The last part of the 3-Part PDPM Blog Series on the “Transition to PDPM,” will discuss cost of errors related to the Nursing and Non-Therapy Ancillary (NTA) for the new Patient Driven Payment Model (PDPM). Part 1 focused on the primary diagnosis and Section GG coding, which primarily effects Physical Therapy (PT) and Occupational Therapy (OT) PDPM Health Insurance Prospective Payment System (HIPPS) coding and the functional portion of the nursing component. Part 2 reviewed the errors related to the Speech Language Pathology (SLP) component. At LW Consulting, Inc. (LWCI), we have been busy assisting clients with PDPM audits to identify whether the PDPM Health Insurance Prospective Payment System (HIPPS) code billed on the Minimum Data Set (MDS) and the UB-04 is supported by the documentation. In part 3 of the PDPM Blog Series, we will discuss highlights of errors we have been seeing related to the Nursing and NTA component.
Let’s begin with a brief overview of the clinical metrics for Nursing and NTA that relate to the PDPM components.
As stated in Part 1 and 2 of this blog series, when reviewing documentation to support PDPM coding the 5-digit HIPPS code, that is on the UB-04, must be deciphered. For more information on the outline of what each of the characters in the HIPPS code refer to, read "[Blog Series] Transition to PDPM Part 1: Cost of Errors Related to Diagnosis Coiding and Section GG."
The third character relates to the nursing component. PDPM utilizes the same basic nursing classification structure as Resource Utilization Group (RUG)-IV but with the following modifications: the function score based on Section GG of the MDS 3.0 is included and there are collapsed functional groups and reducing the number of nursing groups from 43 to 25. The alphabet, from “A” through “Y,” is then used to identify payment group codes for nursing. The HIPPS character of one of the letters of the alphabet relates to one of the nursing payment groups defined for PDPM. The HIPPS coding list is found on page 80 of the Centers for Medicare and Medicaid Services (CMS) PDPM Presentation and can be used as a reference.
Under RUGs IV Prospective Payment System (PPS) review of nursing components, there are several major identifiers that categorize a specific nursing payment group. These identifiers include: Extensive Services (tracheostomy and ventilator and/or infection requiring isolation), Clinical Conditions (including comatose, septicemia, use of respiratory therapy), the Presence of Depression, the Use of Restorative Nursing Services and the Section GG Function Score.
The same Section GG function item set that is used for the PT and OT functional scoring is included in the nursing component. The one difference is that only 7 of the 10 functional tasks are counted into the nursing payment groups. The total score possible for nursing function is 14 points. The tasks are listed in the table below.
|Section GG Item||Functional Score Range|
|GG0130A1 - Self-care: Eating||0 - 4|
|GG0130C1 - Self-care: Toileting Hygiene||0 - 4|
|GG0170B1 - Mobility: Sit to Lying||
0 - 4 (average of 2 items)
|GG0170C1 - Mobility: Lying to Sitting on side of bed|
|GG0170D1 - Sit to Stand||0 - 4 (average of 3 items)|
|GG0170E1 - Mobility: Chair/bed-to-chair transfer|
|GG010F1 - Mobility: Toilet Transfer|
In order for nursing identifiers to count for the payment group, they must be coded in the MDS and there must be supporting documentation, just as been the requirement to capture a nursing component under RUGs IV PPS. This is the one area that has changed the least from the RUGs transition to PDPM. Refer to the link to the CMS Calculation Worksheets for Nursing pages 23-35 for specific information on specifics for nursing categories
All of the coded nursing identifiers entered into the various MDS boxes calculate a nursing Case Mix Group (CMG) that relates to a nursing Case Mix Index (CMI). The CMI is what is used to calculate the nursing payment. The specific payments can be found in LWCI’s PDPM Rate Chart that is available for purchase on the LWCI Learning Center.
The fourth character in the HIPPS code for PDPM is the NTA code. The character always begins with “N,” which probably stands for the “N” in “Non-therapy ancillary.” The payment groups in this category are labeled from NA through NF. CMS has outlined a list of 50 comorbidities and extensive services for NTA classification. These are derived from a variety of MDS sources, with some comorbidities identified by ICD-10-CM codes reported in Item I8000. All of the items on the list must be coded on the MDS and have qualifying documentation in the medical record to support the MDS and contribute to the NTA CMI.
One comorbidity, Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), is reported on the skilled nursing facility (SNF) claim—not the MDS—in the same manner as under RUG-IV. The 50 comorbidities and extensive services each have points associated with them. The list can be found on pages 35-38 in the CMS PDPM Presentation.
The total points correlate with the PDPM CMG, CMI and rate. Classifications for NTA points range from 0 points to 12 points. Here is the example for the NTA Component from LWCI’s PDPM Rate Chart that is available for purchase on the LWCI Learning Center.
|NTA NON-Therapy Ancillary (6 Groups)||NTA Score Range||NTA Case-Mix||NTA CMI||NTA Rural Rate||NTA Urban Rate|
Summary of findings related to recent audits for Nursing and NTA Coding:
- To verify NTA coding on the CMS list, view the “PDPM ICD-10 Mappings” under PDPM Resources.
- LWCI auditors found that additional documentation to support NTA codes may be embedded in hospital discharge information. Review hospital discharge information to determine what the best date is to use as the Assessment Reference Date (ARD) to capture the hospital information in the 7-day look back period. This requires the Interdisciplinary Team (IDT) to discuss and plan the ARD for assessments.
- There was no Section GG data submitted within the first 3 days of the assessment period as per the Resident Assessment Instrument (RAI) manual requirements. Therefore, the MDS data that was used to calculate the billed HIPPS code could not be verified. Either there was additional documentation that was not provided, or the facility miscoded the MDS with information out of the assessment date range for the Section GG coding.
- If diagnosis codes are checked in the MDS Section I, but not specifically entered under Section I8000, they will not support NTA coding. Always verify codes in the PDPM ICD-10 Mappings list to make sure that they are not eligible for NTA reimbursement.
- Often the records uploaded for review are not complete. If a Recovery Audit Contractor (RAC) or Zone Program Integrity Contractor (ZPIC) requests documentation to be submitted, all documentation should be submitted to support the coding of the MDS. LWCI audits attempt to mirror a CMS audit and facilities need to have a system in place to efficiently upload all documentation.
Example of Financial Impact from an Audit
HIPPS Code on MDS: MHTE
HIPPS Code Audited: MHME
Nursing RUG was not documented or coded correctly. Reduced Physical Function was on the MDS, Clinically Complex was audited due to documentation of Expressive Aphasia from the hospital discharge and physician documentation of hemiparesis and left side weakness that were not captured on the facility MDS.
Nursing RUG increases $5.06 per day with the audited HIPPS coding.
HIPPS Code on MDS: KAXDE on MDS, grouper calculated KAXF.
HIPPS Code Audited: KAXE
The MDS coded NTA component of “D” which equals 3-5 NTA points. The CMS grouper calculated NTA component of “F” which equals zero NTA points. The audit identified missed coding for the correct ICD-10 code for morbid obesity which would support the NTA component of “E” for the 1 NTA point for that diagnosis.
The difference between zero NTA points and one NTA point increase of $18.67 per day for days 4-99. Days 1-3 the impact is tripled to $56.01.
Missing documentation on Section GG changes the therapy score from 14 to 9 and the nursing score from 10 to 5. This change effects both the PT, OT and Nursing HIPPS characters.
The changes resulted in an underpayment of $19.10 per day.
HIPPS Code on MDS: OIGD
HIPPs Code Audited: OIKD
The nursing component was not captured. The auditor was not able to find documentation to support evidence of shortness of breath with exertion or when lying flat. The Special Care High nursing component of “G” is dropped to Special Care Low or “K.” There needs to be documentation in the medical record to support the coding on the MDS.
The change in nursing RUG decreases from $197.01 to $151.47 for a difference of $43.52 per day which would be considered an overpayment.
PDPM is a reimbursement system that has many opportunities. Detailed documentation to support coding is required to ensure that payment supports care delivery. The coding on the MDS must be supported by the narrative documentation provided by the physician, nurses and therapists. When the MDS is coded and there is no supporting documentation, this scenario could impose an “overpayment” situation. Now is the time to identify root causes of documentation and coding errors before CMS starts to review records.
For more information on our PDPM support packages to assist you with audits, training, systems and coaching, contact Kay Hashagen at 410-777-5999 or email KHashagen@LW-Consult.com.