Despite what appeared to be finalized in the fiscal year (FY) 2019 skilled nursing facility prospective payment system (SNF PPS) final rule, I8000 (additional active diagnoses) will not play any role in determining the primary diagnosis clinical category for the physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) components of the patient-driven payment model (PDPM) that will implement on Oct. 1, 2019. Instead, new item I0020B, in conjunction with relevant new surgical history items J2100 – J5000, will drive the primary clinical category for PT, OT, and SLP, said officials with the Centers for Medicare & Medicaid Services (CMS) during the Dec. 11 SNF PPS: PDPM National Provider Call. Note: Access the call slides, as well as a transcript and recording, here.

 

Yet I8000 still has a job to do under PDPM. ICD-10-CM diagnosis codes captured in I8000 play two key roles, according to the PDPM Calculation Worksheet for SNFs (aka PDPM Classification Walkthrough):

 

1.      Help identify the presence of an SLP-related comorbidity for the SLP component; and

2.      Contribute to the non-therapy ancillary (NTA) comorbidity score for the NTA component.

 

AANAC created the “I8000 PDPM checklist” at the end of this article to provide a quick reference guide to the conditions that can be coded in I8000 for SLP and NTA classification purposes. Here’s how I8000 fits into these two payment components:

 

SLP-related comorbidities

 

For the SLP component, a SNF patient is assigned into a case-mix payment group based on five classification criteria:

 

·         These three criteria are factored together:

o   The PDPM primary clinical category derived from I0020B and the surgical history items J2100 – J5000 (specifically whether or not the patient classifies into the Acute Neurologic primary clinical category, which provides for a different SLP component classification than any other PDPM clinical category because the other nine primary clinical categories are all designated as Non-Neurologic SLP categories);

o   The presence of an SLP-related comorbidity; and/or

o   Cognitive impairment (any level of cognitive impairment—mild, moderate, or severe— is sufficient to receive credit for this aspect of the SLP classification criteria. The PDPM cognitive score is determined by either the Brief Interview for Mental Status or the Staff Assessment for Mental Status).

·         These two criteria are factored together:

o   The presence of a swallowing disorder (K0100A – K0100D); and/or

o   The presence of a mechanically altered diet while a resident (K0510C2).

 

There are 12 SLP-related comorbidities, and six of those 12 are reported via ICD-10 code in I8000. “The patient qualifies for having an SLP-related comorbidity if any one of the 12 conditions is recorded as being present,” said officials. Table 9 in the calculation worksheet shows which MDS item sources each of the 12 SLP-related comorbidities:

 

The 12 SLP-related comorbidities

MDS Item	Description
I4300	Aphasia
I4500	CVA, TIA, or Stroke
I4900	Hemiplegia or Hemiparesis
I5500	Traumatic Brain Injury
I8000	Laryngeal Cancer
I8000	Apraxia
I8000	Dysphagia
I8000	ALS
I8000	Oral Cancers
I8000	Speech and Language Deficits
O0100E2	Tracheostomy Care While a Resident
O0100F2	Ventilator or Respirator While a Resident

 

Table 10, “Mapping of ICD-10-CM Codes to SLP-Related Comorbidities,” in the PDPM Classification Walkthrough crosswalks the one or more ICD-10 codes that count toward each of the six I8000-derived SLP-related comorbidities. For example, only one ICD-10 code is acceptable for the ALS comorbidity: G12.21 (amyotrophic lateral sclerosis). However, six different ICD-10 codes count toward the Laryngeal Cancer comorbidity. Note: The list appears to include several duplicate codes, so providers should remember that most PDPM tools currently are labeled “draft” and are subject to change.

 

Table 11, “SLP Case-Mix Groups,” in the calculation worksheet shows how the presence or absence of the five SLP classification criteria determines the patient’s SLP payment group. For example, a resident who has an SLP-related comorbidity and a cognitive impairment (i.e., any two of the three criteria that are factored together) plus a swallowing disorder (i.e., either one of the two criteria that are factored together) will qualify for the SH SLP case-mix group, according to Table 11. If that same resident also classifies into the Acute Neurologic primary clinical category (i.e., all three of the three criteria that are factored together), they would then qualify for the SK SLP case-mix group.

 

NTA comorbidity score

 

The NTA component uses the presence of comorbidities and/or the use of extensive services to create an NTA comorbidity score to assign a SNF patient to an NTA payment group. To account for the increased cost of a patient having multiple conditions, as well as for the fact that a single high-cost condition may be more costly than two or three low-cost conditions, the NTA comorbidity score “represents a weighted count of the patient’s comorbidities, with certain conditions counting for more points toward this score than others,” said officials.

 

PDPM uses 50 conditions and extensive services for NTA classification. More than half (27) come from I8000. The following chart, adapted from Table 12 in the calculation worksheet, shows the condition/service, the source of the information about the condition/service, and the points that each condition/service add to the NTA comorbidity score:

 

NTA comorbidity score calculation

Condition/Extensive Service	MDS Item	Points
HIV/AIDS	N/A (SNF claim)	8
Parenteral IV Feeding: Level High	K0510A2, K0710A2	7
Special Treatments/Programs: Intravenous Medication Post-admit Code	O0100H2	5
Special Treatments/Programs: Ventilator or Respirator Post-admit Code	O0100F2	4
Parenteral IV feeding: Level Low	K0510A2, K0710A2, K0710B2	3
Lung Transplant Status	I8000	3
Special Treatments/Programs: Transfusion Post-admit Code	O0100I2	2
Major Organ Transplant Status, Except Lung	I8000	2
Active Diagnoses: Multiple Sclerosis Code	I5200	2
Opportunistic Infections	I8000	2
Active Diagnoses: Asthma COPD Chronic Lung Disease Code	I6200	2
Bone/Joint/Muscle Infections/Necrosis - Except: Aseptic Necrosis of Bone	I8000	2
Chronic Myeloid Leukemia	I8000	2
Wound Infection Code	I2500	2
Active Diagnoses: Diabetes Mellitus (DM) Code	I2900	2
Endocarditis	I8000	1
Immune Disorders	I8000	1
End-Stage Liver Disease	I8000	1
Other Foot Skin Problems: Diabetic Foot Ulcer Code	M1040B	1
Narcolepsy and Cataplexy	I8000	1
Cystic Fibrosis	I8000	1
Special Treatments/Programs: Tracheostomy Care Post-admit Code	O0100E2	1
Active Diagnoses: Multi-Drug Resistant Organism (MDRO) Code	I1700	1
Special Treatments/Programs: Isolation Post-admit Code	O0100M2	1
Specified Hereditary Metabolic/Immune Disorders	I8000	1
Morbid Obesity	I8000	1
Special Treatments/Programs: Radiation Post-admit Code	O0100B2	1
Stage 4 Unhealed Pressure Ulcer Currently present1	M0300D1	1
Psoriatic Arthropathy and Systemic Sclerosis	I8000	1
Chronic Pancreatitis	I8000	1
Proliferative Diabetic Retinopathy and Vitreous Hemorrhage	I8000	1
Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code	M1040A, M1040C*	1
Complications of Specified Implanted Device or Graft	I8000	1
Bladder and Bowel Appliances: Intermittent catheterization	H0100D	1
Inflammatory Bowel Disease	I1300**	1
Aseptic Necrosis of Bone	I8000	1
Special Treatments/Programs: Suctioning Post-admit Code	O0100D2	1
Cardio-Respiratory Failure and Shock	I8000	1
Myelodysplastic Syndromes and Myelofibrosis	I8000	1
Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies	I8000	1
Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage	I8000	1
Nutritional Approaches While a Resident: Feeding Tube	K0510B2	1
Severe Skin Burn or Condition	I8000	1
Intractable Epilepsy	I8000	1
Active Diagnoses: Malnutrition Code	I5600	1
Disorders of Immunity - Except : RxCC97: Immune Disorders	I8000	1
Cirrhosis of Liver	I8000	1
Bladder and Bowel Appliances: Ostomy	H0100C	1
Respiratory Arrest	I8000	1
Pulmonary Fibrosis and Other Chronic Lung Disorders	I8000	1

¹ If the number of Stage 4 Unhealed Pressure Ulcers is recorded as greater than 0, it will add one point to the NTA comorbidity score calculation. Only the presence, not the count, of Stage 4 Unhealed Pressure Ulcers affects the PDPM NTA comorbidity score calculation.

 

* M1040B is included as one of the MDS source items for the comorbidity Other Foot Skin Problems: Foot Infection Code, Other Open Lesion on Foot Code, Except Diabetic Foot Ulcer Code in Table 27 in the FY 2019 SNF PPS final rule, and it is also included in the NTA Comorbidity Score fact sheet. It is not included in Table 12 in the calculation worksheet. Given that M1040B captures diabetic foot ulcers for the comorbidity Other Foot Skin Problems: Diabetic Foot Ulcer Code, AANAC believes that the calculation worksheet is correct and that the final rule and fact sheet tables contain an inadvertent error.

 

** Item I1300 (ulcerative colitis or Crohn’s disease or inflammatory bowel disease) is an existing item on the comprehensive item set, but will be added to the current 5-day PPS assessment and the interim payment assessment (IPA) for NTA classification purposes. Several of these existing items will also be added to the swing-bed item sets. See the MDS Changes fact sheet for details.

 

The ICD-10 NTA Comorbidity Crosswalk maps comorbidities in the NTA component to allowable ICD-10 codes. For example, currently 37 different ICD-10 codes can be coded in I8000 to qualify for the Opportunistic Infections NTA comorbidity.

 

“The patient’s total NTA comorbidity score represents the sum of all points for the conditions from which that patient suffers and are reported on the MDS,” said officials. Put another way, the total NTA score is the sum of the points corresponding to each condition or service present. If none of the 50 conditions/services is present, the resident’s total NTA score is 0.

 

Note: The one exception to the MDS reporting requirement for NTA comorbidities is HIV/AIDS, which will still be reported on SNF Part A claims, not on the MDS, due to certain state privacy laws.

 

Table 13, “NTA Case-Mix Groups,” in the calculation worksheet shows how the patient’s NTA comorbidity score determines their NTA payment group. For example, a comorbidity score of 0 qualifies for the NF NTA case-mix group, while a comorbidity score of 12 or higher qualifies for the NA NTA case-mix group.

 

 

 

I8000 PDPM checklist   Certain ICD-10-CM codes captured in I8000 count toward comorbidities related to the speech-language pathology (SLP) component and the nontherapy ancillary (NTA) component of PDPM classification:   · SLP-related comorbidities: ¨ Laryngeal Cancer; ¨ Apraxia; ¨ Dysphagia; ¨ ALS; ¨ Oral Cancers; ¨ Speech and Language Deficits.   Table 10, “Mapping of ICD-10-CM Codes to SLP-Related Comorbidities,” in the PDPM Calculation Worksheet for SNFs (aka PDPM Classification Walkthrough) crosswalks between the relevant ICD-10 codes and the six I8000-derived SLP-related comorbidities.   · NTA-related comorbidities: ¨ Lung Transplant Status; ¨ Major Organ Transplant Status, Except Lung; ¨ Opportunistic Infections; ¨ Bone/Joint/Muscle Infections/Necrosis - Except: Aseptic Necrosis of Bone; ¨ Chronic Myeloid Leukemia; ¨ Endocarditis; ¨ Immune Disorders; ¨ End-Stage Liver Disease; ¨ Narcolepsy and Cataplexy; ¨ Cystic Fibrosis; ¨ Specified Hereditary Metabolic/Immune Disorders; ¨ Morbid Obesity; ¨ Psoriatic Arthropathy and Systemic Sclerosis; ¨ Chronic Pancreatitis; ¨ Proliferative Diabetic Retinopathy and Vitreous Hemorrhage; ¨ Complications of Specified Implanted Device or Graft; ¨ Aseptic Necrosis of Bone; ¨ Cardio-Respiratory Failure and Shock; ¨ Myelodysplastic Syndromes and Myelofibrosis; ¨ Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies; ¨ Diabetic Retinopathy - Except : Proliferative Diabetic Retinopathy and Vitreous Hemorrhage; ¨ Severe Skin Burn or Condition; ¨ Intractable Epilepsy; ¨ Disorders of Immunity - Except : RxCC97: Immune Disorders; ¨ Cirrhosis of Liver; ¨ Respiratory Arrest; ¨ Pulmonary Fibrosis and Other Chronic Lung Disorders   The ICD-10 NTA Comorbidity Crosswalk maps I8000-derived comorbidities in the NTA component to allowable ICD-10 codes. For example, currently 37 different ICD-10 codes can be coded in I8000 to qualify for the Opportunistic Infections NTA comorbidity.

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