Average daily therapy minutes between 65-99 minutes = Rehabilitation High category (RHx)

  • Average daily therapy minutes between 100-143 minutes = Rehabilitation Very High category (RVx)

  • Average daily therapy minutes 144 or greater = Rehabilitation Ultra High category (RUx)


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The fiscal year 2010 SNF PPS Final Rule also outlined changes in documentation of therapy minutes on the MDS 3.0. Therapists will be required to track and report three different delivery modes of therapy:

  • Individual-One-to-one therapy treatments

  • Concurrent-One professional therapist treats multiple patients at the same time with the patients performing different activities. The MDS 3.0 RUG-IV requirements specify that concurrent therapy is limited to two patients per therapist regardless of payer source, and the treating therapist (or assistant) must have line-of-sight of both patients.

  • Group-One therapist provides the same service to up to four residents. The total group time must not exceed 25% of the resident’s therapy time per therapy discipline.

According to CMS, the actual number of minutes of therapy received by the resident will be recorded for each category, but for concurrent therapy, the grouper software will divide the total minutes by two when calculating the RUG. When the software totals the minutes to calculate the RUG-IV category, it will add the resident’s total individual minutes, total group minutes, and one-half of the total concurrent minutes from item O0400, Therapies.

With MDS 3.0, providers will be required to submit data directly to the CMS national system rather than to the state agency as it is done now, and submission will be required within 14 days after completion of the assessment as opposed to the 31-day time frame in effect with MDS 2.0.

CMS published these RUG-IV regulations in the FY 2010 SNF PPS Final Rule more than a year in advance of implementation in order, they said, to provide plenty of time for providers and software vendors to prepare for implementation. They added, however, that they would continue to evaluate these issues and may make additions or changes between now and the time of implementation. Also, chapter 2 and 6 of MDS 3.0 RAI User’s Manual will contain detailed information and instructions related to timing and scheduling of assessments and other related issues.

Rena R. Shephard, MHA, RN, RAC-MT, C-NE, is the Executive Editor AANAC. She can be reached at (858) 592-6799.

To send your comments to the editor, please e-mail

Long-Term Living 2010 February;59(2):30-32

Topics: Articles , MDS/RAI