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PDPM, Non-Therapy Ancillaries & MDS Section I

PDPM, Non-Therapy Ancillaries & MDS Section I

PDPM includes a new pay category, the non-therapy ancillary or NTA. Everyone I’ve talked to agrees the NTA payment is a good idea. But, since it’s new, we’re going to have to work on understanding how it’s supposed to work, and how we can most easily and efficiently complete the assessment with accurate information.

Section I has a lot of items that can effect NTA pay.

In this post, we going to look at one important piece of the NTA puzzle, section I.

Actually, we’re going to limit our scope to only I8000 items. Section I of MDS 3.0 is reserved for Active Diagnoses and Item I8000 is you to enter up to 10 additional active diagnoses with corresponding ICD-10 codes.

How should you prioritize your search for ICD-10 codes? Which codes are the most important? Which codes are you most likely to actually see in the wild?

MDS 3.0 Section I - That’s a lot of white space.

A good first resource is the PDPM NTA Comorbidity Mapping spreadsheet. In it, you’ll find the 1,612 codes that map to the different comorbidities. Admittedly, that’s a lot to look through. Luckily, code diving is a lot of fun, right?

What if we could limit those codes down to just those ICD-10 codes that are likely to occur. They can’t all be equally likely, right? (At this point, I can feel the cold stares from our MDS Experts. Yes, I am aware that ICD-10 codes do change occasionally. Yes, I’m aware that if you don’t look at every. last. code. you could miss something. Yes, I get that is bad. You should understand those things too, reader.)

Hopefully I don’t lose my blogging privileges, but… I looked at a year’s worth of Part A admissions to every SNF in the country and found, gasp, not all codes occur that often. Some didn’t occur at all.

Based on that, I have made you an extreme cheat sheet, that you should use with extreme caution. Click the comorbidity and see the ICD-10 codes that are most likely to occur. (I did abbreviate a few of the names for sanity.) Remember, the CMS list is authoritative, mine is only for your convenience.

Lung Transplant

Z942Lung transplant status0.01%


M869Osteomyelitis, unspecified0.60%
M4620Osteomyelitis of vertebra, site unspecified0.15%
M86179Other acute osteomyelitis, unspecified ankle and foot0.14%
M8618Other acute osteomyelitis, other site0.11%
M00069Staphylococcal arthritis, unspecified knee0.08%
M8610Other acute osteomyelitis, unspecified site0.08%
M726Necrotizing fasciitis0.04%
M0010Pneumococcal arthritis, unspecified joint0.04%
M86679Other chronic osteomyelitis, unspecified ankle and foot0.04%
M86169Other acute osteomyelitis, unspecified tibia and fibula0.04%
M8660Other chronic osteomyelitis, unspecified site0.03%
M8668Other chronic osteomyelitis, other site0.02%
M01X0Direct infection of unspecified joint in infectious and parasitic diseases classified elsewhere0.02%
M00059Staphylococcal arthritis, unspecified hip0.02%
M01X69Direct infection of unspecified knee in infectious and parasitic diseases classified elsewhere0.02%
M00019Staphylococcal arthritis, unspecified shoulder0.02%
M0008Staphylococcal arthritis, vertebrae0.01%
M86669Other chronic osteomyelitis, unspecified tibia and fibula0.01%
M86159Other acute osteomyelitis, unspecified femur0.01%
M01X8Direct infection of vertebrae in infectious and parasitic diseases classified elsewhere0.01%
M86659Other chronic osteomyelitis, unspecified thigh0.01%
M01X9Direct infection of multiple joints in infectious and parasitic diseases classified elsewhere0.01%
M8619Other acute osteomyelitis, multiple sites0.01%
M00079Staphylococcal arthritis, unspecified ankle and foot0.01%

Chronic Myloid Leukemia

C9210Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission0.03%

Opportunistic Infections

B3781Candidal esophagitis0.04%
B488Other specified mycoses0.04%
B449Aspergillosis, unspecified0.01%
B371Pulmonary candidiasis0.01%

Proliferative Diabetic Retinopathy

E11359Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema0.01%

Severe Skin Burns or Condition

L511Stevens-Johnson syndrome0.01%

Complications of Specified Implanted Device or Graft

T8450XAInfection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter0.15%
T8481XAEmbolism due to internal orthopedic prosthetic devices, implants and grafts, initial encounter0.05%
T82818AEmbolism due to vascular prosthetic devices, implants and grafts, initial encounter0.04%
T84099AOther mechanical complication of unspecified internal joint prosthesis, initial encounter0.04%
T84029ADislocation of unspecified internal joint prosthesis, initial encounter0.03%
T8579XAInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter0.03%
T8460XAInfection and inflammatory reaction due to internal fixation device of unspecified site, initial encounter0.02%
T827XXAInfection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter0.02%
T82390AOther mechanical complication of aortic (bifurcation) graft (replacement), initial encounter0.02%
T84498AOther mechanical complication of other internal orthopedic devices, implants and grafts, initial encounter0.02%
T84119ABreakdown (mechanical) of internal fixation device of unspecified bone of limb, initial encounter0.02%
T826XXAInfection and inflammatory reaction due to cardiac valve prosthesis, initial encounter0.02%
T84039AMechanical loosening of unspecified internal prosthetic joint, initial encounter0.02%
T84019ABroken internal joint prosthesis, unspecified site, initial encounter0.01%
T8381XAEmbolism due to genitourinary prosthetic devices, implants and grafts, initial encounter0.01%

End-Stage Liver Disease

K7210Chronic hepatic failure without coma0.07%
K766Portal hypertension0.05%
I8500Esophageal varices without bleeding0.04%
I8501Esophageal varices with bleeding0.02%
I8510Secondary esophageal varices without bleeding0.01%
K767Hepatorenal syndrome0.01%
I8511Secondary esophageal varices with bleeding0.01%

Cirrhosis of Liver

K7030Alcoholic cirrhosis of liver without ascites0.28%
K709Alcoholic liver disease, unspecified0.03%
K743Primary biliary cirrhosis0.03%

Disorders of Immunity - Except Immune Disorders?

D61818Other pancytopenia0.21%
D709Neutropenia, unspecified0.07%
D61810Antineoplastic chemotherapy induced pancytopenia0.03%
D701Agranulocytosis secondary to cancer chemotherapy0.01%
D708Other neutropenia0.01%
D61811Other drug-induced pancytopenia0.01%

Respiratory Arrest

R092Respiratory arrest0.02%

Cardio-Respiratory Failure and Shock

J9600Acute respiratory failure, unspecified whether with hypoxia or hypercapnia2.55%
J9620Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia0.86%
J9610Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia0.76%
J80Acute respiratory distress syndrome0.14%
J810Acute pulmonary edema0.13%
I469Cardiac arrest, cause unspecified0.11%
I4901Ventricular fibrillation0.06%
J95821Acute postprocedural respiratory failure0.05%
R570Cardiogenic shock0.03%
R579Shock, unspecified0.02%
J95822Acute and chronic postprocedural respiratory failure0.02%
J951Acute pulmonary insufficiency following thoracic surgery0.01%


I38Endocarditis, valve unspecified0.19%
I330Acute and subacute infective endocarditis0.06%
I339Acute and subacute endocarditis, unspecified0.02%
I39Endocarditis and heart valve disorders in diseases classified elsewhere0.01%

Intractable Epilepsy

G40111Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus0.04%
G40911Epilepsy, unspecified, intractable, with status epilepticus0.03%
G40211Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus0.01%
G40311Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus0.01%

Pulmonary Fibrosis and Other Chronic Lung Disorders

J8410Pulmonary fibrosis, unspecified0.35%
J84112Idiopathic pulmonary fibrosis0.10%
J479Bronchiectasis, uncomplicated0.08%
J471Bronchiectasis with (acute) exacerbation0.04%
J84115Respiratory bronchiolitis interstitial lung disease0.02%
J99Respiratory disorders in diseases classified elsewhere0.01%
J8409Other alveolar and parieto-alveolar conditions0.01%
J84111Idiopathic interstitial pneumonia, not otherwise specified0.01%
J84114Acute interstitial pneumonitis0.01%

Diabetic Retinopathy - Except Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

E11311Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema0.16%
E11319Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema0.13%
E10311Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema0.01%
E11329Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema0.01%
E08311Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema0.01%

Narcolepsy and Cataplexy

G47419Narcolepsy without cataplexy0.03%

Specified Hereditary Metabolic/Immune Disorders

E8801Alpha-1-antitrypsin deficiency0.01%

Morbid Obesity

E6601Morbid (severe) obesity due to excess calories1.39%
Z6841Body mass index (BMI) 40.0-44.9, adult0.10%
E662Morbid (severe) obesity with alveolar hypoventilation0.08%
Z6842Body mass index (BMI) 45.0-49.9, adult0.06%
Z6843Body mass index (BMI) 50-59.9 , adult0.04%
Z6844Body mass index (BMI) 60.0-69.9, adult0.01%
Z6845Body mass index (BMI) 70 or greater, adult0.01%

Chronic Pancreatitis

K861Other chronic pancreatitis0.17%

Inflammatory Bowel Disease

K5190Ulcerative colitis, unspecified, without complications0.21%
K5090Crohn's disease, unspecified, without complications0.17%
K5180Other ulcerative colitis without complications0.06%
K5100Ulcerative (chronic) pancolitis without complications0.01%
K5120Ulcerative (chronic) proctitis without complications0.01%
K5000Crohn's disease of small intestine without complications0.01%
K5010Crohn's disease of large intestine without complications0.01%

Aseptic Necrosis of Bone

M87059Idiopathic aseptic necrosis of unspecified femur0.05%
M8700Idiopathic aseptic necrosis of unspecified bone0.04%
M8708Idiopathic aseptic necrosis of bone, other site0.01%

Psoriatic Arthropathy and Systemic Sclerosis

L4054Psoriatic juvenile arthropathy0.04%
M340Progressive systemic sclerosis0.03%

Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies

M3210Systemic lupus erythematosus, organ or system involvement unspecified0.18%
M3500Sicca syndrome, unspecified0.07%
M316Other giant cell arteritis0.06%
M459Ankylosing spondylitis of unspecified sites in spine0.03%
M3130Wegener's granulomatosis without renal involvement0.02%
M3320Polymyositis, organ involvement unspecified0.02%
M461Sacroiliitis, not elsewhere classified0.01%
M3390Dermatopolymyositis, unspecified, organ involvement unspecified0.01%
M359Systemic involvement of connective tissue, unspecified0.01%
M4690Unspecified inflammatory spondylopathy, site unspecified0.01%
M310Hypersensitivity angiitis0.01%

Myelodysplastic Syndromes and Myelofibrosis

D469Myelodysplastic syndrome, unspecified0.20%
D460Refractory anemia without ring sideroblasts, so stated0.01%

Immune Disorders

D849Immunodeficiency, unspecified0.01%
D801Nonfamilial hypogammaglobulinemia0.01%
D8989Other specified disorders involving the immune mechanism, not elsewhere classified0.01%
D899Disorder involving the immune mechanism, unspecified0.01%

PDPM Non-Therapy Ancillary Pay

PDPM Non-Therapy Ancillary Pay

PDPM and Non-Therapy Ancillaries

The non-therapy ancillary (NTA) part of the patient driven payment model (PDPM) is considered by most people I've talked to as being better than what we're currently doing. It more accurately accounts for expenses and isn't overshadowed by therapy. 

In this post I'm going to take a deeper look at it and calculate the average NTA payment by state and facility. I'll also compare urban versus rural facilities when it comes to NTA case-mix.

(By the way, we created a PDPM Calculator for you to experiment with and get a better understanding of how PDPM works. Try it out!)

Let's get started!

Your NTA payment is driven by the presence of a number of conditions and/or extensive services. Points are scored if the condition or service is present. See the table below. 

Condition/Extensive Service MDS Items Points
N/A (SNF claim) 8
K0510A2,K0710A2 7
O0100H2 5
O0100F2 4
K0510A2,K0710A2,K0710B2 3
I8000 3
O0100I2 2
I8000 2
I5200 2
I8000 2
I6200 2
I8000 2
I8000 2
I2500 2
I2900 2
I8000 1
I8000 1
I8000 1
M1040B 1
I8000 1
I8000 1
O0100E2 1
I1700 1
O0100M2 1
I8000 1
I8000 1
O0100B2 1
M0300X1 1
I8000 1
I8000 1
I8000 1
M1040A,M1040B,M1040C 1
I8000 1
H0100D 1
I8000 1
I8000 1
O0100D2 1
I8000 1
I8000 1
I8000 1
I8000 1
K0510B2 1
I8000 1
I8000 1
I5600 1
I8000 1
I8000 1
H0100C 1
I8000 1
I8000 1

A few things you might have noticed:

  • There are a lot of items from section I8000. Far more items than would actually fit on the MDS 3.0 Instrument. (10 items fit). This isn't exactly a new problem, but it didn't drive reimbursement before.
  • How often will the items on this list be available to you when you are doing the 5 day assessment? Any delay in getting this information is going to be problematic. This problem isn't new either but now it will drive reimbursement. It's interesting to note that the data CMS provided, that I am using here, came from some assessments that we no longer will be doing. I would really like to see how item I8000 changes on a resident from the 5 day to later assessments. If you are adding additional I8000 items in later assessments, you will no longer get the opportunity to do that without a sig-change.
NTA Score Range NTA Case-Mix Group Case-Mix Index
12+ NA 3.2499
9-11 NB 2.5348
6-8 NC 1.8515
3-5 ND 1.3394
1-2 NE 0.9649
0 NF 0.7203

Once we have totaled the score from the table above, we use it to map to a case-mix group and case-mix index. (Right) 

Next you multiply the case-mix index by the rate, either rural ($74.56) or urban ($78.05).


Given that CMS has released the distribution of case-mix groups for NTA for all skilled nursing facilities, we can calculate an average case-mix index for everyone. Based on that, we can calculate the rate. I've done that for urban and rural for every state. 

Urban - click to enlarge

Rural - click to enlarge

Note that for the first 3 days of the stay you get 3 times the rate shown on the map. On day 4 it goes back to the rate shown.

These maps look significantly different from a lot of the others we've seen. The southwest of the US, Michigan, Ohio and West Virginia would have the highest NTA rates. Remember this is using 2017 data so it assumes that providers make no adjustments which is not realistic. This simply shows you a starting point. If your facility has a low NTA rate, it may just mean you have work to do, documentation-wise.

Speaking of individual facilities, let's take a look at that as well. The map below shows every SNF in the US that accepted Medicare Part A patients in 2017. The visualization is interactive. You can view either rural, urban or both. You can filter by NTA rate. (Note that this map is showing ONLY the NTA rate. There are a total of five rates that make up your pay under PDPM.) You can also zoom in to see detail. Hover over a facility to see the name, NTA Rate, NTA case-mix index and whether the facility is urban or rural. (This isn't going to work well on mobile devices, FYI.)

Use the rate filter to show only the highest or lowest NTA rates. Notice there is a big pocket of low NTA rates that covers most of Iowa. Also notice there are very few facilities with low NTA rates in the Appalachians.

Lastly, let's look a little more closely at rural versus urban. 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. AVONA confirms that rural facilities do indeed have lower NTA case-mix. (Click either image to enlarge.)

It is not clear why this would be the case. If you have an idea let's discuss!

ANOVA - Rural versus Urban NTA case-mix (click to enlarge)

If you have additional questions about this information or would like a custom analysis for your business, please call or text me: 704-918-5241.