The Centers for Medicare & Medicaid Services (CMS) has been collecting feedback from healthcare providers on how to improve the Non-Therapy Ancillary (NTA) component of the Patient-Driven Payment Model (PDPM) in Skilled Nursing Facilities (SNFs). In response to concerns and data analysis from Fiscal Year (FY) 2019-2022, CMS has proposed several changes to simplify and improve how NTA points are assigned. While the NTA changes were not in effect on October 1, 2024, CMS has indicated that the NTA Component will change, considering the comments and feedback from providers after the Proposed Rule was issued.
What is the NTA Component, and Why is it Important?
The NTA component is one of the five categories used to determine reimbursement for SNFs under the PDPM. It accounts for the non-therapy services and treatments a resident may need during their stay, such as medications, medical supplies, and specialized treatments. NTA points are assigned based on resident conditions that require these types of non-therapy services. The more complex a resident’s medical needs, the more NTA points they may be assigned, which can increase reimbursement.
Currently, NTA points can be derived from two primary sources:
- Minimum Data Set (MDS) checkboxes: These are boxes on the MDS assessment form that, when checked, indicate the presence of certain conditions or treatments.
- ICD-10 Codes in Section I8000: These are specific codes that identify medical conditions and are used to map to the NTA points based on the CMS PDPM ICD-10 mapping file.
However, confusion can arise when points for a particular condition come from the MDS checkboxes or the ICD-10 codes listed in the MDS Section I8000. In some cases, the same condition appears in both places, but the point assignment may depend on which source is used. The source is the PDPM Calculation Worksheet for SNFs, Chapter 6 of the RAI Manual. This duplication for coding requirements has led to errors in coding and missed reimbursement opportunities.
What Changes Are CMS Proposing for the NTA Component?
The changes CMS proposes focus on simplifying how NTA points are assigned and reducing inconsistencies. Here are the expected future changes:
1. Relying More on MDS Checkboxes
One of the significant changes is that CMS intends to use MDS checkboxes to determine NTA points whenever possible. This could reduce confusion about which data source to use, making the process more straightforward.
Example: If a resident has cirrhosis, currently, you may need to enter an ICD-10 code for cirrhosis in MDS I8000 to capture the NTA point. However, CMS is moving towards allowing the checkbox in MDS I1100, Cirrhosis, to automatically trigger the point without referencing the ICD-10 code list in MDS I8000.
This change aims to streamline coding practices and reduce errors in point assignments, ultimately leading to more accurate reimbursements for providers.
2. Clarification on Point Categories
Currently, some NTA point categories are listed in both the MDS checkboxes and the ICD-10 codes, which can lead to confusion. For instance, Respiratory Failure appears in the MDS I6300 checkbox, and diagnosis is listed in MDS I8000, the ICD-10 mapping file under the Cardio-Respiratory Failure and Shock category. To avoid duplication, CMS wants to eliminate this redundancy and ensure that points are only assigned from one source.
Example:
Currently, checking MDS I6300, Respiratory Failure in the MDS will not automatically assign 1 NTA point. The corresponding ICD-10 code for Respiratory Failure in MDS I8000 is required to capture the NTA point.
By removing this duplication, CMS hopes to make it more straightforward for providers where points should be derived, leading to more accurate coding.
3. Changes in Point Values for Specific Conditions
CMS has also reviewed the NTA point values for specific conditions. Some items will see a decrease in point value, while others will see an increase. Here’s a breakdown:
- 9 Items will have lower NTA Point Value:
- HIV/AIDS
- IV Feeding: High and Low Level
- Transfusion Post Admit
- Bone/Joint/Muscle Infections
- Asthma/COPD (I6200)
- Ventilator Post Admit
- Multiple Sclerosis
- Wound Infection
- 4 Items will have increased NTA Point Value:
- Lung Transplant Status
- Cystic Fibrosis
- Cirrhosis
- Endocarditis
This adjustment is designed to reflect better the actual resources required for each condition. For example, Cirrhosis and Lung Transplant Status are more complex and require specialized care, so their point values are being increased to align with the resources needed to care for residents with these conditions.
4. New MDS Checkbox Additions
Another change is the addition of new MDS checkboxes that can trigger NTA points. Some of the newly added checkboxes include:
- Section B: Comatose
- Section G: Limb Prosthesis
- Section I: PTSD, Heart Failure, Respiratory Failure, Anxiety Disorder, and Bipolar Disorder
- Section M: Surgical Wounds
These additions allow more conditions to be captured directly through the MDS, improving accuracy and reducing the need for additional ICD-10 coding.
5. Elimination of Some NTA Categories
Finally, CMS proposes removing specific NTA point categories that are less relevant or have been identified as confusing. Examples of these categories being removed include:
- Tracheostomy Post-Admit
- Radiation Post-Admit
- Certain ICD-10 diagnoses like respiratory arrest, aseptic necrosis of bone, and end-stage liver disease.
These removals simplify the NTA system by focusing on the most clinically relevant conditions and treatments.
Why Are These Changes Happening?
CMS’s decision to revise the NTA component is based on an analysis of updated data from FY 2019-2022 and feedback from providers who expressed concerns over the complexity and inconsistencies in the current system. By simplifying the NTA point assignment process, CMS aims to improve coding accuracy, ensure fair reimbursement for providers, and ultimately enhance the quality of care for residents in SNFs.
How Will These Changes Affect Providers?
Providers must stay updated on these changes and adjust their coding practices accordingly. Some steps that will be helpful include:
- Training staff on the new MDS checkbox items and the updated coding requirements.
- Reviewing resident charts to ensure that all relevant conditions are captured correctly. This can occur during the Weekly Medicare Meeting or at Triple Check.
- Adjusting workflows to align with the more streamlined process for assigning NTA points from MDS checkboxes.
- Monitoring point changes for conditions increasing or decreasing point value to ensure accurate reimbursement.
The future changes to the NTA component may initially require an adjustment period. Still, it should lead to a simpler and more accurate system for assigning NTA points and determining reimbursement in the long run.
The upcoming changes to the NTA component are a step in the right direction for simplifying and clarifying the reimbursement process for skilled nursing facilities. By reducing redundancies, clarifying point assignment rules, and introducing new MDS checkboxes, CMS hopes to make it easier for providers to capture the necessary data for accurate reimbursement. Staying informed and preparing for these changes will help ensure that facilities continue to receive fair payment for the non-therapy services they provide.
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