nta, section j, & nursing · 2020. 10. 15. · be a common cause of skin infections such as...

NTA, Section J, & Nursing

Presented by:

Verona Bair, RN, RAC-CTClinical Reimbursement Specialist

Gina Tomcsik, LPTA, RAC-CTDirector of Compliance and Regulatory Strategy

Karen Welsh, MA CCC-SLP, RAC-CT Director of Clinical Outcomes

Therapy services and intellectual property provided by Functional Pathways. ©2019 All rights reserved. This information and materials was created by and is proprietary to Functional Pathways of Tennessee, LLC. Any unauthorized use, dissemination, distribution, or copying of this information and material, in whole or in part, is strictly prohibited.

NTA Cue Card

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html


Missed Opportunity Case Scenario: NTA 0• Resident has ostomy;• Ostomy not captured on MDS;• Coded as always incontinent of bowel.

Correct Coding Opportunity Case Scenario:• Ostomy H0100C=1 point;• H0400 9-’not rated’ (resident had an

ostomy)

Missed out on 1 point in the NTA count

MDS Section H


MDS Section I


MDS Section IMissed Opportunity Case Scenario: NTA=2• Resident has COPD and Diabetes Mellitus (DM) actively being treated;• I2900 check marked for Active Diagnosis of DM;• I6200 not checked for COPD but I8000 has ICD-10 code listed.

Correct Coding Opportunity Case Scenario:• COPD I6200 checked= 2 points

Missed out on 2 additional points in the NTA count


MDS Section I, M, OMissed Opportunity Case Scenario: NTA=0• Resident has 2 days IV antibiotic in SNF for foot wound infection;• Wound Infection Code not captured in I2500;• Did not capture foot infection in M1040A/Other Open Lesion on Foot Code M1040B;• IV not captured on MDS in section O0100H2;

Correct Coding Opportunity Case Scenario:• Wound Infection Code I2500= 2 points;• Foot Infection Code M1040A/Other Open Lesion on Foot M1040B= 1 point;• IV in section O0100H2= 5 points.

Missed out on 8 point on the NTA count


Multiple Use Medications

Medications can have multiple FDA approved purposes, depending on dose. For example, 1mg of Propecia, generic name Finasteride, is used to treat hair loss in men but at 5mg, it is used to treat an enlarged prostate (brand name Proscar).

Fluoxetine is an antidepressant that is branded as both Sarafem and Prozac. Prozac has a variety of approved uses: major depressive disorder, obsessive compulsive disorder, bulimia, and panic disorder. Sarafem on the other hand does not have a generic version and is only approved for the treatment of a severe form of PMS, premenstrual dysphoric disorder (PMDD).

Dilantin is an anticonvulsant medication to treat seizures and is also commonly used to treat behaviors in patients with Dementia.

Benadryl is an antihistamine used to treat allergies and is also commonly used to treat insomnia.

Trazodone, also known as Desyrel, is an antidepressant to treat depression and is also commonly used to treat insomnia.

Raloxifene: The FDA approved Raloxifene to reduce the risk of invasive breast cancer in postmenopausal women in 2007. It was initially developed to treat osteoporosis

Tamoxifen: This hormone therapy treats metastatic breast cancers, or those that have spread to other parts of the body, in both women and men, and it was originally approved in 1977. Thirty years later, researchers discovered that it also helps people with bipolar disorder by blocking the enzyme PKC, which goes into overdrive during the manic phase of the disorder.

*it is important that the nurse consults with the physician to determine and confirm the correct use of the medication for a resident for accurate recording of the medical conditions and the capturing of active diagnoses on the MDS.


NTA Missed Opportunity- Medication

Resident was admitted to the hospital for a fall and pain in lower back. Resident is diagnosed with osteoarthritis of lower back and treated for pain then sent to a skilled nursing facility. The SNF admitting nurse was adding orders into the EMR and adds Humira with a diagnosis of Osteoarthritis of Spine. When MDS completed the Initial Medicare Assessment, she does not question the medication order for Humira being for Osteoarthritis of the Spine, which is captured in Item I3700 for Arthritis (e.g. degenerative joint disease (DJD, Osteoarthritis, and rheumatoid arthritis (RA).

In the hospital H & P, it talks about the resident needing to continue to take Humira for her Severe Psoriasis. The facility physician has written in his progress note in the first 5 days since SNF admission to continue the resident on Humira for severe Psoriasis.

The Psoriasis diagnosis is not captured in I8000. Capturing a Severe Skin Burn or Condition in I8000 would gain 1 point for the NTA count.


Opportunistic Infections Defined

An opportunistic infection is an infection caused by pathogens (bacteria, viruses, fungi, or protozoa) that take advantage of an opportunity not normally available, such as a host with a weakened immune system, an altered microbiota (such as a disrupted gut microbiota) or breached integumentary barriers. Many of these pathogens do not cause disease in a healthy host that has a normal immune system. However, a compromised immune system, which is seriously debilitated and has lowered resistance to infection, a penetrating injury, or a lack of competition from normal bacteria presents an opportunity for the pathogen to infect.


Some Opportunistic Infection Organisms ExamplesAsperguillusCandida AibicansClostridium difficileCoccidioides immitisCryptococcus neoformansCryptosporidiumCytomegalovirusGeomyces destructansHistoplasma capsulatumIsospora belliPolyomavirus JC polyomavirus, virus that causes Progressive Multifocal LeukoencephalopathyKaposi’s Sarcoma caused by Human Herpesvirus * (HHV8), also called Kaposi’s sarcoma-associated herpesvirus (KSHV)Legionnaires’ Disease (Legionella pneumophila)MicrosporidiumMycobacterium avium complex (MAC) (Nontuberculosis Mycobacterium)Mycobacterium tuberculosisPneumocystis jirovecil, previously known as Pneumocystis carinii f. hominisPseudomonas aeruginosaSalmonellaStaphylococcus aureusStreptococcus pneumoniaeStreptococcus pyogenesToxoplasma gondii

Opportunistic Infection Organisms


Resident had chronic leg ulcers from PVD, which if not kept moist several times a week with whirlpools, he would develop Pseudomonas Aeruginosa, which is considered an Opportunistic Infection caused by Immunodeficiency or Immunosuppression caused by skin damage.

Clostridium Difficile (C-Diff) is considered an opportunistic infection cause by antibiotic treatment leading to the disruption of the extremely diverse and complex community, known as the good bacteria in the gut. This causes some microorganisms to outcompete others and becomes a pathogenic producing disease.

Candida Albicans is considered an opportunistic infection when overgrowth occurs. It is also considered the fourth most common source of hospital acquired infections. Also known as Thrush. We all have small amounts of candida fungus in our mouths, digestive tract, and on our skin, which is normal. But sometimes certain illnesses, medication such as corticosteroids or antibiotics can cause an overgrowth.

Salmonella is one of the most common causes of food poisoning and considered opportunistic. Most humans become infected most frequently through contaminated food or water. It can also be obtained from humans touching their pets, like reptiles and birds, while not properly washing their hands after handling.

Staphylococcus Aureus if frequently found in our upper respiratory tract and on our skin as a microbiota of the body. With overgrowth, it is considered opportunistic. It can be a common cause of skin infections such as boils, abscesses, respiratory infections like sinusitis and food poisoning. It is one of the five most common causes of hospital-acquired infections and it is often the cause of wound infections. If you have a diagnosis of Bacteremia listed as cause for infection in the hospital record, make sure you obtain culture and sensitivity because it will usually be Staphylococcus Aureus.

Streptococcus pneumonia is a form of very contagious pneumonia considered opportunistic. Normally we do not think of pneumonia as being contagious. This bacteria usually presents asymptomatically in healthy carriers colonizing in the respiratory tract, sinuses and nasal cavity. However in susceptible individuals with a weaker immune system, the bacterium may become pathogenic and spread. It spreads by direct contact via droplets and are elderly are highly susceptible.

Opportunistic Infections


Inflammatory Bowel DiseaseInflammatory Bowel Disease Examples: Crohn’s

Disease, Ulcerative ColitisA 92-year-old was sent to the hospital by her son for persistent diarrhea, abdominal pain and some rectal bleeding. During ER examination, it is determined that she should be admitted for possible Inflammatory bowel disease. The next morning the patient is scheduled for a combination procedure of an endoscopy and a colonoscopy. Results from the colonoscopy showed that the resident has a positive diagnosis of Ulcerative Colitis in the large intestine and the rectum. She was given multiple injections of biologics until her condition was under control with no further diarrhea, abdominal pain or rectal bleeding. The resident was transferred to the SNF for rehabilitation with orders to continue prednisone, and salofalk. The nurse admitting the resident at the SNF wrote the order for salofalk and prednisone for arthritis. These medications could be used for inflammation of the joint, however, the resident had never had a diagnosis of arthritis.

In this case, the hospital record and the facility physician progress note stated that the resident was to be continued on salofalk and prednisone for ulcerative colitis.

Ulcerative Colitis and Crohn’s Disease are two conditions characterized by chronic inflammation of the gastrointestinal tract. Therefore, Inflammatory Bowel Disease should be captured under I1300 capturing 1 point on your NTA score.


Cardio-Respiratory Failure and Shock ExampleThis resident was at home and felt dizzy, fell, and was complaining of right hip pain. She could not get up, so 911 was called and she went to the ER and was diagnosed with a right hip fracture. While being cleared for surgery, resident had and EKG and was noted to have a debilitating arrhythmia, which could have been the reason for her fall. Symptoms of arrhythmia is low blood pressure anddizziness, among others. Further testing showed her to have cardiogenic shock where the heart was failing to function properly due to damage. She was cardioverted and started on medication. Her hip surgery was completed when her heart condition was stabilized. She was admitted to the SNF where her orders for heparin were continued for what the nurse wrote as a preventative. The H & P states that she was started on Heparin right after surgery to prevent blood clots due to the diagnosis of Cardiogenic Shock listed in her diagnosis list, and the subcutaneous heparin is to continue in the SNF. When this diagnosis is added to her use of heparin and captured on the MDS under I8000, as an active diagnosis, it will add 1 additional point to her NTA count.


Documentation

RAI Manual:Check the following information sources in the medical record for the last 30 days to identify “active” surgeries: • Transfer documents, • Physician progress notes, • Recent history and physical, • Recent discharge summaries, • Nursing assessments, • Nursing care plans, • Medication sheets, • Doctor’s orders, • Consults,• Official diagnostic reports,• Other Sources as available

Other Sources:• Operating Room report• Surgical consult report• Labs• X-Ray

*Consult reports before and after surgical procedure


MDS Section J


MDS Section J

Hemiarthroplasty Defined: a surgical procedure for repair of an injured or diseased hip joint involving replacing the head of the femur with a prosthesis without reconstruction of the acetabulum.

Partial Hip Replacement Defined: also called hip hemiarthroplasty, is a surgical procedure where only the femoral head (the ball) of the damaged hip joint is replaced. The acetabulum (the socket) is not replaced.

By contrast, in total hip replacement, the acetabulum is replaced with a prosthetic.


MDS Section JThis resident had a pathologic fracture with subsequent hemiarthroplasty performed which corrected the

fracture. She is coded under J2510 for Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot). This resident should be coded under J2310 for a Hip Replacement – partial or total. Below is a chart showing the missed opportunities

PDPM Clinical Category: Other Ortho


MDS Section JThis resident had a pathologic fracture with subsequent hemiarthroplasty performed which corrected the

fracture. She is coded under J2510 for Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot). This resident should be coded under J2310 for a Hip Replacement – partial or total. Below is a chart showing the correct coding.

PDPM Clinical Category: Major Joint or Spinal Surgery

Surgical Procedures J2510 J2310

Clinical Category Other Orthopedic Major Joint Replacement or Spinal Surgery

Therapy Function Score 10 10

PT/OT Case Mix Group TG TC

PT Case Mix Group 1.67 ($115.65*) 1.88 ($130.19*)

OT Case Mix Group 1.64 ($104.30*) 1.69 ($107.48*)

PT: $115.65 x 20 days = $2,313*OT: $104.30 x 20 days = $2,086*

PT: $130.19 x 20 days = $2,603.80*OT: $107.48 x 20 days = $2,149.60*

PT: ($290.80*); OT: ($63.60*)Total: ($354.40*)

*not including wage index adjustment


MDS Section J


Nursing ComponentHierarchical Classification System- the first category the resident falls into, based off the clinical characteristics of the resident, is the nursing clinical category.

First step is to determine the Nursing Function Score.

Second step is to begin at the top of the clinical category hierarchy, identifying if the resident meets criteria in that category. If not, move on down the hierarchy to the next clinical category to identify if the resident meets criteria in the next category down, and if not, move on down again. The process continues until the resident Characteristics meet criteria in the category.

Extensive Services

Special Care High

Special Care Low

Clinically Complex

Behavioral Symptoms & Cognitive Performance

Reduced Physical Function


Nursing Component Nursing Function Score: Section GG

Nursing Function Score:

Eating Toileting Hygiene Bed Mobility

• Sit to lying • Lying to sitting on side of bed

Transfer• Sit<>stand• Chair/Bed>chair• Toilet Transfer

Admission Performance (Column 1) =

Function Score =

05,06 4

4 3

3 2

2 1

1, 07, 09, 10, 88, missing 0

*Reminder: GG = ‘usual performance’ versus G = ‘most need ’.


Nursing Component: Extensive Services

Determine whether the resident is coded for one of the following treatments or services:

O0100E3 Tracheostomy care while a resident.

O0100F2 Ventilator or respirator while a resident.

O0100M2 Isolation or quarantine for active infectious disease while resident.

If the resident does not receive one of these treatments or services, skip to the Special Care High Category now.

If at least one of these treatments or services is coded and the resident has a total PDPM Nursing Function Score of 14 or less, he/she classifies in the Extensive Services Category. Move to Step 3.

If the resident's PDPM Nursing function Score is 15 or 16, he/she classifies as Clinically Complex. Skip to the Clinically Complex Category, Step 2.

The resident classifies in the Extensive Services category according to the following chart:

Extensive Service Conditions PDPM Nursing Classification

Tracheostomy care and ventilator/respirator while a resident ES3

Tracheostomy care or ventilator/respirator while a resident ES2 PDPM Nursing Classification

Isolation or quarantine for active infectious disease

-without tracheostomy care while a resident -without ventilator/respirator while a

resident

ES1


Nursing Component: Special Care High

Determine whether the resident is coded for one of the following conditions or services:

B0100, Section GG itemsComatose and completely dependent or activity did not occur at admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1, GG0170E1, and GG0170F1, all equal 01, 09, or 88)

I2100 Septicemia

I2900, N0350A,BDiabetes with both of the following:

-Insulin injections (N0350A) for all 7 days-Insulin order changes on 2 or more days (N0350B

I5100, Nursing Function Score Quadriplegia with Nursing Function Score <= 11

I6200, J1100C Chronic obstructive pulmonary disease and shortness of breathwhen lying flat

J1550A, others

Fever and one of the following: -I2000 Pneumonia-J1550B Vomiting

-K0300 Weight loss (1 or 2)-K0510B1 or K0510B2 Feeding tube

*Tube feeding classification requirements:(1) K0710A3 is 51% or more of total calories OR

(2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days.

K0510A1 or K0510A2 Parental/IV feedings

O0400D2 Respiratory therapy for all 7 days

If the resident does not have one of these conditions, skip to the Special Care Low Category now.

If at least one of the special care conditions above is coded and the resident has a total PDPM Nursing Function Score of 14 or less, he or she classifies as

Special Care High. Move to Step #3. If the resident's PDPM Nursing Function Score is 15 or 16, he or she classifies

as Clinically Complex. Skip to the Clinically Complex Category, Step #2.Evaluate for depression. Signs and symptoms of depression are used as a

third-level split for the Special Care High category. Residents with signs and symptoms of depression are identified by the Resident Mood Interview (PHQ-

9©) or the Staff Assessment of Resident Mood(PHQ-9-OV©). Instructions for completing the PHQ-9© are in Chapter 3,

Section D. Refer to Appendix E for cases in which the PHQ-9© or (PHQ-9-OV©) is complete but all questions are not answered. The following items comprise

the PHQ-9©:

Select the Special Care High classification based on the PDPM Nursing Function Score and the presence or absence of depression according to this

table:

Nursing Function Score Depressed? PDPM Nursing Classification

0-5 Yes HDE2

0-5 No HDE1

6-14 Yes HBC2

6-14 No HBC1


Nursing Component: Special Care LowDetermine whether the resident is coded for one of the following

conditions or services:

I4400, Nursing Function Score Cerebral palsy, with Nursing Function Score <=1

I5200, Nursing Function Score Multiple sclerosis, with Nursing Function Score <=11

I5300, Nursing Function Score Parkinson’s disease, with Nursing Function Score <=1

I6300, O0100C2 Respiratory failure and oxygen therapy while a resident

K0510B1 or K0510B2 Feeding tube*

M0300B1 Two or more stage 2 pressure ulcers with two or more selected skin treatments**

M0300C1, D1, F1Any stage 3 or 4 pressure ulcer with two or

more selected skintreatments**

M1030 Two or more venous/arterial ulcers with two or more selected skin treatments**

M000B1, M10301 stage 2 pressure ulcer and 1

venous/arterial ulcer with 2 or moreselected skin treatments**

M1040A,B,C; M1200IFoot infection, diabetic foot ulcer or other

open lesion of footwith application of dressings to the fee

O0100B2 Radiation treatment while a resident

O0100J2 Dialysis treatment while a resident

If the resident does not have one of these conditions, skip to the Clinically Complex Category now.

If at least one of the special care conditions above is coded and the resident has a total PDPM Nursing Function Score of 14 or less, he or she classifies as Special Care Low.

Move to Step #3. If the resident's PDPM Nursing Function Score is 15 or 16, he or she classifies as Clinically Complex. Skip to the Clinically Complex Category, Step #2.

Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the Special Care Low category. Residents with signs and symptoms of

depression are identified by the Resident Mood Interview (PHQ-9©) or the Staff Assessment of Resident Mood

(PHQ-9-OV©). Instructions for completing the PHQ-9© are in Chapter 3, Section D. Refer to Appendix E for cases in which the PHQ-9© or (PHQ-9-OV©) is complete but all

questions are not answered. The following items comprise the PHQ-9©:

Select the Special Care Low classification based on the PDPM Nursing Function Score and the presence or absence of depression according to this table:


0-5 Yes LDE2

0-5 No LDE1

4-16 Yes LBC2

4-16 No LBC1


Nursing Component: Clinically ComplexDetermine whether the resident is coded for one of the following

conditions or services:

MDS Item Condition or Service

I2000 Pneumonia

I4900, Nursing Function Score

Hemiplegia/hemiparesis with Nursing Function Score <= 11

M1040D,EOpen lesions (other than ulcers, rashes, and cuts) with any selected skin treatment* or

surgical wounds

M1040F Burns

O0100A2 Chemotherapy while a resident

O0100C2 Oxygen Therapy while a resident

O0100H2 IV Medications while a resident

O0100I2 Transfusions while a resident

*Selected Skin Treatments: M1200F Surgical wound care, M1200G Application of nonsurgical dressing (other than to feet), M1200H

Application of ointments/medications (other than to feet)

If the resident does not have one of these conditions, skip to the Behavioral Symptoms and Cognitive Performance Category now.

Select the Special Care High classification based on the PDPM Nursing Function Score and the presence or absence of depression according to this

table:


0-5 Yes HDE2

0-5 No HDE1

6-14 Yes HBC2

6-14 No HBC1

Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the Special Care Low category. Residents with signs and symptoms of depression are identified by the Resident Mood Interview (PHQ-9©) or the Staff Assessment of Resident Mood(PHQ-9-OV©). Instructions for completing the PHQ-9© are in Chapter 3, Section D. Refer to Appendix E for cases in which the PHQ-9© or (PHQ-9-OV©) is complete but all questions

are not answered. The following items comprise the PHQ-9©:


Nursing Component: Behavioral Symptoms & Cognitive Performance

Determine the resident’s PDPM Nursing Function Score. If the resident's PDPM Nursing

Function Score is 11 or greater, go to Step #2.

If the PDPM Nursing Function Score is less than 11, skip to the Reduced Physical Function Category now.

Determine the resident’s cognitive status based on resident interview using the BIMS or staff assessment.

Determine Restorative Nursing Count

H0200C, H0500** Urinary toileting program and/or bowel toileting program

O0500A,B** Passive and/or active range of motionO0500C Splint or brace assistance

O0500D,F** Bed mobility and/or walking trainingO0500E Transfer trainingO0500G Dressing and/or grooming trainingO0500H Eating and/or swallowing trainingO0500I Amputation/prostheses careO0500J Communication training

Determine whether the resident presents with one of the following behavioral symptoms:

E0100A Hallucinations

E0100B Delusions

E0200A Physical behavioral symptoms directed toward others (2 or 3)

E0200B Verbal behavioral symptoms directed toward others (2 or 3)

E0200C Other behavioral symptoms not directed toward others (2 or 3)

E0800 Rejection of care (2 or 3)

E0900 Wandering (2 or 3)

If he or she does not present with behavioral symptoms, skip to the Reduced Physical Function category.

If the resident presents with one of the behavioral symptoms, then he/she classifies in Behavioral Symptoms and Cognitive Performance.


Nursing Component: Reduced Physical Function

Determine Restorative Nursing Count

H0200C, H0500** Urinary toileting program and/or bowel toileting program

O0500A,B** Passive and/or active range of motion

O0500C Splint or brace assistance

O0500D,F** Bed mobility and/or walking training

O0500E Transfer trainingO0500G Dressing and/or grooming trainingO0500H Eating and/or swallowing trainingO0500I Amputation/prostheses careO0500J Communication training

Determine the resident’s PDPM Nursing Function Score. If the resident's PDPM Nursing

Function Score is 11 or greater, go to Step #2.


Nursing Component: Nursing Documentation

SOB while lying flat documentation is extremely important and will place the resident in a Special Care High depending on the Nursing Function Score


Nursing Component: Nursing Documentation


Nursing Component


If you have any questions or need support, please email [email protected]. We are here to help!

Client Portal Access: https://fprehab.com/pdpm-academy/

mailto:[email protected]

https://fprehab.com/pdpm-academy/

nta, section j, & nursing · 2020. 10. 15. · be a common cause of skin infections such as...

Documents