How Nursing Facilities are Reimbursed, Types of Services, and ADL Scores

Skilled Nursing Facilities (SNFs) are paid in a Medicare Part A stay through the Medicare Prospective Payment System (PPS). PPS uses a case mix system that assigns residents to groups (RUGs) representing the quantity of resources used by the resident. Each group is placed into categories which have a daily dollar amount rate paid to SNFs.

These categories in order from most intensive to least are:

• Rehab Plus Extensive Services (Ultra High, Very High, High, Medium, Low)
• Rehabilitation (Ultra High, Very High, High, Medium, Low)
• Extensive Services
• Special Care High
• Special Care Low
• Clinically Complex
• Behavioral Symptoms and Cognitive Performance
• Reduced Physical Function

Each category is further broken down into individual groups (RUGs) based on "Activities of Daily Living" (ADL) as well as other factors like signs of depression or infection.  An "ADL index" is determined by summing up all the individual ADL scores for each of the four daily activities: bed mobility, transfer, eating, and toilet use. A higher score represents a greater dependency and a need for more assistance by nursing staff. The range of the ADL scale is 0-16 and each of the four areas of activity can have a maximum of 4 points.

Below is a brief description of each of the categories mentioned above:

Rehabilitation Plus Extensive Services (Ultra High):

Rehabilitation must take place at least 720 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week
• A second rehabilitation discipline three days/week
• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Rehabilitation Plus Extensive Services (Very High):

Rehabilitation must take place at least 500 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week
• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Rehabilitation Plus Extensive Services (High):

Rehabilitation must take place at least 325 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week
• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Rehabilitation Plus Extensive Services (Medium):

Rehabilitation must take place at least 150 minutes per week, with all of the following requirements:

• Five days any combination of three rehabilitation disciplines
• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Rehabilitation Plus Extensive Services (Low):

Rehabilitation must take place at least 45 minutes per week, with all of the following requirements:

• Three days any combination of three rehabilitation disciplines
• Two restorative nursing services six days/week (see Reduced Physical Function for services)
• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Rehabilitation (Ultra High):

Rehabilitation must take place at least 720 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week
• A second rehabilitation discipline three days/week

Rehabilitation (Very High):

Rehabilitation must take place at least 500 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week

Rehabilitation (High):

Rehabilitation must take place at least 325 minutes per week, with all of the following requirements:

• At least one rehabilitation discipline five days/week

Rehabilitation (Medium):

Rehabilitation must take place at least 150 minutes per week, with all of the following requirements:

• Five days any combination of three rehabilitation disciplines

Rehabilitation (Low):

Rehabilitation must take place at least 45 minutes per week, with all of the following requirements:

• Three days any combination of three rehabilitation disciplines
• Two restorative nursing services six days/week (see Reduced Physical Function for services)

Extensive Services:

Following requirements:

• Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident
• Activities of Daily Living (ADL) score of 2 or more

Special Care High:

Following requirements:

• Comatose OR
• Septicemia OR
• Diabetes with daily injections and order change on 2 or more days OR
• Quadriplegia with ADL score>=5 OR
• Chronic obstructive OR
• 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 AND
• Activities of Daily Living (ADL) score of 2 or more

Special Care Low:

Following requirements:

• Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score ≥ 5 OR
• Respiratory failure and oxygen therapy while a resident OR
• Feeding tube (calories ≥ 51 percent or calories = 26-50 percent and fluid ≥ 501 mLs) OR
• Ulcers (two or more stage II or one or more stage III or IV pressure ulcers OR
• Two or more venous/arterial ulcers OR
• One stage II pressure ulcer and one venous/arterial ulcer) with two or more skin care treatments OR
• Foot infection/diabetic foot ulcer/open lesions of foot with treatment OR
• Radiation therapy while a resident OR
• Dialysis while a resident AND
• Activities of Daily Living (ADL) score of 2 or more

Clinically Complex:

Following requirements:

• Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1 OR
• Pneumonia OR
• Hemiplegia with ADL score ≥ 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

Behavioral Symptoms and Cognitive Performance:

Following requirements:

• Cognitive impairment BIMS score ≤ 9 or Cognitive Performance Scale (CPS) ≥ 3 OR
• Hallucinations or delusions OR
• Physical, verbal, or other behavioral symptoms, rejection of care, or wandering AND
• Activities of Daily Living (ADL) score of 5 or less

Reduced Physical Function:

Restorative nursing services:

• Urinary and/or bowel training program
• Passive and/or active Range of Motion (ROM)
• Amputation/prosthesis care training
• Splint or brace assistance
• Dressing or grooming training
• Eating or swallowing training
• Transfer training
• Bed mobility and/or walking training
• Communication training