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The NTA Component of PDPM: Best Practices for Accurate Scoring

Skilled nursing facilities now have more than a year of experience with the Patient-Driven Payment Model (PDPM), the updated case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) that includes five case-mix-adjusted payment components: physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and non-therapy ancillaries (NTA). The NTA component uses a weighted comorbidity score (i.e., high-cost conditions or extensive services count for more points) to assign a SNF resident to an NTA case-mix group.

 

A resident’s NTA score is the sum of the points associated with each comorbidity that they have. For example, a resident with IV medications (5 points) coded in MDS item O0100H2, diabetes mellitus (2 points) coded in I2099, isolation (1 point) coded in O0100M2, and wound infection (2 points) coded in I2500 would have a total NTA comorbidity score of 10. The NTA case-mix groups are based on NTA score ranges: 0 (NF), 1 – 2 (NE), 3 – 5 (ND), 6 – 8 (NC), 9 – 11 (NB), or 12+ (NA), according to table 17, “NTA Case-Mix Groups,” in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Therefore, a resident with an NTA comorbidity score of 10 would qualify for the NB NTA case-mix group.

 

The bottom line is that accurate payment in the NTA component depends on coding each and every NTA comorbidity the resident qualifies for according to the coding instructions in the RAI User’s Manual. Taking the following steps can help nurse assessment coordinators (NACs) capture the optimal NTA comorbidity score:

 

Become more familiar with the NTA comorbidities

Fifty conditions and extensive services can contribute points (ranging from a high of 8 points to a low of 1) to a resident’s case-mix classification in the NTA component. “The list of NTA comorbidities is extensive,” acknowledges Beckie Dow, RN, RAC-MT, a nurse consultant in Bell, FL. “NACs, especially new NACs, should keep that list handy. You want to be able to flip through the NTA list and other PDPM references any time you do a chart review. PDPM is still less than two years old, and it just takes time to memorize how each of the components works.”


Note: The Centers for Medicare & Medicaid Services (CMS) lists the NTA comorbidities in table 16, “NTA Comorbidity Score Calculation,” in chapter 6 of the RAI User’s Manual. This table can be found at the end of the article.




Be aware of the need for coding specificity

“More than half of the NTA comorbidities derive from ICD-10-CM codes captured in item I8000 (Additional Active Diagnoses). It can be very difficult to select ICD-10 codes with appropriate specificity for the NTA component—or for any other PDPM component—if NACs don’t know how to do ICD-10 coding,” says Tracy Montag, BSN, RN, RAC-MT, clinical consultant with the Senior Living Services Consulting Group at RKL LLP in York, PA.

 

“Sometimes, busy NACs will use whatever simple term or unspecified ICD-10 code that the physician writes down. The thought process is: ‘The physician didn’t specify, so I shouldn’t specify,’” explains Montag. “However, an unspecified code may not represent a diagnosis that is accurate for the resident. NACs need to have the education and training to be able to identify opportunities to collaborate with the physician and confirm a more specific diagnosis.”

 

Note: AANAC offers an ICD-10 certificate and training program specifically designed for NACs and other SNF interdisciplinary team members.

 

Use the mapping tool to learn NTA’s ICD-10 coding options

The Fiscal Year (FY) 2021 PDPM ICD-10-CM Mappings file includes the NTA Comorbidity to ICD-10-CM Mapping, which maps comorbidities in the NTA component that are captured in item I8000 to allowable ICD-10 codes. “This NTA Mapping tool makes clear that the conditions that CMS has identified as NTA comorbidities that can be captured as ICD-10 codes in I8000 are umbrella terms for categories of diagnoses,” says Montag. “For example, 14 diagnosis codes can be coded in I8000 to qualify a resident for the lung transplant status NTA comorbidity (3 points), 27 diagnosis codes can qualify for the cardio-respiratory failure and shock NTA comorbidity (1 point), and 124 diagnosis codes can qualify for the proliferative diabetic retinopathy and vitreous hemorrhage NTA comorbidity (1 point).”

 

While unable to diagnose, NACs can use the NTA Mapping tool to identify potential diagnoses, says Montag. “Then you can collaborate with the physician to select the appropriate and specific active diagnosis and make sure you don’t miss any diagnosis that supports why the resident is in the SNF for care.”

 

Code NTA qualifiers in the source identified in table 16

“All NTA comorbidities must be coded directly in the source identified by CMS in table 16 in chapter 6 of the RAI User’s Manual,” says Montag. “If the comorbidity is not coded where that table says it should be coded, the NTA points will not calculate.”

 

A perfect example of that is respiratory failure, explains Montag. “Respiratory failure is a checkmark MDS item, specifically I6300. However, in order to get the NTA point, you must have the supporting documentation to code I8000 with one of the respiratory failure diagnoses that is included in the NTA Mapping tool under the cardio-respiratory failure and shock umbrella category. In this instance, you would code respiratory failure in both items: I8000 to capture the NTA point, and I6300 to possibly help qualify the resident in the Special Care Low category of the nursing component.”

 

In addition, some MDS software systems use the electronic health record to seed ICD-10 codes in section I (Active Diagnoses), which can lead to problems, says Montag. “For example, the software will code a diagnosis in I8000, but will fail to auto-populate the corresponding checkbox in I0100 – I6500. Consequently, not only do you need to review auto-populated diagnoses to ensure they are still active, but you also need to make sure they are coded in the correct MDS item to satisfy the requirements for an NTA comorbidity or for any other PDPM payment component.”


Note: The source of each NTA comorbidity is listed in the MDS Item column of table 16, below.

 

Do a strong admission chart review

Most NACs do a quick initial chart review for new SNF admissions to become familiar with the resident, notes Dow. “When doing this review, it’s important to look at the chart from the perspective of ‘When I do the MDS, what am I going to want to code?’ This includes having an eye out for the NTA qualifiers.”


The admission chart review should include more than just the discharge summary from the acute-care hospital, says Montag. “You want to look through all of the key records that may have been signed off by a physician and that that you can pull diagnoses from. For example, what was the resident’s history and physical (H&P) when they were first admitted to the acute-care hospital? What does the lab work show? Are there any surgical reports? Are there any tests, such as X-rays, a computerized tomography (CAT or CT) scan, or a magnetic resonance imaging (MRI)?”

 

Knowing upfront which NTA comorbidities the resident is most likely to have can help NACs get the supporting documentation in line before the assessment reference date (ARD) of the 5-day PPS MDS, says Dow. “Preferably on day 1 of the resident’s stay, but at least by day 2 or day 3, you can start working with physicians to obtain any needed physician clarification orders. You also will want to alert the nursing team about any areas where you may want to focus nursing documentation to support the coding of those NTA qualifiers. That way, you won’t end up in a situation where you are past the ARD and you realize you could have coded an NTA comorbidity if you only had documentation within the look-back period.”


The benefits of a good initial chart review don’t stop with the NTA and other PDPM components, adds Dow. “Taking a little time to do this review on the front end also will help you develop a better care plan and ultimately provide better care for the resident because you can identify the resident’s needs, strengths, and weaknesses more quickly. As a team, you will have the information you need to sit down and see what you can do to help the resident have a more successful recovery.”


Coordinate with dietary managers/dietitians

Under PDPM, dietary managers and dietitians should be more involved in the MDS process, suggests Dow. “You need additional input from these interdisciplinary team members because of two factors: (1) The NTA qualifiers morbid obesity, which is coded in item I8000 (1 point), and malnutrition, which is coded in I5600 (1 point), and (2) The coding in section K—items K0100 (Swallowing Disorder) and K0510C2 (Mechanically Altered Diet While a Resident)—that helps drive the SLP payment component.”


NACs may need to do retraining to ensure that dietary managers and dietitians understand how these items are coded, says Montag. “For example, dietitians need to know that item I5600, the checkbox that is the source for the malnutrition comorbidity, can be coded if the resident either has a diagnosis of malnutrition or is at risk for malnutrition, according to the coding instructions on page I-10 in chapter 3 of the RAI User’s Manual.”

 

If the dietitian determines that a resident has malnutrition, that diagnosis needs to be confirmed by the physician, notes Montag. “Similarly, if the dietitian identifies that a resident is at risk for malnutrition, that assessment should be supported by the physician as well so that it can be coded in I5600 to get that NTA point. For example, some dietitians will write out a note to the physician, and the physician will co-sign to say, ‘I agree this resident is at risk for malnutrition.’”

 

Part of this education should focus on interdisciplinary communication requirements, adds Dow. “The dietitian should know that if they assess that a resident meets the criteria for malnutrition or morbid obesity, they should flag the NAC using e-mail or whatever interdepartmental communication system the facility uses. This will jumpstart the process of turning those working diagnoses identified by the dietary manager or dietitian into physician-documented diagnoses if appropriate.”


Occasionally, a physician-documented diagnosis may not be strictly required, points out Dow. “For example, five of the seven allowable ICD-10 codes that qualify a resident for morbid obesity in the FY 2021 NTA Comorbidity to ICD-10-CM Mapping are actually body mass index (BMI) diagnoses. BMI is one of the few exceptions to the requirement that ICD-10 code assignment must be based on physician documentation. Other clinicians, such as the dietitian, can document BMI, according to the FY 2021 ICD-10-CM Official Guidelines for Coding and Reporting.”

 

However, even when coding one of those five allowable BMI diagnoses, the best practice is to have all of the links connected in the chart—and it will also keep I8000 coding consistent with the coding instructions for section I in the RAI User’s Manual, says Dow. “The dietitian should note the BMI and have a plan in place for weight reduction if appropriate, and the physician should sign off and acknowledge that that is part of the resident’s overall plan of care.”


Discuss NTAs in the interdisciplinary PPS meeting

The old PPS meetings discussing therapy minutes and Other Medicare Required Assessments (OMRAs) may be gone forever, but it’s still important to have an interdisciplinary PPS meeting to get the entire team’s perspective, says Dow. “Think of it as an overall chart/MDS discussion that includes a focus on the NTA qualifiers. Under PDPM, there are so many payment ‘balls in the air’ when you do a PPS MDS. Everyone’s expertise has to be used in order to have an accurate assessment. It is helpful for the entire team to have that quick discussion to ensure that you are all on the same page about the resident’s conditions and services around, for example, day 3 – 5 of their Part A stay.”


In addition to ensuring no services or conditions are missed for PDPM calculations, this meeting is also another step in improving resident care, says Dow. “If you identify an issue, you can have it in the care plan sooner rather than later, and you also can focus your nursing assessments and other team members’ assessments on those areas that would best serve the residents.”


Get physicians on board with diagnosis queries

In an audit, it’s still fairly common to find a diagnosis coded in section I because a nurse says, “I know this is true about this resident,” says Dow. “However, for the NTA qualifiers, you must have the appropriate supporting documentation secured in the chart within the look-back period for the resident’s ARD—just like you need supporting documentation to back up any MDS item.”


“You have to follow the coding rules in the RAI User’s Manual,” adds Montag. “Therefore, there must be a physician-signed diagnosis, and that diagnosis must be considered active within the seven-day lookback period for every NTA diagnosis captured in section I. You need to collaborate closely with the physician to ensure you have documentation that these requirements have been met.”

 

Physician extenders (e.g., nurse practitioners) often can be the most helpful in obtaining needed clarifications on diagnoses, points out Dow. “Typically, you can have more facetime with physician extenders in your building, so it’s easier to develop relationships and get those clarifications.”

 

Table 16: NTA Comorbidity Score Calculation

Condition/Extensive Service MDS Item Points

HIV/AIDS

N/A (SNF claim) 8

Parenteral IV Feeding: Level High

K0510A2, K0710A2 7

Special Treatments/Programs: Intravenous Medication Post-admit Code

O0100H2 5

Special Treatments/Programs: Ventilator or Respirator Post-admit Code

O0100F2 4

Parenteral IV feeding: Level Low

K0510A2, K0710A2, K0710B2 3

Lung Transplant Status

I8000 3

Special Treatments/Programs: Transfusion Post-admit Code

O0100I2 2

Major Organ Transplant Status, Except Lung

I8000 2

Active Diagnoses: Multiple Sclerosis Code

I5200 2

Opportunistic Infections

I8000 2

Active Diagnoses: Asthma COPD Chronic Lung Disease Code

I6200 2

Bone/Joint/Muscle Infections/Necrosis – Except: Aseptic Necrosis of Bone

I8000 2

Chronic Myeloid Leukemia

I8000 2

Wound Infection Code

I2500 2

Active Diagnoses: Diabetes Mellitus (DM) Code

I2900 2

Endocarditis

I8000 1

Immune Disorders

I8000 1

End-Stage Liver Disease

I8000 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code

M1040B 1

Narcolepsy and Cataplexy

I8000 1

Cystic Fibrosis

I8000 1

Special Treatments/Programs: Tracheostomy Care Post-admit Code

O0100E2 1

Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code

I1700 1

Special Treatments/Programs: Isolation Post-admit Code

O0100M2 1

Specified Hereditary Metabolic/Immune Disorders

I8000 1

Morbid Obesity

I8000 1

Special Treatments/Programs: Radiation Post-admit Code

O0100B2 1

Stage 4 Unhealed Pressure Ulcer Currently Present1

M0300D1 1

Psoriatic Arthropathy and Systemic Sclerosis

I8000 1

Chronic Pancreatitis

I8000 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code

M1040A,

M1040C

1

Complications of Specified Implanted Device or Graft

I8000 1

Bladder and Bowel Appliances: Intermittent Catheterization

H0100D 1

Inflammatory Bowel Disease

I1300 1

Aseptic Necrosis of Bone

I8000 1

Special Treatments/Programs: Suctioning Post-admit Code

O0100D2 1

Cardio-Respiratory Failure and Shock

I8000 1

Myelodysplastic Syndromes and Myelofibrosis

I8000 1

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

I8000 1

Diabetic Retinopathy – Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

I8000 1

Nutritional Approaches While a Resident: Feeding Tube

K0510B2 1

Severe Skin Burn or Condition

I8000 1

Intractable Epilepsy

I8000 1

Active Diagnoses: Malnutrition Code

I5600 1

Disorders of Immunity – Except : RxCC97: Immune Disorders

I8000 1

Cirrhosis of Liver

I8000 1

Bladder and Bowel Appliances: Ostomy

H0100C 1

Respiratory Arrest

I8000 1

Pulmonary Fibrosis and Other Chronic Lung Disorders

I8000 1

If the number of Stage 4 Unhealed Pressure Ulcers is recorded as greater than 0, it will add one point to the NTA comorbidity score calculation. Only the presence, not the count, of Stage 4 Unhealed Pressure Ulcers affects the PDPM NTA comorbidity score calculation.

 

Source: Table 16, Chapter 6, RAI User’s Manual.


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