non-therapy ancillary services conditions/extensive services · 2019-04-12 · non-therapy...

Non-Therapy Ancillary Services—Conditions/Extensive Services

Non-Therapy Ancillary Services (NTA) classification is determined by the presence of certain conditions or

the provision of extensive services that are associated with additional costs for medical care. A weighted

co-morbidity scoring process is used to create the NTA component of the total reimbursement for care

and services for Medicare A recipients.

Diagnoses and conditions included in this classification should be entered into the resident’s electronic

health record, as appropriate. Care and services related to these diagnoses and/or conditions are docu-

mented in the resident’s electronic health record, as indicated.

The following conditions and extensive services categories are used in the Non-Therapy

Ancillary Services scoring component:

CONDITION/EXTENSIVE SERVICE POINT TOTAL

HIV/AIDS 8

Parenteral IV Feeding: Level High 7

Intravenous Medication Post-admit Code 5

Ventilator or Respirator Post-admit Code 4

Parenteral IV Feeding: Level Low 3

Lung Transplant Status 3

Transfusion Post-admit Code 2

Major Organ Transplant Status (except Lung) 2

Active Diagnoses Codes: Multiple Sclerosis 2

Opportunistic Infections 2

Active Diagnoses Codes: Asthma, COPD, Chronic Lung Disease 2

Chronic Myeloid Leukemia 2

Wound Infection Code 2

Active Diagnoses Codes: Diabetes Mellitus 2

Endocarditis 1

Immune Disorders 1

End-stage Liver Disease 1

Other Foot Skin Problems: Diabetic Foot Ulcer Code 1

Narcolepsy and Cataplexy 1

Cystic Fibrosis 1

Tracheostomy Care Post-admit Code 1

Active Diagnoses Codes: Multi-drug Resistant Organism (MDRO) 1

Isolation Post-admit code 1

Specified Hereditary Metabolic/Immune Disorders 1

Morbid Obesity 1

1

For informational purposes only. Not intended for clinical/financial advice.

Non-Therapy Ancillary Services—Conditions/Extensive Services

The following conditions and extensive services categories are used in the Non-Therapy

Ancillary Services scoring component:

CONDITION/EXTENSIVE SERVICE POINT TOTAL

Radiation Post-admit Code 1

Highest Stage of Unhealed Pressure Ulcer—Stage IV 1

Psoriatic Arthropathy and Systemic Sclerosis 1

Chronic Pancreatitis 1

Proliferative Diabetic Retinopathy and Vitreous Hemorrhage 1

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code (except Diabetic Foot Ulcer Code) 1

Complications of Specified Implanted Device or Graft 1

Bladder and Bowel Appliances: Intermittent Catheterization 1

Inflammatory Bowel Disease 1

Aseptic Necrosis of Bone 1

Suctioning Post-admit Code 1

Cardio-Respiratory Failure and Shock 1

Myelodysplastic Syndromes and Myelofibrosis 1

Systemic Lupus Erythematosis, Other Connective Tissue Disorders, and Inflammatory Spondylopathies 1

Diabetic Retinopathy (except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage) 1

Nutritional Approaches while a Resident—Tube Feeding 1

Severe Skin Burn or Condition 1

Intractable Epilepsy 1

Active Diagnoses Codes: Malnutrition 1

Disorders of Immunity (except RxCC97: Immune Disorders) 1

Cirrhosis of Liver 1

Bladder and Bowel Appliances—Ostomy 1

Respiratory Arrest 1

Pulmonary Fibrosis and Other Chronic Lung Disorders 1

The Non-Therapy Ancillary Services (NTA) component is a total score of all listed conditions and/or extensive

services that apply to the resident. The score determines NTA payment groups and indices. These groups and

indices, combined with other components of the payment system, provide a total reimbursement process that

improves payment accuracy while focusing on a more resident-centered care model that is unique, individual-

ized, and takes into account the characteristics and goals of the resident.

2


1

PDPM: NTA (Non Therapy Ancillary) Supporting Documentation

Conditions/Extensive Service Source Points

awarded in PDPM

PCC Documentation Location Hospital Records Location

HIV/AIDS SNF Claim 8

Medical Diagnosis, Orders, MAR/TAR, Nursing Admission Data Collection UDA,

Daily Skilled Charting UDA, Nutrition UDAs, Pain UDAs, Braden Scale UDA,

Wts/Vitals, Care Plan, POC tasks/interventions, Progress Notes

Hospital Transfer orders, History & Physical, Discharge Summary, Progress Notes, Lab/Diagnostic

Reports, Consultant Progress Notes, Hospital Med/Treatment

Administration records, hospital therapy documentation; Orders,

Lab/Diagnostic reports

Parenteral IV Feeding: Level High

MDS Item K0510A2, K0710A2

7

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Nutrition

UDAs, Orders, Enteral Feed Administration Record, Care Plan,

Progress Notes, Wts/Vitals, applicable Medical Diagnosis

Hospital Transfer, Hospital H&P, Hospital Discharge Summary,

Progress Notes, Consultant Progress Notes, Hospital Parenteral Feed Admin records, Lab/Diagnostic

reports

Special Treatments/Programs: Intravenous Medication Post-

admit Code

MDS Item O0100H2

5

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Orders,

MAR, IV Flow Sheet, Care Plan, Wts/Vitals, Progress Notes, applicable Medi-

cal Diagnosis

Hospital Transfer, Hospital H&P, Hospital Discharge Summary, Progress Notes, IV Med Admin

records, Consultant progress notes, Lab/Diagnostic reports

Special Treatments/Programs: Ventilator or Respirator Post-

admit Code

MDS Item O0100F2

4

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale

UDA, Pain UDAs, Nutrition UDAs, Or-ders, MAR/TAR, Care Plan, Wts/Vitals,

Progress Notes


Progress Notes, Consultant Progress Notes, Hospital Ventilator or

Respirator records, Lab/Diagnostic reports


2



awarded in PDPM

PCC Documentation Location Hospital Record Location

Parenteral IV feeding: Level Low

MDS Item K0510A2, K0710A2, K0710B2

3

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Nutri-

tion UDAs, Orders, Enteral Feed Administration Record, Care Plan,

Progress Notes, Wts/Vitals, applicable Medical Diagnosis


Progress Notes, Consultant Progress Notes, Hospital Parenteral Feed

Admin records

Lung Transplant Status MDS Item

18000 3

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled

Charting UDA, Pain UDAs, Nutrition UDAs, Orders,

Treatment administration records, Non-Pressure Weekly Wound UDAs, Care

Plan, Progress Notes, Wts/Vitals, POC - ADLs


Progress Notes, Consultant Progress Notes, Hospital Med Administration

Records, hospital therapy notes, Orders, Lab/Diagnostic reports

Special Treatments/Programs: Transfusion Post-admit Code

MDS Item O0100I2

2

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Nutri-

tion UDAs, Orders, Med/Treatment Administration Records, Care Plan,

Progress Notes, Wts/Vitals, POC - ADLs


Hospital progress notes, Consultant Progress Notes, Hospital

Med/Treatment Administration Records

Major Organ Transplant Status, Except Lung

MDS I8000 2

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Braden

Scale UDA, Orders, Treatment admin-istration records, Non-Pressure Weekly

Wound UDAs, Nutrition UDA, Care Plan, Progress Notes, Wts/Vitals, POC -

ADLs

Hospital Transfer Orders, Hospital History & Physical, Hospital

Discharge Summary, Hospital progress notes, Consultant Notes,

Hospital MAR/TAR, Hospital Therapy notes, Orders, Lab/Diagnostic

reports, Physician/provider progress notes


3



awarded in PDPM


Major Organ Transplant Status, Except Lung

MDS I8000 2


Scale UDA, Orders, Treatment admin-istration records, Non-Pressure Week-ly Wound UDAs, Nutrition UDA, Care Plan, Progress Notes, Wts/Vitals,

POC-ADLs




reports, Physician/provider progress notes

Active Diagnoses: Multiple Sclerosis Code

MDS Item I5200 2

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA,

Pain UDAs, Nutrition UDAs, Orders, Wts/Vitals, Care Plan, Progress Notes




reports, Physician/provider progress notes, Therapy documentation

Opportunistic Infections MDS Item I8000 2

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Nutrition UDA, Pain UDAs, Orders, MAR/TAR records,

Care Plan, Progress Notes, Wts/Vitals



Hospital MAR/TAR, Orders, Lab/Diagnostic reports,

physician/provider progress notes

Active Diagnoses: Asthma, COPD, Chronic Lung Disease

Code MDS Item I6200 2


Charting UDA, Nutrition UDAs, Pain UDAs, Orders, MAR, Wts/Vitals, Care

Plan, Progress Notes, POC - ADLs


Discharge Summary, Hospital progress/consultant notes, Hospital MAR/TAR, Lab/Diagnostic reports,

Hospital therapy notes, Orders, physician/provider progress notes


4



awarded in PDPM


Bone/Joint/Muscle Infections/ Necrosis - Except Aseptic

Necrosis of Bone MDS Item I8000 2

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Braden Scale UDA, Nutrition UDA, Orders, Medication Administration Records,

Progress Notes, Care Plan, Wts/Vitals



Hospital therapy notes as applicable, Orders, physician/provider progress

notes

Chronic Myeloid Leukemia MDS Item I8000 2


Charting UDA, Braden Scale UDA, Pain UDAs, Nutrition UDAs, Orders, Pro-gress Notes, Care Plan, Wts/Vitals



Hospital therapy notes as applicable, Orders, physician/provider progress

notes, therapy records

Wound Infection Code MDS Item I2500 2


Charting UDA, Braden Scale UDA, Pain UDAs, Orders, Progress Notes, Care

Plan, Wts/Vitals, Pressure and/or Non-Pressure Weekly Wound UDAs,

Nutrition UDAs, POC tasks/interventions


Discharge Summary, Hospital progress/consultant notes, Hospital MAR/TAR, Lab/Diagnostic reports

Active Diagnoses: Diabetes Mellitus (DM) Code

MDS Item I2900 2

Medical Diagnosis (monitor for com-bined diabetic conditions - ICD-10-CM combination codes), Nursing Admis-

sion Data Collection UDA, Daily Skilled Charting UDA, Nutrition UDAs, Braden Scale UDAs, Wts/Vitals,

Orders, MAR, Progress Notes, Care Plan

Hospital Transfer Orders, History & Physical, Discharge Summary,

progress/consultant notes, MAR/TAR, Lab/Diagnostic reports,

Orders, physician/provider progress notes


5



awarded in PDPM


Endocarditis MDS Item I8000 1


Charting UDA, Pain UDAs, Nutritional UDAs, Wts/Vitals, Orders, MAR, Pro-gress Notes, Care Plan, POC - ADLs

Hospital Transfer orders, history & Physical, Discharge Summary,

progress/consultant notes, MAR/TAR, Lab/Diagnostic reports,

Orders

Immune Disorders MDS Item I8000 1


Charting UDA, Nutrition UDAs, Wts/Vitals, Orders, MAR, Progress Notes,

Care Plan, POC - ADLs

Hospital Transfer orders, History &Physical, Hospital Discharge

Summary, progress/consultant notes, MAR/TAR, Lab/Diagnostic reports,

Orders

End-Stage Liver Disease MDS Item I8000 1


Charting UDA, Nutrition UDAs, Braden Scale UDAs, Pain UDAs, Wts/Vitals, Orders, MAR, Progress Notes, Care

Plan, POC - ADLs

Hospital Transfer orders, History & Physical, Discharge Summary,

progress/consultant notes, Lab/Diagnostic reports, therapy

notes; Orders

Other Foot Skin Problems: Diabetic Foot Ulcer Code

MDS Item M104B

1

Med Diagnosis, Nursing Admission Da-ta Collection UDA, Daily Skilled Chart-ing UDA, Nutrition UDAs, Non-Pressure Weekly Wound UDAs, Orders, MAR/

TAR, Wts/Vitals, Care Plan, POC - ADLs, Progress Notes



notes; Orders


6



awarded in PDPM


Narcolepsy and Cataplexy MDS Item I8000 1


Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Progress Notes,



progress/consultant notes; Orders

Cystic Fibrosis MDS Item I8000 1

Medical Diagnosis, Orders, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA, Pain UDAs, Nutrition UDAs,

MAR/TAR, Therapy Notes, Wts/Vitals, Progress Notes, Care Plan, POC -

ADLs


progress/consultant notes; lab/diagnostic reports; Orders;

Therapy

Special Treatments/Programs: Tracheostomy Care

Post-admit Code

MDS Item O0100E2

1


Scale UDA, Orders, MAR/TAR, Wts/Vitals, Care Plan, Progress Notes,

ADLs-POC, Therapy Notes


progress/consultant notes; lab/diagnostic reports, therapy

notes; Orders,

Active Diagnoses: Multi-Drug Resistant Organism (MDRO)

Code I1700 1

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Orders, MAR, Wts/

Vitals, Laboratory Reports, Progress Notes, Care Plan


progress/consultant notes; lab/diagnostic reports; Orders


7



awarded in PDPM


Special Treatments/Programs:

Isolation Post-admit Code

MDS Item O0100M2

1


Progress Notes, Wts/Vitals, Care Plan, Orders, POC - ADLs and

tasks/interventions


lab/diagnostic reports, progress/consultant notes; Orders

Specified Hereditary Metabolic/ Immune Disorders

MDS Item I8000 1


Pain UDAs, Nutrition UDAs, Orders, MAR, Progress Notes, Care Plan, Wts/

Vitals


progress/consultant notes; lab/diagnostic reports, therapy notes; Orders; Therapy records

Morbid Obesity MDS Item I8000 1

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA, Nutrition UDAs, Orders, Therapy

Notes, Wts/Vitals, Progress Notes, Care Plan, POC - ADLs


lab/diagnostic reports, progress/consultant notes; Orders;

therapy records


Radiation Post-admit Code

MDS Item O0100B2

1

Nursing Admission Data Collection UDA, Braden Scale UDA, Nutrition UDA, Care Plan, Orders, Progress

Notes, Non-Pressure Weekly Wound UDA, as applicable, Wts/Vitals


labs/diagnostic reports, progress/consultant notes; therapy

records; Orders

Highest Stage of Unhealed Pressure Ulcer - Stage 4

MDS Item M0300D1

1

Medical Diagnosis, Nursing Admission Data Collection UDA, Braden Scale UDA, Pressure Ulcer Weekly Wound

UDAs, Nutrition UDAs, Orders, Thera-py Notes, Care Plan, Progress Notes,

Wts/Vitals, POC - ADLs


progress/consultant notes; lab/diagnostic reports, therapy notes; Orders; Therapy records


8



awarded in PDPM


Psoriatic Arthropathy and Systemic Sclerosis

MDS Item I8000 1


Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders, MAR, Lab/Diagnostic Reports, Therapy Notes, Progress Notes, Care Plan, POC -

ADLs


progress/consultant notes; lab/diagnostic reports, therapy

notes; Orders

Chronic Pancreatitis MDS Item I8000 1


Charting UDA, Pain UDAs, Nutritional UDAs, Wts/Vitals, Orders, MAR, Pro-gress Notes, Care Plan, POC - ADLs


progress/consultant notes; Lab/Diagnostic records; Orders

Proliferative Diabetic Retinopathy and Vitreous

Hemorrhage MDS Item I8000 1

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDA, Orders,

MAR, Progress Notes, Care Plan, POC-ADLs


progress/consultant notes; lab/diagnostic reports; Orders;

Therapy records

Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code,

Except: Diabetic Foot Ulcer Code

MDS Item M1040A, M1040B,

M1040C 1


Charting UDA, Non-Pressure Weekly Wound UDAs, Pain UDAs, Braden

Scale UDA, Progress Notes, Therapy Notes, Orders, MAR/TAR, Wts/Vitals,

Care Plan, POC -ADLs and Tasks


progress/consultant notes, lab/diagnostic reports, therapy notes; Orders; Therapy records

Complications of Specified Implanted Device or Graft

MDS Item I8000 1

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Orders,

MAR/TAR, Wts/Vitals, Progress Notes, Lab/Diagnostic Reports, Care Plan,

POC -ADLs


progress/consultant notes, Orders, Lab/Diagnostic reports; therapy

records


9



awarded in PDPM


Bladder and Bowel Appliances: Intermittent

Catheterization

MDS Item H0100D

1

Applicable Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Orders, MAR/

TAR, Bowel & Bladder UDAs, Care Plan, Progress Notes,

Wts/Vitals, POC—ADLs


progress/consultant notes, Lab/Diagnostic reports; Orders,

therapy records

Inflammatory Bowel Disease MDS Item I1300 1

Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Bowel & Bladder

UDAs, Pain UDAs, Orders, MAR, Wts/Vitals, Progress Notes,



progress/consultant notes, lab/diagnostic reports, therapy

records, Orders

Aseptic Necrosis of Bone MDS Item I8000 1


Scale UDA, Orders, MAR/TAR, Wts/Vitals, Diagnostic Reports, Therapy Notes, Care Plan, Progress Notes,

POC - ADLs


progress/consultant notes, lab/diagnostic reports; Orders


Suctioning Post-admit Code

MDS Item O0100D2

1

Nursing Admission Data Collection UDA, Daily Skilled Charting UDA,

Orders, MAR/TAR, Wts/Vitals, Pro-gress Notes, Therapy Notes, Care

Plan

Hospital Transfer orders,History & Physical, Discharge Summary,

progress/consultant notes, lab/diagnostic reports; Orders

Cardio-Respiratory Failure and

Shock MDS Item I8000 1


Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders, MAR, Pro-gress Notes, Care Plan, POC - ADLs


progress/consultant notes, lab/diagnostic reports, Therapy

records; Orders


10



awarded in PDPM


Myelodysplastic Syndromes and Myelofibrosis

MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily

Skilled Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders,

MAR, Therapy Notes, Progress Notes, Care Plan, POC - ADLs


progress/consultant notes, lab/diagnostic reports; Orders,

therapy

Systemic Lupus Erthematosus, Other Connective Tissue

Disorders, and Inflammatory Spondylopathies

MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily

Skilled Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders,

MAR, Therapy Notes, Progress Notes, Care Plan, POC - ADLs


progress/consultant notes, lab/diagnostic reports; Orders;

therapy

Diabetic Retinopathy - Except Proliferative Diabetic

Retinopathy and Vitreous Hemorrhage

MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily Skilled Charting UDA, Nutrition

UDAs, Braden Scale UDA, Orders, MAR/TAR, Care Plan, POC -ADLs,

Progress Notes, Diagnositc Reports


progress/consultant notes, lab/diagnostic reports; Orders;

therapy

Nutritional Approaches While a Resident: Feeding Tube

MDS Item K0510B2

1

Applicable Medical Diagnosis, Nurs-ing Admission Data Collection UDA, Daily Skilled Charting UDA, Orders, MAR/TAR, Nutrition UDAs, Weight/Vitals, Progress Notes, Care Plan


Orders; physician progress notes; Lab/Diagnostic reports


11



awarded in PDPM


Severe Skin Burn or Condition MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily Skilled Charting UDA, Non-Pressure Weekly Wound UDAs, Pain UDAs, Nutrition UDAs, Braden Scale UDA, Orders, Wts/Vitals, Progress Notes, Care Plan, POC-ADLs


Orders, progress notes; Lab/Diagnostic reports; Skin/Burn

consultant notes, therapy

Intractable Epilepsy MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA, Orders, Wts/Vitals, Progress Notes, Care Plan, POC - ADLs


progress/consultant notes, Lab/Diagnostic reports; Orders

Active Diagnoses: Malnutri-tion Code

MDS Item I5600 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily Skilled Charting UDA, Nutrition UDAs, Braden Scale UDA, Orders, MAR/TAR, Weights/Vitals, Labora-tory Reports, Progress Notes, Care Plan, POC-ADLs


progress/consultant notes, Lab/Diagnostic reports

Disorders of Immunity - Except: RxCC97: Immune

Disorders MDS Item I8000 1

Medical Diagnosis, Nursing Admis-sion Data Collection UDA, Daily Skilled Charting UDA, Pain UDA, Nutrition UDAs, Braden Scale UDA, Orders, MAR, Laboratory/ Diagnos-tic Reports, Wts/Vitals, Progress Notes, Care Plan

Hospital Transfer orders, History& Physical, Discharge Summary,

progress/consultant notes, Lab/Diagnostic reports, Orders


12



awarded in PDPM

PCC Documentation Loca-tion

Hospital Record Location

Cirrhosis of Liver MDS Item I8000 1

Medical Diagnosis, Nursing Ad-mission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Nutrition UDAs, Labora-tory/Diagnostic Reports, Wts/Vitals, Orders, MAR, Progress Notes, Care Plan



notes; Orders

Bladder and Bowel Appliances: Ostomy

MDS Item H0100C

1

Applicable Medical Diagnosis, Nursing Admission Data Collec-tion UDA, Daily Skilled Charting UDA, Bowel and Bladder UDAs, Orders, TAR, Wts/Vitals, Progress Notes, Care Plan, POC-ADLs and tasks


progress/consultant notes; Orders, lab/diagnostic reports

Respiratory Arrest MDS Item I8000 1

Medical Diagnosis, Nursing Ad-mission Data Collection UDA, Daily Skilled Charting UDA, Or-ders, MAR/TAR, Wts/Vitals, Pro-gress Notes, Care Plan, POC - ADLs


progress/consultant notes, lab/diagnostic reports, therapy

notes; Orders

Pulmonary Fibrosis and Other Chronic Lung Disorders

MDS Item I8000 1

Medical Diagnosis, Nurse Admission Data Collection UDA, Daily Skilled Charting UDA, Or-ders, MAR/TAR, Therapy, Wts/Vitals, Progress Notes, Care Plan, POC- ADLs


progress/consultant notes, lab/diagnostic reports, Orders,

therapy


non-therapy ancillary services conditions/extensive services · 2019-04-12 · non-therapy...

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