RUG Mail to: Department of Labor & Industries HSA PO Box 44322 Olympia WA 98504-4322 If any section does not apply, leave blank and go to next section Provider name Provider Number Assessor's name ADL Score Calculations (Resource Utilization Group) Residential Care Services for Injured Workers This form does not apply to Self-Insurers Claim number Number value Step # 1 Step # 2 Enter numeric score Bed mobility: Transfer: Toilet use: 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. Eating: Total ADL Score: Step # 3 RUG Calculation Place X in correct box Category 1 (of 7) - Rehabilitation - RUG Hierarchical Classification Rehab Ultra High - 720 minutes expected or actual therapy per week. 1discipline for 5 days a week and a 2nd discipline for 3 days per week. Bill REHAB ULTRA HIGH Using Code 8880H Rehab Very High - 500 to 719 minutes total therapy per week and 1 discipline for 5 days and a 2nd discipline for 3 days per week. Bill REHAB VERY HIGH Using Code 8881H Rehab High - 325 to 499 minutes total therapy per week and 1 discipline for 5 days per 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 7) - Extensive Services - RUG Hierarchical Classification ADL score greater than or equal to 7, with parental / IV, or IV Medication, or suctioning, or tracheotomy care, or ventilator or respirator. Bill EXTENSIVE SERVICES Using Code 8885H Category 3 (of 7) - Rehabilitation - RUG Hierarchical Classification ADL less than or equal to 6 WITH: a. Parental IV, or b. IV medication, or c. Suctioning, or d. Tracheotomy care, or e. Ventilator or respirator or ADL Greater than or equal to 10 WITH: a. Cerebral palsy, or b. Multiple sclerosis, or c. Quadriplegia or ADL Greater than 7 WITH: a. Fever AND one of the following: 1. Pneumonia, or 2. Dehydration, or 3. Vomiting, or 4. Weight loss, or 5. Tube feeding WITH: 50% or more calorie intake, or 26% to 50% calorie intake with at least 501 cc fluid intake b. Tube feeding and aphasia c. Ulcers any stage 2+ sites with 2 or more skin treatments d. Pressure ulcers any state 3 or 4 with 2 or more skin treatments e. Surgical wound on oxygen with 1 or more surgical wound treatments f. radiation treatment Place X here if g. Respiration therapy for 7 days applicable. Bill SPECIAL CARE using Code 8886H F245-052-000 resource utilization group 07-2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com Claim number Mail to: Department of Labor & Industries HSA PO Box 44322 Olympia WA 98504-4322 Category 4 (of 7) - Clinically Complex - RUG Hierarchical Classification Coded for one of the following: Coma and not awake and completely ADL dependent (ADL greater than or equal to 12), or diabetes mellitus and injection 7 days, or Hemiplegia and ADL sum greater than or equal to 10, or Pneumonia, or Septicemia, or Dehydration, or Internal bleeding, or Tube feeding, or Burns, or Foot infections, or Chemotherapy, or Dialysis, or Oxygen therapy, or Transfusions, or Frequent order changes, or Frequents physician visits Place X here if applicable. Bill CLINICALLY COMPLEX Using Code 8887H Category 5 (of 7) - Impaired Cognition - RUG Hierarchical Classification Coma and not awake and completely ADL dependent, or moderate or greater cognitive skills impairment (poor decisions or supervision required), or severe problems being understood or severely impaired cognitive skills or wandering. Bill IMPAIRED COGNITION Using Code 8888H Place X here if applicable. Category 6 (of 7) - Behavior Only - RUG Hierarchical Classification ADL less than or equal to 10 and one of the following: Wandering or verbal abuse or physical abuse or inappropriate behavior or resisted care or Delusions or Hallucinations. Bill BEHAVIOR ONLY Using Code 8889H Place X here if applicable. Category 7 (of 7) - Reduced Physical Function - RUG Hierarchical Classification Place X here if applicable. ADL from 4 to 16, does not fit into any other category. Bill REDUCED PHYSICAL FUNCTION Using Code 8890H Mail pages 1 and 2 to the address above. F245-052-000 resource utilization group 07-2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com Please complete and FAX this page to the Dept of Labor & Industries. Obtain FAX number from Claims Unit ONC or by calling the Claims Unit at (360) 902-5013. MAIL pages 1 and 2 of this form to the address below. RUG Department of Labor & Industries HSA PO Box 44322 Olympia WA 98504-4322 (Resource Utilization Group) Residential Care Services for Injured Workers This form does not apply to Self-Insurers Provider name Provider Number Assessor's name Claim number PLACE "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 (OCN) has authorized a new RUG assessment INITIAL RUG ASSESSMENT Initial RUG Category assessed (7 categories possible) Initial RUG code assessment Initial RUG payment rates (see table pages 4 and 5) Initial RUG billing code (see table pages 4 and 5) NEW RUG ASSESSMENT Current RUG category assessed (7 categories possible) Current RUG code assessed Current RUG payment rate (see table pages 4 and 5) Current RUG billing code (see table pages 4 and 5) New RUG category assessed (7 categories possible) New RUG code assessed New RUG payment rate (see table pages 4 and 5) New RUG billing code (see table pages 4 and 5) F245-052-000 resource utilization group 07-2007 Page 3 American LegalNet, Inc. www.FormsWorkflow.com RUG ASSESSMENT: Residential Care Services for Injured Workers For Self-Insured Claims: Self Insurers will negotiate rates. Contact the self-insurer directly. FOR L&I INJURED WORKERS ONLY F245-052-000 resource utilization group 07-2007 Page 4 American LegalNet, Inc. www.FormsWorkflow.com RUG ASSESSMENT: Residential Care Services for Injured Workers For Self-Insured Claims: Self Insurers will negotiate rates. Contact the self-insurer directly. FOR L&I INJURED WORKERS ONLY F245-052-000 resource utilization group 07-2007 Page 5 American LegalNet, Inc. www.FormsWorkflow.com