United States

Senior Living Health Care Connection: New PDPM case mix (part 3)

Nontherapy ancillaries

SENIOR LIVING HEALTH CARE CONNECTION

This is the third of four articles dealing with the patient-driven payment model (PDPM). Under PDPM each patient is classified into a group for each of the five case-mix adjusted components. The payment for each of the case-mix adjusted components is calculated by multiplying the case-mix indicator by the base rate in each group and then taking into consideration the variable per diem schedule when applicable.

Our first article reviewed the physical therapy, occupational therapy and speech language pathology components. The second article reviewed the nursing components. This article reviews the nontherapy ancillaries (NTA) component. The NTA component is determined based on the presence of certain conditions and comorbidities. There are 50 conditions and extensive services that contribute to the NTA payment calculations. Some comorbidities are associated with higher costs and are assigned into higher point tiers while those associated with lower costs are grouped into lower point tiers. Here is a listing of those comorbidities with their assigned points:

Conditions/extensive services

Points

HIV/AIDS

8

Parenteral IV feeding: Level high

7

Special treatments/programs: IV medications post-admit code

5

Special treatments/programs : Vent or respirator post-admit code

4

Parenteral IV feeding: Level low

3

Lung transplant status

3

Special treatments/programs: Transfusion post-admit code

2

Major organ transplant status, except lung

2

Active diagnoses: Multiple sclerosis (MS) code

2

Opportunistic infections

2

Active diagnoses: Asthma, chronic obstructive pulmonary disease (COPD), chronic lung disease code

2

Bone/joint/muscle infections or necrosis—Except aseptic necrosis of bone

2

Chronic myeloid leukemia

2

Wound infection code

2

Active diagnoses: Diabetes mellitus (DM) code

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

Special treatments/programs: Tracheostomy care post-admit code

1

Active diagnoses: Multidrug resistant organism (MDRO) code

1

Special treatments/programs: Isolation post-admit code

1

Specified hereditary metabolic/immune disorders

1

Morbid obesity

1

Special treatments/programs: Radiation post-admit code

1

Highest stage of unhealed pressure ulcer—stage 4

1

Psoriatic arthropathy and systemic sclerosis

1

Chronic pancreatitis

1

Proliferative diabetic retinopathy and vitreous hemorrhage

1

Other foot and 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

Special treatments/programs: Suctioning post-admit code

1

Cardio-respiratory failure and shock

1

Myelodysplastic syndromes and myelofibrosis

1

Systemic lupus erythematosus, other connective tissue disorders and inflammatory spondylopathies

1

Diabetic retinopathy—except proliferative diabetic retinopathy and vitreous hemorrhage

1

Nutritional approaches while a resident: Feeding tube

1

Severe skin burn or condition

1

Intractable epilepsy

1

Active diagnoses: Malnutrition code

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

 

This listing shows the actual condition. They are captured on the MDS in order to receive credit for these services. For the full list and placement on the MDS please refer to the PDPM page and view the Fact Sheets, NTA Comorbidity Score.

NTA case-mix index

The comorbidity scores reflect a weighted count of NTA costs. Higher points are awarded for higher cost services. Higher points earn a higher case mix index and therefore higher rate calculation.

NTA score range

NTA case-mix group

NTA CMI

12+

NA

3.25

9-11

NB

2.53

6-8

NC

1.85

3-5

ND

1.34

1-2

NE

0.96

0

NF

0.72

 

The variable adjustment for NTA is sizeable and should be noted.
The variable per-diem adjustment factor for the NTA component is as follows:

Medicare payment days

Adjustment factor

1-3

3.0

4–100

1.0

 

Once classified into the appropriate NTA group, the per diem rate for those groups is then multiplied by the adjustment factor. Payment decreases after the first three days and then continues to be paid at the lower rate.

Our next article will cover best practices to ensure success with the new PDPM payment methodology.

Please contact Joan McCarthy at joan.mccarthy@rsmus.com for more information.

How can we help you?

To discuss how our team can help your business, contact us by phone 800.274.3978 or



Events / Webcasts

LIVE WEBCAST

Senior Living PDPM webcast

  • June 19, 2019

RECORDED WEBCAST

Health care industry spring 2019 webcast series

  • May 15, 2019

IN-PERSON EVENT

Healthcare and Life Sciences Private Equity and Finance Conference

  • February 20, 2019