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 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 |
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 Group | NTA Case Mix Index
|
| 12+ | NA | 3.25 |
| 9–11 | NB | 2.53 |
| 6–8 | NC | 1.85 |
| 3–5 | ND | 1.34 |
| Any 1–2 | NE | .96 |
| 0 | NF | .72 |
How can you reduce missed NTA opportunities? Let’s review some tips:
- 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.
- 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”.
- 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
- 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
- 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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