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This PDPM model aims to utilize the individual patient's characteristics and needs based on diagnosis as opposed to the RUG-IV system relying on volume of services. 0000278826 00000 n Facilities must ensure efficient processes are in place when selecting the primary diagnosis. The presence of these conditions and extensive services is reported by providers . ENSURE TO CAPTURE EVERYTHING PRIOR TO COMPLETION OF THE 5-DAY MDS ASSESSMENT! Rehab and Nursing staff should complete the Section GG on the MDS form for indicated ADL tasks on Day 1-3 of admission with the admission date as Day 1. 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. 0000002280 00000 n However, if a provider chooses to ignore the importance of this MDS item, it will cost them 1 NTA point which could possibly impact their Case Mix Group's CMI. 0000001865 00000 n All disciplines should complete all their assessments ON TIME to CAPTURE all skilled services and accurately calculate residents daily rate PRIOR TO completion and transmission of the MDS 5-day assessment. ~,/-I\!/JfB. PDPM or Patient-Driven Payment Model is the new system, replacing the RUG-IV, for calculating reimbursement by Medicare in the skilled nursing setting. You should understand those things too, reader.). I0020 is also a gateway to the I0020B Primary Diagnosis code. In this fourth webinar of our six part series, learn which items on the MDS or Medicare claim will be used to determine the NTA score and its impact on payment. border: 1px solid black; Under PDPM, there are six payment components. Think about this A resident with a Stage IV pressure ulcer has physician orders and Registered Dietician recommendations for a protein supplement. SNF PDPM Provider-Specific Impact File. 463 0 obj <>stream 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. While the SNF certs and the Therapy Certs may contain this documentation, they are often not signed or approved until after the ARD. One can see from the table above that if comorbidities are missed, the facility could possibly miss out on reimbursement. <<50FFC127310FCF468ABFE4B7414A5B70>]/Prev 423154>> Click the comorbidity and see the ICD-10 codes that are most likely to occur. Custodial care does not require the assistance of a licensed staff. The idea is that the facility should be paid for the care they are delivering, based on the patients characteristics. Either way, you must still also code the I0020B primary condition I0010 through I8000. Remember this is using 2017 data so it assumes that providers make no adjustments which is not realistic. You can view either rural, urban or both. Yes, I get that is bad. PDPM includes a new pay category, the non-therapy ancillary or NTA. For the NTA component, the CMI is multiplied against the applicable per diem adjustment factor and is then applied to determine the case-mix adjusted payment associated with each of these payment components for each utilization day under PDPM. Yes, you can, just not in I0020B. We earn 1 NTA point when Other Skin Problems (foot ulcers/lesions) is coded in MDS item M1040A (infection of the foot such as cellulitis or purulent drainage), M1040B (diabetic foot ulcer), or M1040C (other open lesion of foot). Payment is based on services provided by five disciplines: physical therapy, occupational therapy, speech language pathology, nursing, and non-therapy ancillary (NTA). Identification of NTA conditions and services should start even before the SNF admission. It more accurately accounts for expenses and isn't overshadowed by therapy. Documentation by the physician and nursing must also support the skilled nature of the codes that are recorded as NTA conditions. 0000004542 00000 n You can read more about this in the Official ICD10 Guidelines for Coding and Reporting FY2020, Section II, Subsection K. For example: The definition of Group Therapy has changed. Lastly, lets look a little more closely at rural versus urban. Remember, a diagnosis has to be active and documented by a physician or nonphysician extender to qualify as an NTA item. A} 2?d`aYW!3,8h|J/K\J:s&Ve>1|9WiixusVo\sGP8saBT!+(z$lYnAZZp@6Y1m`[ jKeMQ5i.7HCGIC1iGIc' background-color: #2c4a88; Actually, were going to limit our scope to only I8000 items. PDPM NTA Case Mix Classification Groups NTA Score Range NTA Case Mix Group NTA Case Mix Index NTA HIPPS Character 12+ NA 3.24 A 9-11 NB 2.53 B 6-8 NC 1.84 C 3-5 ND 1.33 D 1-2 NE 0.96 E 0 NF 0.72 F . mp:U@|8B *zL$#Tk\*SU%mQlTYA Rj&-N _VjWpb[5R8'i, The MDS software programs such as PointClick Care, Matrix, Net Solutions, to name just a few, automatically calculate the PDPM rates once the MDS assessment is completed. We earn. 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. Reimbursement, LW Consulting, Inc.5925 Stevenson Avenue, Suite GHarrisburg, PA 17112, Ph:800-320-5401Local Ph: 717-233-6100Fx:717-233-4633. PDPM consists of five case-mix adjusted components: Physical therapy (PT) Occupational therapy (OT) Speech-language pathology (SLP) Nursing Non-therapy ancillary (NTA) PDPM also includes a variable per diem (VPD) adjustment that adjusts the per diem rate to reflect varying costs throughout a patient's stay. hbspt.cta._relativeUrls=true;hbspt.cta.load(2297384, '30c35813-92d3-4fa1-bc3f-6b232de017b1', {"useNewLoader":"true","region":"na1"}); Topics: Also, there is a 25% combined limit on concurrent and/or group therapy. The non-therapy ancillary (NTA) classification of PDPM reinforces why ICD-10 coding plays a key role under PDPM. The PDPM clinical categories represent groups of similar diagnosis codes, which are used as part of the resident's classification under the PT, OT, and . The PDPM program has six payment components. Stay tuned. Contact us now and sign up to receive our newsletters here. For example, if the MDS Coordinator counts only two of the three comorbidities that a patient has, the CMI for NTA would be 0.96 instead of 1.34. When reviewing the CMI components driving PDPM reimbursement its important to consider the critical role of the Non-Therapy Ancillary (NTA) score. View D0AD3F24-D6BD-4273-B139-8FCA97487E6A.jpeg from NURSING MISC at St. Clair County Community College. #2 Diagnosis Status - The diagnosis must have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. %PDF-1.6 % 0000001405 00000 n .center {text-align: center;}, Foot Code, Except Diabetic Foot Ulcer Code, Once we have totaled the score from the table above, we use it to map to a case-mix group and case-mix index. Whats in it for me? The administration of IV fluids may qualify for the Parenteral/IV Feeding - High or Parenteral/IV Feeding - low NTA points. Hover over a facility to see the name, NTA Rate, NTA case-mix index and whether the facility is urban or rural. (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. The patients functional score which is coded on Section GG of the MDS form is derived by assessing the patients usual self-performance in the ADL task areas during the first three days of facility stay. The Patient-Driven Payment Model focuses on the patients unique characteristics and needs based on diagnosis which arise during inpatient hospital stay. Skilled nursing services are covered under the Federal Governments Medicare program for a limited time or on a short-time basis and must meet the following requirements: The role of the Minimum Data Set (MDS) nurses has evolved all these years from being a clinician to a financial analytical nurse because the MDS assessments have become the basis for facility reimbursement by the Medicare program. ,: >i*S7O=X8ZA'ic2+(!olVz`zz_"K@I In it, youll find the 1,612 codes that map to the different comorbidities. to You are never alone in this field and resources are available in seminars, webinars, the CMS website, MDS manual, etc. or privately paid by the patient if he/she does not qualify under the Medi-Cal program. The correct coding for NTA will require a team effort and diligent review of coding and supporting documentation to ensure 100% accuracy. endstream endobj 1695 0 obj <>stream We also qualify for Special Care Low in the Nursing Category when there is an application of a dressing to the foot with the ulcer. Not having the correct codes can have a domino effect and result in missed reimbursement, or claim inaccuracies. &)` R #V? U? 3HFDRkse$:stHqPJoHK-qL_sh|Kg?unioWAsfH8[^9{'~-? The decision to change the definition was because CMS believes that therapists, using their clinical judgment, will allow for more flexibility and that residents often benefit from the psychosocial aspects of group therapy. The long-term care facilities have emerged not only as a permanent home for the elderly during their retirement or post-retirement years but as respite and recuperative facilities even for the younger patients. Recently, a provider stated that its not that important because the QM high risk determination includes impaired mobility and transfer, which most of their residents with pressure ulcers already have, so that already qualifies them for high risk even if I5600 is not coded. Under the PDPM structure, there are no rules regarding when nursing home staff can perform an IPA, McCarthy noted, and even slight changes to a resident's care plan could result in additional NTA points that could bring in extra per-day reimbursement dollars. Daily Medicare charting should focus on all possible nursing clinical categories, special care high, special care low, clinically complex, behavioral symptoms and cognitive performance, and reduced physical function. Overview In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. Specialties What Is a SANE Nurse? Each patient has a different reimbursement rate as compared to the RUG-IV PPS rate in the past. Preparedness for coding changes will be the key to a smooth transition. %PDF-1.4 % Patient has at least three qualifying inpatient days in an acute hospital. The PT and OT payment would be based on: primary reason for SNF care and functional status at admission The sum of the lowest per diem rate under each PDPM component, plus the non-case-mix component is the: default code Which of the following is NOT a case-level adjustment for a MS-LTC-DRG long term stay outlier The more comorbidities a patient has, the more medications he or she probably requires. It more accurately accounts for expenses and isnt overshadowed by therapy. by Proactive LTC Consulting | Jan 6, 2020 | Audits, Compliance, Education, MDS, Medical Review, PDPM. The Patient-Driven Payment Model focuses on the patients unique characteristics and needs based on diagnosis which arise during inpatient hospital stay. It will be imperative that the coding is accurate on the MDS for the NTA conditions. The PDPM Clinical Categories are discussed below. Under PDPM, long-term care facilities will receive reimbursement based on services that each resident receives. I believe that this payment method acknowledges not only the skilled rehabilitation services provided to the patient, but also the complexity of skilled nursing services rendered to the patient and appropriately incorporated in the PDPM rate calculation. First, it corrects an issue where diagnosis codes were mapped to NTA comorbidities as 1 to 1 mappings where 1 to 2 mappings were intended from the PDPM_ICD10_Mappings_FY20XX Excel sheet. Try it out!). The Centers for Medicare & Medicaid Services (CMS) realizes that the cost impact of medications, at the time of admission, is extensive. (I did abbreviate a few of the names for sanity.) It is not clear why this would be the case. It is for this type of services they offer which also categorize them as skilled nursing and rehabilitation facilities becoming a, A long-term care facility provides custodial care requiring supervised, minimal or total dependence in the performance of the activities of daily living (. ) To assist stakeholders in understanding the potential impacts of the proposed PDPM, we are providing a provider-specific impact analysis file, which details the estimated . On any device & OS. This list of options is not used for PDPM payment, but is used as risk adjustments for some of the QRP Quality Measures. 66y% endstream endobj 451 0 obj <>stream We earn 2 NTA points if Diabetes is coded in MDS item I2900. Far more items than would actually fit on the MDS 3.0 Instrument. Understanding the Value of the MDS Nurse Under PDPM, Psoriatic Arthropathy & Systemic Sclerosis, Myelodysplastic Syndromes and Myelofibrosis. Functional scoring is one of the factors used to calculate the PDPM rate for the PT, OT and Nursing components. Base rates are either rural or urban as determined by geographic location. RUG-IV vs Patient-Driven Payment Model (PDPM), Prior to October 1, 2019, all SNFs which participate under the Medicare program are paid under the Skilled Nursing Facility (SNF). They are assisted by certified nursing assistants (. yid T[KaEev0D/wRDQhDB['QgDTBEB)2"xt"Xn2 QN[%=> FhzdBI^8/HD Observation services are not covered as part of the inpatient stay. The general method for calculation of any NTA category is as follows: Updates the ICD-10 mapping used to classify patients under the PDPM framework. Under PDPM, CMS identified 50 conditions that were related to increases in NTA costs for a skilled nursing facility (SNF). Perhaps the most "transformative" component relates to Non-Therapy Ancillary (NTA) Services. Ensure you have staff who are trained in ICD-10 coding. In this article, we discuss the non-therapy ancillary (NTA) component. It is critical that all coded conditions are accurate AND supported by nursing and physician documentation. Refer to RAI pages J37-J38 for more on coding J2100. Under PDPM, an adjustment is applied to certain PDPM components that varies the per diem payment over the course of the stay. It is for this type of services they offer which also categorize them as skilled nursing and rehabilitation facilities becoming a step-down facility from an acute hospital stay. HVmo0)>bbJS:i>h4B6u~>!bB8lr lk4-M~V CIExej[_@{wpuCm/8yU\mqpC1!Ll%5##P:a,Orh[a%zDUd V#~RLXP9BZ,/Y798(|&a"#.G. They are assisted by certified nursing assistants (CNAs) and licensed staff assist them during medication administration ordered by the patients attending physician in the facility. With the transition from Resource Utilization Group Version IV (, ) to the Patient-Driven Payment Model (PDPM) on October 1, 2019, the. (By the way, we created a PDPM Calculator for you to experiment with and get a better understanding of how PDPM works. After a qualifying hospital stay, he has returned to the SNF for aftercare of the hip fracture. The PDPM diagnosis list determines the reimbursements for a Medicare Part A stay. CMS identified a list of 50 conditions and extensive services that were associated with increases in NTA costs. Under PDPM, CMS identified 50 conditions that were related to increases in NTA costs for a skilled nursing facility (SNF). To find out if you're leaving any money on the table email MDS Consultants for a PDPM review at info@mds-consultants.com, Find the PDPM ICD-10 Mapping tool at: https://mds-consultants.com/helpful-cms-info/, PDPM step-by-step scoring guide at https://mds-consultants.com/mds-tools/, https://mds-consultants.com/helpful-cms-info/, Coding N2001 N2005: Part A Drug Regimen Review, The Struggle with Antipsychotic Reduction . The International Code for Diseases, Tenth Revision, Clinical Modification Codes which popularly known as the ICD-10 CM which is coded on Section I0020B of the MDS assessment is mapped to a clinical category which will be part of the determinant of payment for the PDPM components. code. When the severe skin burn is also coded in MDS section I8000, we qualify for the Nursing Clinically Complex Category. This update addresses two issues with the NTA comorbidities mapping. endstream endobj 447 0 obj <> endobj 448 0 obj <> endobj 449 0 obj [278 0 0 0 0 889 0 0 333 333 0 0 278 333 0 278 556 556 556 556 556 556 556 556 556 556 278 0 0 584 0 0 0 667 667 722 722 667 611 778 722 278 500 667 556 833 722 778 667 0 722 667 611 722 667 944 0 667 0 0 0 0 0 0 0 556 556 500 556 556 278 556 556 222 222 500 222 833 556 556 556 0 333 500 278 556 500 722 500 500 500] endobj 450 0 obj <>stream 0000001690 00000 n Hoo0#=)HU64*)T%DH!$swwb4fc|i]\/8gr? For example, Mr. Steve is a long term care resident due to Parkinson's Disease. Under PDPM, 50 conditions and extensive services are considered for NTA classification. . 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 437 27 The NTA component is an important component to capture and reimburse the facility for costly medications, services, and supplies needed to care for residents. Q: Our EMR system will calculate the BMI. Re-calculate expected daily rate based on the completed Rehab and Nursing Functional Scores and re-review principal diagnosis. See the table below. "FE"u PsFO;416ib_z/[E>#~.G+Y6l|)31}Q50B}Wk?/1wo USIek~)zR*u:1\np2}HPs}@I#RM=e1JtJ22;3(TYt&8W1UN@ID7{V Z +MykUW? Points are added together for all conditions. SNF FY 2022 Proposed Rule Learn the Facts Behind the Headlines Part 3: How is My Rate Calculated, Regulatory Reminder! IV medications provided as a resident and coded in Section O would also qualify for NTA points. 0000009034 00000 n All PDPM components are assigned an appropriate score to multiply to the federally assigned case mix index group. In 2019, CMS has further revised and finalized the version of PDPM that will go into effect October 1, 2019. oYyTQb`y{y;..nI^vY5[3?O%5;5E8_kT}m}02|E}}q4:>9=6 /W=.8,w,8m_?Y\Y\v &0,/}["JO=>?]"y;?P'WY4[;of}7gh.RF)# `,J Z5FXMM:&Dh,A*hJtiL."%oKt 0000004207 00000 n Highlights: Hiring both part-time 2 days/week and full-time 4-5 days/week (benefits for FT only) Hours: Monday-Friday ~7am to 4pm; no evenings, weekends, call, or holidays . Try Now! You can see in the histogram that not only are there a lot fewer rural facilities, but they also appear to have lower average case-mix. $HJ0!$j-g#W d9bEi0~og$.J8-Lb =lZ.SSz|'!`%/ h4Pj0^z[ 8 >BRA$+Vfa Each component has its case mix index to determine the component rate. Center for Medicare and Medicaid Services. 0000277284 00000 n 0000006001 00000 n endstream endobj 1696 0 obj <>stream The most up to date guidelines are available at. 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. The Non-Therapy Ancillaries (NTA) component of PDPM can significantly increase revenue depending on MDS and ICD-10 coding. 2 &r}p")|@ O&]LpLk| Mvl(Pv[C0AMfxYp&NymfJXdO@QhCec*2-K8P3Tjp6'+Q :~_%`n/[w}_,0-|:%?h6'#%?7?\o(@Ln 9w9Fhe`P8B09@(@DT\QG+ (CQ {dX r4`H*B4,&0hl3()%zI[)jCN8{SNa%PED~ eT T(m:l] 43FH&"@`BN`Kk(f eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer assessed on the first three days of admission to the facility with the admission day counted as day 1. These are: Physical Therapy (PT): 14 MDS items Occupational Therapy (OT): 14 MDS items Speech Language Pathology (SLP): 33 MDS items Nursing: 129 MDS items Non-Therapy Ancillary (NTA): 33 MDS items RUG-IV: Resource Utilization Groups version 4 It may also include a condition that started while the patient was getting care in the SNF for a hospital-related medical condition such as antibiotic medications via intravenous (IV) route to treat infections even if it was not the reason the patient was admitted to the acute hospital. Which codes are the most important? But, since its new, were going to have to work on understanding how its supposed to work, and how we can most easily and efficiently complete the assessment with accurate information. Patient classification system where patients are grouped according to their care and resource needs. 0000189184 00000 n Sometimes the code may be a qualifier for other PDPM components, sometimes it won't be. (difference of NE-NF and NA-NB). For situations like this, the MDS nurse will choose to complete an Interim Payment Assessment (IPA) to capture such changes and eventually increase the daily reimbursement rate. If the resident went from the hospital directly to a LTCH first, then to your SNF, you can code the surgery because an LTCH is a post-acute long term care hospital, not an acute care hospital. As a result, client facilities realize improved wound healing results, improved survey scores and NTA reimbursement under PDPM. Inappropriate Schizophrenia Diagnosis/Coding and Survey Citation Posting, Regulatory Reminders: Consolidated Billing Update 2023. AVONA confirms that rural facilities do indeed have lower NTA case-mix. b!+XQ{ +LgOIYe/Q6RVpYY_N/.~iMu1fY*eR}W_E[,7vrR!XSF};qZW&e"S5!CW}3GU|muc?_X`dcg7(zRU8k? (This isnt going to work well on mobile devices, FYI.). You only need one SLP co-morbidity (either in one of those check boxes or listed in I8000) to meet that SLP co-morbidity qualifier. With this component being paid at a 3x rate for 1st 3 days of stay, its important to quickly and accurately identify and code patient conditions. color: white; 5!!!!!May!be!used!by!permission!only!Proactive!Medical!Review,!LLC!!!!!www.proactivemedicalreview.com!!!!