Reducing Missed Non-Therapy Ancillary (NTA) Opportunities

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.