THE M3 REVIEW - I8000 NTA Point Opportunities

Could one missed I8000 diagnosis change your NTA score?  Are you capturing NTA point opportunities or just assuming you are?

Transcript

SPEAKER_00 0:02

Welcome back to the M3 Review. Today let's talk about one of the areas of the MDS that can be incredibly easy to overlook. But when it is overlooked, the financial impact can be significant. Listeners, we're diving into I-8000 and NTA point opportunities because sometimes the clinical picture is there. The diagnosis is there, the treatment is there, but if that diagnosis never makes it onto the MDS, those NTA points simply don't exist for reimbursement purposes. Here's what I want you to think about throughout this episode. What is sitting in the medical record that we're failing to translate into the MDS? I-8000 is much more than a place to list additional diagnoses just to generate points. It's about recognizing conditions that are clinically present, meet the MDS coding requirements, and are supported in the medical record. But they may never make it onto an assessment. So as we work through these opportunities, I want you to look beyond the diagnosis list. Look at the medications, look at the treatments, look at the physician documentation, look at the hospital record, and then ask yourself: does the resident have a qualifying condition we simply haven't connected to I-8000? Because when the diagnosis exists and qualifies but isn't coded, the NTA opportunity can disappear. Let's start with opportunity number one. Listener, I hope you have the slides for this because they are very important because we have lots of visual lists. We're going to start with the endocrine. This is a great category to start watching closely because these diagnoses can become so familiar that we stop seeing them as reimbursement opportunities. Look at morbid obesity and a BMI of 40 or greater. Those are two separate diagnoses. They're two separate NTA points listed on your software, but you will not stack NTAs for them. You will get only one point, even if you have both there and both validated and supported. We need to make sure that we capture both, not assuming one takes the place of another, but you will only get one point. Then we have conditions like pancreatitis, cirrhosis, end-stage liver disease, and certain immunodeficiencies. We often query about liver issues and liver diseases to get those drilled down to diagnoses for the facilities. They may not be the primary reason for the skilled stay, but that doesn't mean they're irrelevant to PDPM. If the condition is active, documented, and meets the coding requirements, that additional complexity matters. And I really want to draw your attention to risk for malnutrition. This one's different because you don't need an ICD 10 code to receive that NTA point. You do need documentation that supports the resident's nutritional risk that does need to come from a physician. Things like weight transport intake, nutritional interventions, and assessments can tell a story that the resident is at risk. Hospitalization puts them at risk because of change of environment, illness, different medications, things like that. That's my opinion. So we often will query the physician when someone has been hospitalized and ask them if they believe they're at risk. I want to review an important theme throughout NTA coding. If you see multiple qualifying indicators on the record, that doesn't mean you're going to get multiple points. BMI obesity is one of those examples. Another is diabetes. You might have diabetic wounds, diabetes mellitus, diabetic neuropathy. You're only going to get the two points. You won't just stack diabetes points upon diabetes points. If you guys have any questions about endocrine, metabolic or nutritional, let us know. Let's move into cardiac and respiratory conditions. There are tons of these, and I do not list them all. None of these slides, you don't have the entire list for that system. But several of these conditions, cardiac arrest, respiratory arrest, shock, VFib, ARDS, pulmonary edema, they may have occurred during the acute hospitalization. And remember, pulmonary edema is not a chronic restrictive lung disease, but it will get you an NTA point. By the time the resident reaches your building, they may look much more stable and you might overlook these diagnoses. But if you can validate them and support them as active, you may use them. Don't simply carry a hospital diagnosis forward. Ask yourself if it meets the MDS active diagnosis requirements during the look back period and whether your documentation supports coding it. And notice that the points are not all equal. Some are worth one, some are worth two, some are worth three. So when you receive your hospital record, don't just look for the diagnosis that brought the resident to you. Look at the entire clinical story. You should be doing that anyway. That thought goes perfectly with my next one. We're moving into neuro and musculoskeletal. These diagnoses are sometimes hid. This is a very short slide, but it's not insignificant. Take systemic sclerosis or scleroderma. This is a complex autoimmune disease, and the diagnosis may be buried in the resident's medical history. While the current documentation is focusing on the contents of the disease like swallowing, skin involvement, pulmonary complications, pain, mobility limitations. So when you look back into your clinical picture, you see more. There is more to the story. The same principle applies to psoriatic arthropathy. Don't stop at seeing arthritis or even psoriasis. Those terms are not interchangeable. We need the actual diagnosis appropriately documented and supported. But when psoriatic arthropathy is present and recognized, it carries an NTA point. And then there's narcolepsy and cataplexy. You probably aren't going to see this very often, and that's exactly why I put it on here. Rare diagnoses are easy to overlook because they're just not on your mental checklist. This is where I want you to develop a different habit when reviewing I-8000. Don't look for what you expect to find. Look at what is actually there. And then you can always do your research and find out if it's something that you need to pursue and drill down. You want to present the most accurate clinical picture of the resident that's possible. Read the hospital story, review the physician diagnosis notes, look at the specialist documentation, pay attention to meds that make you stop and ask, what is this med? Why are they taking it? Remember, you're just not coding something because it appeared somewhere in the history. It still has to meet all the requirements during the MDS look back period. One overlooked point can be the point that changes the NTA case mix group, as you know. Infections and immune disorders. I'm absolutely not going to read this list to you. I want you to see it because the size of this list is the lesson. When we get into infection and immune conditions, there's a tremendous number of potential NTA opportunities, and some carry considerably more weight than others. And I want you to notice there's a big variety. You have infections, osteomyelitis, fungal conditions, autoimmune diseases, immunodeficiencies, resistant organisms, and some very specific complications. Those are diagnoses that can easily be buried in a hospital record, specialist note, culture history, or past medical history. And look at the points. Some are worth one, two, three, four. HIV is seven, but remember that one is claims-based. You can put that on your MDS in Missouri, but not all states allow that. The bigger lesson here is that when your resident has a complicated infectious or immune history, slow down. Don't rely just on the face sheet. Pay particular attention to the specificity. Arthritis may not tell you what you need to know. The specific condition and sometimes the organism, location, or complication is what makes the difference. So we're not going to memorize this list. I don't know how you could. This is not an exclusive or conclusive list at all. None of these slides are. We're learning to recognize that we need to go looking. And when you see a clinically complex resident with infection or immune involvement, this is one of the places where I want your NTA radar to go up. Our next category brings together cancer, blood disorders, and some very serious skin conditions. Again, don't try to memorize the slide codes. We just want you to be able to recognize diagnoses that deserve a second look. One thing I wanted you to notice is that chronic myeloid leukemia carries two NTA points, while several of the blood disorders here, myelodysplasia, pancytopenia, fanconium anemia, myelofibrosis, they carry one. Those are diagnoses that may be sitting in hematology or oncology documentation rather than jumping out in your HP or your admission summary, discharge summaries. Skin conditions at the bottom are less common here, but potentially very clinically significant. Severe burns. We won't see that very often, but I have seen that in long-term care. Stephen Johnson syndrome, 10, and related conditions that represent residents with substantial clinical complexity. So when you have a resident coming to you from hematology or oncology, or they have a complicated dermatological history, don't let the primary reason for the sniff stay become tunnel vision because these diagnoses in the background will count towards your NTA. Go back through the medical history, ask what other active conditions are contributing to the resident's care. Again, you're not trying to manufacture points. We're looking for the MDS that reflects the complexity of the resident that is already present. Let's talk about ophthalmic NTAs. Diabetic retinopathy is grouped separately than neuropathy, and there are NTA points. Notice on the slide that the diagnosis codes end in a dash-dash. That's because there are many different kinds and they carry one to three points each. Just train yourself that when you see diabetes in a resident, look for neuropathy, kidney disease, retinopathy, look for other complications. CMS does allow certain diabetic NTA comorbidities to have their own codes and points. Then we go into T codes. Complications. There are so many of these, but adverse effects are everywhere in the medical world. So on the slide, I listed four numeric ICD10 codes with several dashes because it is a lot. Infections following a surgical procedure, T81, two points, but there's so many kinds. If you have breakdown, displacement, leakage, mechanical complication of vascular grafts, you have T82 with several different combinations afterwards, one and TA point. Any complication pertaining or due to a graft, prosthesis device that is broken, dislocated, displaced, loosened, periprostatic osteolysis, mechanical complications, breakdown, wear of articular bearings, infection, inflammatory reaction, embolism, hemorrhage, fibrosis, stenosis, pain, or thrombosis, that's all in NTA. Complications pertaining to or due to a urinary, intrauterine, penile, testicular, urinary, sphincter, graph, urethral mesh, prosthesis, device, catheter stent implant, displace, leaked, mechanical complications, breakdown infection, inflammatory reaction, embolism, hemorrhage, fibrosis, stenosis, thrombosis, erosion, or exposure is all complications worth an NTA point. NTA complications and adverse effects are very extensive. So when you have those problems, and those are frequently the reason residents are admitted to a sniff, investigate what exactly the complication is because otherwise you are leaving NTA points behind. What I really want you to take away from this entire M3 review session is I-8000 deserves more than a quick glance at the end of the assessment. These opportunities aren't necessarily going to jump off the page at you. Sometimes they're buried in a specialist note or a hospital diagnosis, a complication, or documentation that requires us to stop and connect the clinical dots. But remember, an opportunity is only an opportunity when it's real. The diagnosis has to meet the coding requirements, it has to be clinically supported, withstand validation. We're not chasing points, we're just making sure that the MDS accurately represents the complexity of the resident that we are caring for. And that's where revenue integrity comes in. Find it, code it, support it, protect it. Because reimbursement should reflect the care and complexity that is truly there. This is Melinda with the M3 Review Podcast. Thanks again for listening, and I'll catch you next time.