In Part 4: Non-Therapy Ancillaries Case Mix Groups, of our PDPM series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions about PDPM.
Your Questions on PDPM’s Non-Therapy Ancillaries Case Mix Groups
Q: Currently we don’t do Section GG for Advantage Plans. Won’t we need to start doing Section GG since it is factoring into the new payment system?
A: Yes, If the specific Medicare Advantage plan is going to adopt the PDPM payment system, then you would need to complete Section GG to get the PT/OT and Nursing Function Scores.
Q: Where can you find the 2020 proposed rates?
Q: Do the NTA diagnosis have to be active? (i.e. asthma) What if they aren’t on any medications or oxygen therapy?
A: You must follow the MDS coding rules for Section I which indicates that only active diagnoses should be coded. Although no treatment may be provided, do the conditions still require nursing monitoring? Are the conditions care planned? Review the definition of Active Diagnosis in Section I coding guidelines.
Q: Will there be a specified list that breakdowns what diagnoses qualify in such Diagnosis NTA’s as Specified Hereditary Metabolic/Immune Disorders, etc.?
A: CMS has provided an NTA ICD-10 Mapping document that identifies which ICD-10 codes would qualify for the different NTA conditions. For example, CMS identifies 2 diagnosis codes (D64.1 and E88.01) that qualify for the Specified Hereditary/Immune Disorders.
For reference, here is a link to the NTA ICD-10 Mapping document.
Q: The vast majority of our Medicare A residents are our long-term care residents who have a 3 midnight hospital stay- usually for pneumonia, COPD exacerbation, CHF. If they have a history of diabetes (are on medications) or other diseases which are not the reason for their skilled stay- can you count these? They are active diagnoses being treated but usually without any change from pre-hospital.
A: As long as the diagnosis is active (i.e., not a resolved condition) it should be coded in Section I. This would include chronic stable conditions such as diabetes, COPD, CHF. These are usually conditions that are still being monitored and treated.
Q: States that prohibit reporting HIV/AIDS on MDS, will you please clarify again regarding coding in MDS?
A: If a State prohibits the coding of HIV/AIDS on the MDS you can still report the appropriate ICD-10-CM code on the Medicare Claim. It is the Medicare claim that will be used to determine if the resident qualifies for the HIV/AIDS NTA points.
Q: Crohn’s has an NTA mapping and also coded on MDS in section I – which is appropriate or is there a difference?
A: Crohn’s would fall under the NTA condition of Inflammatory Bowel Disease. Reviewing CMS documents, it appears that this was originally going to be determined by ICD-10 codes from I8000 of the MDS and was included in the NTA to ICD-10 Mapping. Based on the latest information Inflammatory Bowel Disease NTA is no longer determined using ICD-10 codes in I8000 but rather this condition will be determined by MDS item I1300. The ICD-10 codes for this NTA have been removed from the most recent version of the ICD-10 NTA Mapping.
Q: Can you please clarify what kinds of IV fluid we can code? Is it only IV medications or any fluid?
A: There is no change to the coding of these items on the MDS. IV fluids that meet the coding requirements for K0510 and K0710 would be counted in the NTA as long as they were provided while a resident. The administration of IV fluids may qualify for the Parenteral/IV Feeding – High or Parenteral/IV Feeding – low NTA points. Refer to the PDPM Calculation Worksheet for more information.
IV medications provided as a resident and coded in Section O would also qualify for NTA points.
Q: Our EMR system will calculate the BMI. Can this be used or does there have to be documentation from MD or dietitian?
A: The BMI should be documented by the provider or other clinician, such as a dietitian.
Q: Will you have to do an IPA after IV medications or fluids are completed?
A: An Interim Payment Assessment is an OPTIONAL assessment. There is no requirement to complete an IPA when IV medications or IV fluids are completed.
Q: Is there a possibility to obtain further information about querying a physician? I am sure there are specific rules that must be followed. Can you direct us to proper resources?
A: Here are 2 resources that provide guidance related to querying a physician related to ICD-10 coding accuracy:
Q: Where might we find the list of States that prohibit HIV Aids on the MDS?
A: The SNF PPS Proposed Rule for FY2020 indicates, as in the PDPM presentation, 16 states that prohibit coding of HIV/AIDS on the MDS. View the proposed rule.
You can always contact your State RAI Coordinator if in doubt about your state requirements.
Q: What is MDRO?
A: MDRO is the acronym for Multi-Drug Resistant Organism. This would include, for example, VRE, MRSA, MSSA, CephR-Klebsiella, CRE, and ESBL (not an all exhaustive list).
For additional information, check out the top questions asked for our entire PDPM webinar series.
- FAQs from Part 1: Laying the Foundation
- FAQs from Part 2: Therapy Case Mix Groups
- FAQs from Part 3: Nursing Case Mix Groups
- FAQs from Part 4: Non-Therapy Ancillaries Case Mix Groups
- FAQs from Part 5: Assessment Requirements
- FAQs from Part 6: Putting It All Together
As the focus shifts from therapy resource utilization to one of clinical characteristics and conditions, it will be important for SNF providers to receive accurate and up-to-date information related to this system. Our six part PDPM webinar series is designed with your concerns in mind. You can view the entire PDPM Webinar Series on demand today.