Case Mix Reimbursement and Case Mix Review

Case Mix Reimbursement and Case Mix Review A. The Division of Medicaid utilizes a resource utilization grouper-version 4 (RUG-IV) forty- eight (48) group model for case mix calculation for reimbursement. 1. Each of the forty-eight (48) resident classifications as well as the default classification is assigned case mix weights. 2. The classifications are calculated electronically using the minimum data set (MDS) assessment data and the RUG-IV calculation program. B. Clinical documentation must be maintained in the clinical record which supports the MDS 3.0 assessment and substantiates the resources and services needed to provide care to the resident. 1. Review results are based only on the supporting original clinical documentation available and presented during the review. 2. No additional original clinical documentation will be accepted after the exit conference. C. Documentation for case mix reimbursement must adhere to the Division of Medicaid’s Supportive Documentation Requirements. D. In addition to the clinical documentation review, the case mix review process includes a review of the facilities’ official bed hold record which includes therapeutic and hospital leave records.