non-therapy ancillary services conditions/extensive services · 2019-04-12 · non-therapy...
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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
For informational purposes only. Not intended for clinical/financial advice.
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
Hospital Transfer, Hospital H&P, Hospital Discharge Summary,
Progress Notes, Consultant Progress Notes, Hospital Ventilator or
Respirator records, Lab/Diagnostic reports
For informational purposes only. Not intended for clinical/financial advice.
2
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
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
Hospital Transfer, Hospital H&P, Hospital Discharge Summary,
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
Hospital Transfer, Hospital H&P, Hospital Discharge Summary,
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 Transfer, Hospital H&P, Hospital Discharge Summary,
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
For informational purposes only. Not intended for clinical/financial advice.
3
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
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 Week-ly 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
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
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, 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 Transfer Orders, Hospital History & Physical, Hospital
Discharge Summary, Hospital progress notes, Consultant Notes,
Hospital MAR/TAR, Orders, Lab/Diagnostic reports,
physician/provider progress notes
Active Diagnoses: Asthma, COPD, Chronic Lung Disease
Code MDS Item I6200 2
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
Charting UDA, Nutrition UDAs, Pain UDAs, Orders, MAR, Wts/Vitals, Care
Plan, Progress Notes, POC - ADLs
Hospital Transfer Orders, Hospital History & Physical, Hospital
Discharge Summary, Hospital progress/consultant notes, Hospital MAR/TAR, Lab/Diagnostic reports,
Hospital therapy notes, Orders, physician/provider progress notes
For informational purposes only. Not intended for clinical/financial advice.
4
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
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 Transfer Orders, Hospital History & Physical, Hospital
Discharge Summary, Hospital progress/consultant notes, Hospital MAR/TAR, Lab/Diagnostic reports,
Hospital therapy notes as applicable, Orders, physician/provider progress
notes
Chronic Myeloid Leukemia MDS Item I8000 2
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
Charting UDA, Braden Scale UDA, Pain UDAs, Nutrition UDAs, Orders, Pro-gress Notes, Care Plan, Wts/Vitals
Hospital Transfer Orders, Hospital History & Physical, Hospital
Discharge Summary, Hospital progress/consultant notes, Hospital MAR/TAR, Lab/Diagnostic reports,
Hospital therapy notes as applicable, Orders, physician/provider progress
notes, therapy records
Wound Infection Code MDS Item I2500 2
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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
Hospital Transfer Orders, Hospital History & Physical, Hospital
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
For informational purposes only. Not intended for clinical/financial advice.
5
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
Endocarditis MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, Lab/Diagnostic reports, therapy
notes; Orders
For informational purposes only. Not intended for clinical/financial advice.
6
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
Narcolepsy and Cataplexy MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Progress Notes,
Care Plan, POC - ADLs
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes; lab/diagnostic reports; Orders;
Therapy
Special Treatments/Programs: Tracheostomy Care
Post-admit Code
MDS Item O0100E2
1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Braden
Scale UDA, Orders, MAR/TAR, Wts/Vitals, Care Plan, Progress Notes,
ADLs-POC, Therapy Notes
Hospital Transfer Orders, History & Physical, Discharge Summary,
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
progress/consultant notes; lab/diagnostic reports; Orders
For informational purposes only. Not intended for clinical/financial advice.
7
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
Special Treatments/Programs:
Isolation Post-admit Code
MDS Item O0100M2
1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA,
Progress Notes, Wts/Vitals, Care Plan, Orders, POC - ADLs and
tasks/interventions
Hospital Transfer Orders, History & Physical, Discharge Summary,
lab/diagnostic reports, progress/consultant notes; Orders
Specified Hereditary Metabolic/ Immune Disorders
MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Braden Scale UDA,
Pain UDAs, Nutrition UDAs, Orders, MAR, Progress Notes, Care Plan, Wts/
Vitals
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
lab/diagnostic reports, progress/consultant notes; Orders;
therapy records
Special Treatments/Programs:
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
progress/consultant notes; lab/diagnostic reports, therapy notes; Orders; Therapy records
For informational purposes only. Not intended for clinical/financial advice.
8
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
Psoriatic Arthropathy and Systemic Sclerosis
MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders, MAR, Lab/Diagnostic Reports, Therapy Notes, Progress Notes, Care Plan, POC -
ADLs
Hospital Transfer Orders, History & Physical, Discharge Summary,
progress/consultant notes; lab/diagnostic reports, therapy
notes; Orders
Chronic Pancreatitis MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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; 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
Hospital Transfer Orders, History & Physical, Discharge Summary,
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
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
progress/consultant notes, Orders, Lab/Diagnostic reports; therapy
records
For informational purposes only. Not intended for clinical/financial advice.
9
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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,
Care Plan, POC - ADLs
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, lab/diagnostic reports, therapy
records, Orders
Aseptic Necrosis of Bone MDS Item I8000 1
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled Charting UDA, Pain UDAs, Braden
Scale UDA, Orders, MAR/TAR, Wts/Vitals, Diagnostic Reports, Therapy Notes, Care Plan, Progress Notes,
POC - ADLs
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, lab/diagnostic reports; Orders
Special Treatments/Programs:
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
Medical Diagnosis, Nursing Admission Data Collection UDA, Daily Skilled
Charting UDA, Pain UDAs, Nutrition UDAs, Wts/Vitals, Orders, MAR, Pro-gress Notes, Care Plan, POC - ADLs
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, lab/diagnostic reports, Therapy
records; Orders
For informational purposes only. Not intended for clinical/financial advice.
10
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
Orders; physician progress notes; Lab/Diagnostic reports
For informational purposes only. Not intended for clinical/financial advice.
11
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
awarded in PDPM
PCC Documentation Location Hospital Record Location
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
For informational purposes only. Not intended for clinical/financial advice.
12
PDPM: NTA (Non Therapy Ancillary) Supporting Documentation
Conditions/Extensive Service Source Points
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
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, Lab/Diagnostic reports, therapy
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
Hospital Transfer orders, History & Physical, Discharge Summary,
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
Hospital Transfer Orders, History & Physical, Discharge Summary,
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
Hospital Transfer orders, History & Physical, Discharge Summary,
progress/consultant notes, lab/diagnostic reports, Orders,
therapy
For informational purposes only. Not intended for clinical/financial advice.
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