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PDPM: Clearing Up NTA Confusion

At first glance, the methodology of the non-therapy ancillary (NTA) component of the Patient-Driven Payment Model (PDPM) seems simple: code qualifying items on the MDS to achieve points. Yet while the purpose of the NTA component is simple—to capture high expense medications and supplies—its calculation is more complex. Under PDPM, the NTA methodology does not directly consider medications or supplies, but rather captures conditions, comorbidities, and services that have an associated high cost of medications or supplies. A closer examination of the methodology reveals many nuances that may leave the nurse assessment coordinator (NAC) a bit confused. Here are four tips to simplify the NTA methodology and reduce confusion around this component, resulting in accurate MDS coding and reimbursement.

1. NACs need to know if the diagnoses will use a checkbox or an ICD-10-CM code in section I for NTA mapping.

The NTA methodology is detailed in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual and simplified on AAPACN’s PDPM At-a-Glance Tool. Thirty-four of the 50 qualifying items under the NTA component use diagnosis coding, 27 use ICD-10-CM codes at MDS item I8000, and the remaining seven use checkboxes in section I, items I0100-I7900. Recognizing where a diagnosis code maps from is a key part of understanding the methodology. For example, an active diagnosis for diabetes mellitus will only map from the checkbox item I2900. If this box is not checked, the two points for this diagnosis will not be applied to the HIPPS code, even if a more specific diagnosis is entered at I8000. Similarly, non-proliferative diabetic retinopathy only maps from I8000; if this diagnosis is only coded with the diabetes mellitus at I2900, then the additional points for the diabetic retinopathy would not be counted. In addition, any diagnosis that is mapped from I8000 must be included on the CMS PDPM NTA Mapping file. If the ICD-10-CM code is not on the file, it will not qualify for the NTA points. Moreover, when checkboxes add points to the NTA calculation, the checkbox can only count once. For example, if a resident has a diagnosis of asthma and chronic obstructive pulmonary disease (COPD), both of these diagnoses are reflected at I6200, and since this box can only be checked one time, only two total points can be achieved. Even if the NAC provides the specific diagnoses in I8000, no additional points will be added, since the mapping is only from the checkbox at I6200.  

2. NACs must ensure documentation supports that the diagnosis meets all criteria to be coded on the MDS.

To code a diagnosis on the MDS, it must meet two criteria: it must be documented by a physician within the last 60 days and must have documentation to support that the diagnosis was active in the last seven days. The designation of “active” means that the diagnosis has a current relationship to the resident’s functional, cognitive, mood or behavior status, medical treatments, nurse monitoring, or risk of death during the seven-day look-back period. It is the responsibility of the NAC or team member who codes section I to verify the accuracy of the MDS, which includes verifying that the documentation is in place. In addition to following the RAI User’s Manual guidance, the staff member responsible for assigning ICD-10-CM codes must also follow the ICD-10-CM Official Guidelines for Coding and Reporting for the appropriate fiscal year.

An important coding convention provided in the ICD-10-CM guidance addresses when documentation by clinicians other than the physician can be used to support a diagnosis. For example, body mass index (BMI) is often documented in the medical record by the registered dietitian. However, a diagnosis of morbid obesity cannot be coded solely based on the BMI; rather, a diagnosis of morbid obesity must be documented by the physician, after which the dietitian’s documentation of the BMI can be used to assign the most appropriate diagnosis code.

3. NACs need to recognize when documentation from “while not a resident” will impact PDPM methodology.  

A few items on the MDS require the designation of whether the resident received services “while a resident” or “while not a resident.” Nutritional approaches, coded at MDS item K0510, is one item that uses this approach and is a qualifier for the NTA component. K0510A, Parenteral/IV feeding, and K0510B, Feeding Tube, can qualify, but only if the resident received these approaches while a resident in the facility, meaning after entry or reentry into the facility. This would also include services provided in other settings, such as during an emergency room visit, observation stay of less than 24 hours, or physician office visit—as long as the resident did not discharge from the facility prior to the services being provided. In addition, parenteral and IV feedings utilize K0710, Percent Intake by Artificial Route—and for the purposes of PDPM methodology for the NTA component, this item also only uses column 2, which specifies “while a resident.”

However, it is still important that the NAC review the documentation of services received while in the hospital because these items may affect other areas of the PDPM methodology and may impact the care plan. For example, if a resident received IV fluids for dehydration during the hospital stay, this service may qualify for the Special Care High category of the Nursing component of PDPM when received “while not a resident” and may also prompt the clinical team to develop a dehydration risk care plan if this continues to be a risk for this resident.

In addition to items in section K, items listed under O0100 also require the designation of “while a resident” or “while not a resident.” Several of these items can qualify for NTA points, but only if received “while a resident” in the facility. Specifically, even if received in the hospital, prior to admission to the nursing facility, and captured on the MDS, items such as IV medication, ventilator, transfusions, tracheostomy care, isolation, radiation, or suctioning will not count toward the NTA component.  

4. NACs should investigate the root cause of actual or potential problems.   

The NTA component relies heavily on recognizing, documenting, and coding diagnoses, conditions, and comorbidities. When the NAC and team members have investigated the resident’s history and identified potential root-causes to ongoing problems, they can uncover comorbidities that are affecting the resident’s health. For example, a diabetic resident who has reported recent worsening of his vision may have no diagnosed cause of the worsening. This could potentially be related to a diabetic eye disease, diabetic retinopathy. This information should be communicated to the physician for review or a possible referral to an ophthalmologist. If a diagnosis of diabetic retinopathy is documented, it will impact the NTA component, but more importantly, discovery of this condition may prevent worsening of vision and potential risk of blindness. 

Another example would be a resident who admits following internal fixation of a fracture, such as a femur, and develops an infection. The facility team should work with the physician to identify the root-cause of the infection. If the infection is a reaction to the internal fixation device and the appropriate diagnosis code is assigned, this will also impact the NTA component, but more importantly, identifying the root cause will lead to the right treatment for the infection and likely a better outcome for the resident.   

Summary

Often, especially when inadequate time is allotted for MDS coding, the MDS will be completed with the information received during the look-back period without any additional research. While this may accurately represent the resident, it may also leave unanswered questions. When the NAC develops the ability to review the resident’s conditions, recognize potential problems, and research root causes, this will lead to a more accurate overall assessment of the resident. Additionally, working with the physician to identify additional comorbidities impacting care and obtain the required physician documentation to support any new or clarified diagnoses will result in a more effective care plan and accurate reimbursement under the NTA component.

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