When reviewing the CMI components driving PDPM reimbursement it’s important to consider the critical role of the Non-Therapy Ancillary (NTA) score. The NTA component score is based on the presence of certain comorbidities and/or the use of extensive services. CMS identified 50 conditions and services that were related to an increased cost for skilled nursing facilities. When these conditions and extensive services are reported on the MDS 3.0, they are weighted and used to classify a resident into a specific NTA case-mix group. Comorbidities are assigned points based on the cost in care associated with the condition or service, with points ranging from 1 to 8.

In order to determine the patient’s NTA comorbidity score accurately, providers must identify all comorbidities for which a resident would qualify, then total the points.  The resulting sum is the  NTA comorbidity score, which is used to classify each resident into an NTA  case-mix group. As mentioned earlier, these NTA  comorbidities are reported (coded) throughout the MDS. Section I8000 alone has 27 of these conditions, while sections K, M, N, and O also have items that can contribute to the NTA score. It is important to note the one exception to the MDS coding for NTA comorbidities is HIV/AIDS, which is reported on the SNF Part A claim, but not on the MDS, due to certain state privacy laws.

Below is the full listing of conditions and services used for NTA classification and the associated number of points for that comorbidity.

Condition/Extensive ServiceMDS ItemPoints
HIV/AIDSN/A (SNF claim)8
Parenteral IV Feeding: Level HighK0510A2, K0710A27
Special Treatments/Programs: Intravenous Medication Post-admit CodeO0100H25
Special Treatments/Programs: Ventilator or Respirator Post-admit CodeO0100F24
Parenteral IV feeding: Level LowK0510A2, K0710A2, K0710B23
Lung Transplant StatusI80003
Special Treatments/Programs: Transfusion Post-admit CodeO0100I22
Major Organ Transplant Status, Except LungI80002
Active Diagnoses: Multiple Sclerosis CodeI52002
Opportunistic InfectionsI80002
Active Diagnoses: Asthma COPD Chronic Lung Disease CodeI62002
Bone/Joint/Muscle Infections/Necrosis – Except: Aseptic Necrosis of BoneI80002
Chronic Myeloid LeukemiaI80002
Wound Infection CodeI25002
Active Diagnoses: Diabetes Mellitus (DM) CodeI29002
EndocarditisI80001
Immune DisordersI80001
End-Stage Liver DiseaseI80001
Other Foot Skin Problems: Diabetic Foot Ulcer CodeM1040B1
Narcolepsy and CataplexyI80001
Cystic FibrosisI80001
Special Treatments/Programs: Tracheostomy Care Post-admit CodeO0100E21
Active Diagnoses: Multi-Drug Resistant Organism (MDRO) CodeI17001
Special Treatments/Programs: Isolation Post-admit CodeO0100M21
Specified Hereditary Metabolic/Immune DisordersI80001
Morbid ObesityI80001
Special Treatments/Programs: Radiation Post-admit CodeO0100B21
Stage 4 Unhealed Pressure Ulcer Currently present1M0300D11
Psoriatic Arthropathy and Systemic SclerosisI80001
Chronic PancreatitisI80001
Proliferative Diabetic Retinopathy and Vitreous HemorrhageI80001
Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer CodeM1040A,

M1040C*

1
Complications of Specified Implanted Device or GraftI80001
Bladder and Bowel Appliances: Intermittent catheterizationH0100D1
Inflammatory Bowel DiseaseI1300**1
Aseptic Necrosis of BoneI80001
Special Treatments/Programs: Suctioning Post-admit CodeO0100D21
Cardio-Respiratory Failure and ShockI80001
Myelodysplastic Syndromes and MyelofibrosisI80001
Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory SpondylopathiesI80001
Diabetic Retinopathy – Except: Proliferative Diabetic Retinopathy and Vitreous HemorrhageI80001
Nutritional Approaches While a Resident: Feeding TubeK0510B21
Severe Skin Burn or ConditionI80001
Intractable EpilepsyI80001
Active Diagnoses: Malnutrition CodeI56001
Disorders of Immunity – Except: RxCC97: Immune DisordersI80001
Cirrhosis of LiverI80001
Bladder and Bowel Appliances: OstomyH0100C1
Respiratory ArrestI80001
Pulmonary Fibrosis and Other Chronic Lung DisordersI80001

Once you have identified the condition/extensive service on the MDS or claim, the points associated with each comorbidity are added up for a total NTA score which is associated with 1 of the 6 case-mix groups shown below.

NTA Score Range

 

NTA Case Mix GroupNTA Case Mix Index

 

12+NA3.25
9–11NB2.53
6–8NC1.85
3–5ND1.34
Any 1–2NE.96
0NF.72

How can you reduce missed NTA opportunities? Let’s review some tips:

  1. Diligent review of the medical history and clinical record is essential. It is critical that all coded conditions are accurate AND supported by nursing and physician documentation. This is especially important for those residents who are long-term and later qualify for skilled care. These residents may have a significant number of inaccurate or resolved diagnoses if a facility doesn’t have a process for ongoing diagnosis reconciliation. Remember, a diagnosis has to be active and documented by a physician or nonphysician extender to qualify as an NTA item.
  1. Verify coding, don’t assume. Educate yourself on the ICD-10 NTA Comorbidity Crosswalk. The conditions considered NTA comorbidities are not necessarily all-inclusive. For example, 37 different ICD-10 codes can be coded in I8000 for the Opportunistic Infections NTA comorbidity, but there are many more that will not result in NTA points. Should a resident require IV treatment for an opportunistic infection during their time in your facility, the condition could fetch 7 additional NTA points: 5 for IV medication (O0100H2) and 2 for opportunistic infections (I8000), so it’s important to be familiar with those conditions that “count”.
  1. Involve the Interdisciplinary Team. For example, if a resident admits and the dietitian notes the BMI is over 40, query the physician to confirm a morbid obesity diagnosis. The following ICD-10 codes qualify:
    • 41 Body mass index (BMI) 40.0-44.9, adult
    • 42 Body mass index (BMI) 45.0-49.9, adult
    • 43 Body mass index (BMI) 50-59.9, adult
    • 44 Body mass index (BMI) 60.0-69.9, adult
    • 45 Body mass index (BMI) 70 or greater, adult
    • 01 Morbid (severe) obesity due to excess calories
    • 2 Morbid (severe) obesity with alveolar hypoventilation
  1. Cross-train. Ensure you have staff who are trained in ICD-10 coding. With such a close relationship to payment, it is critical the staff member(s) responsible for ICD-10 coding are knowledgeable in this area. Not having the correct codes can have a domino effect and result in missed reimbursement, or claim inaccuracies. Anyone involved with ICD-10 coding should have ready access to the coding guidelines. The most up to date guidelines are available at https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf
  1. Start (and continue) the conversation. Identification of NTA conditions and services should start even before the SNF admission. Consider adding the list of NTAs to current pre-admission screening forms or otherwise creating a way to identify and communicate potential conditions and services that may continue during the SNF stay. Incorporate NTA identification into the daily clinical meeting as it is ever important to identify when a change in condition or services takes place. Was there a need for an IV? Suctioning? Wound Care? Intermittent Catheterization? These conditions may warrant completion of an Interim Payment Assessment (IPA) thus increasing the NTA component score and potentially the total per diem.

References

Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

Center for Medicare and Medicaid Services. (2019) Fact Sheet: NTA Comorbidity Score https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_NTAComorbidityScoring_v2_508.pdf

Center for Medicare and Medicaid Services. (2019) Fact Sheet: PDPM Payments for SNF Patients with HIV/AIDS https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_AIDS_v3_508.pdf

 

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Blog by Jessica Cairns, RN, RAC-CT, CMAC, and Eleisha Wilkes, RN, RAC-CTA