(This isnt going to work well on mobile devices, FYI.). It more accurately accounts for expenses and isn't overshadowed by therapy. The PDPM Clinical Categories are discussed below. yid T[KaEev0D/wRDQhDB['QgDTBEB)2"xt"Xn2 QN[%=> FhzdBI^8/HD 66y% Some didnt occur at all. The NTA component score is based on the presence of certain comorbidities and/or the use of extensive services. PDPM includes a new pay category, the non-therapy ancillary or NTA. This simply shows you a starting point. ANOVA Rural versus Urban NTA case-mix (click to enlarge). It's easy to get to those 50, but the tricky part is understanding which ICD-10 codes match to the comorbidities. #2 Diagnosis Status - The diagnosis must have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Yes, Im aware that if you dont look at every. CMS identified a list of 50 conditions and extensive services that were associated with increases in NTA costs. The higher the score, the higher the NTA rate. In order to determine the patients NTA comorbidity score accurately, providers must identify all comorbidities for which a resident would qualify, then total the points. Incorporate NTA identification into the daily clinical meeting as it is ever important to identify when a change in condition or services takes place. For example, an I69.091 code (dysphagia following non-traumatic sub-arachnoid hemorrhage) in I0020B will map to Acute Neurological category and contribute to determining the case mix group. you could miss something. Patient classification system where patients are grouped according to their care and resource needs. To further understand the difference between long-term care facilities and skilled nursing/rehabilitation facilities, we will focus on the services they offer. Anyone involved with ICD-10 coding should have ready access to the coding guidelines. PDPM includes a new pay category, the non-therapy ancillary or NTA. It is important that the completion of an IPA does not reset the VPD. SANE is an acronym that stands for Sexual Assault Nurse Examiner. 0000189184 00000 n His I0020B Primary Diagnosis and his claim's Principal Diagnosis is now the aftercare of the hip fracture. Re-calculate expected daily rate based on the completed Rehab and Nursing Functional Scores and re-review principal diagnosis. 0000002038 00000 n The new nurse assessment coordinator (NAC) may be overwhelmed with the numerous tasks required of the position. One can see from the table above that if comorbidities are missed, the facility could possibly miss out on reimbursement. Payment is based on services provided by five disciplines: physical therapy, occupational therapy, speech language pathology, nursing, and non-therapy ancillary (NTA). After the PDPM rate for each component is determined, the sum of the PDPM component rates is added to the fixed non-case mix rate which will be the final reimbursement rate for the patient for the entire skilled nursing facility stay. It is highly advisable for MDS nurses to review each assessment to ensure that all skilled services are captured during the assessment period to maximize reimbursement rate for the facility based on the patients diagnosis and acuity. This NTA CMI is added to the other components to calculate the total reimbursement for the patient. The long-term care facilities have emerged not only as a permanent home for the elderly during their retirement or post-retirement years but as respite and recuperative facilities even for the younger patients. The functional scoring is based on residents performance in. 0000005276 00000 n The saying, haste makes waste applies in the completion of MDS assessments and calculation of the maximized PDPM rate for the patient. Determinant for payment is based on the number of therapy minutes provided regardless of residents acuity, diagnosis and other skilled nursing services provided. Request for labs, imaging studies and surgical reports whichever is applicable. 0000008175 00000 n Focuses on clinically relevant factors rather than volume-based services or RUG levels. We know now that every diagnosis and condition counts. endstream endobj 1697 0 obj <>stream or privately paid by the patient if he/she does not qualify under the Medi-Cal program. It may also include a condition that started while the patient was getting care in the SNF for a hospital-related medical condition such as antibiotic medications via intravenous (IV) route to treat infections even if it was not the reason the patient was admitted to the acute hospital. endstream endobj 453 0 obj <>stream They cant all be equally likely, right? The RUG-IV consists of two case-mix adjusted components: Therapy which is based on volume of services provided and nursing. ^(:eOCQ'SM7(Rmnvr/+eO.)hicZjz.,vO&u. Once completing his Part A stay, the hip fracture will no longer appear on his claim, and Parkinson's Disease now returns as the Principal Diagnosis. Holds on recalibrating the PDPM "parity adjustment" that is designed to ensure budget neutrality under the new model to assist SNFs in meeting the demands of the COVID-19 pandemic until FY 2023. ~,/-I\!/JfB. SNF PDPM Provider-Specific Impact File. These groups and indices, combined with other components of the payment system, provide a total reimbursement process that When the variable per diem adjustment is applied, the increase NTA component goes up 3x; in the example above, the daily rate for days 1-3 would increase by $87.70 for Urban and $83.78 for Rural. Character 3: Nursing Case Mix Group (NSG CMG) Character 4: NTA Case Mix Group (NTA CMG) Character 5: Assessment Indicator HIPPS Code PT/OT CMG SLP CMG NSG CMG NTA CMG HIPPS Code A TA SA ES3 NA A B TB SB ES2 NB B C TC SC ES1 NC . Either way, you must still also code the I0020B primary condition I0010 through I8000. For more information on preparing for the transition to PDPM, register for our 9-Part PDPM Webinar Series. The NTA component score is based on the presence of certain comorbidities and/or the use of extensive services. NTA Componenet NTA Component NTA Comorbidity Score NTA Case Mix Group 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 Presumption of Coverage Comorbidities Included in NTA Comorbidity Score and Assigned Points Condition/Extensive Service MDS Item Points HIV/AIDS SNF Claim ICD-10 B20 8 Parenteral IV Feeding: Level High Stay tuned. In this post, we going to look at one important piece of the NTA puzzle, section I. Under the PDPM structure, there are no rules regarding when nursing home staff can perform an IPA, McCarthy noted, and even slight changes to a resident's care plan could result in additional NTA points that could bring in extra per-day reimbursement dollars. Therefore, the code in I0020B must be directly related to the I0020 Primary Medical Condition. (10 items fit). If the Primary Diagnosis you listed in I0020B also happens to be a SLP Comorbidity qualifier from the SLP Comorbidity list, the grouper software will pick it up as a comorbidity from I8000. The Non-Therapy Ancillaries (NTA) component of PDPM can significantly increase revenue depending on MDS and ICD-10 coding. With PDPM payment method, the determinants of payment are categorized into the following case-mix adjusted components: The PDPM rate is adjusted over the course of facility stay by the inclusion of a variable per diem (VPD) adjustment on the following three components: PT, OT and NTA. SNF FY 2022 Proposed Rule Learn the Facts Behind the Headlines Part 3: How is My Rate Calculated, Regulatory Reminder! Learn More Resource PDPM Series Part 5: Assessment Requirements. The more comorbidities a patient has, the more medications he or she probably requires. Daily Medicare charting should focus on all possible nursing clinical categories, special care high, special care low, clinically complex, behavioral symptoms and cognitive performance, and reduced physical function. o NTA = All NTA items identified with a value of two or more points on the NTA table. program for a limited time or on a short-time basis and must meet the following requirements: hospital insurance and have eligible days left to use during the benefit period. The following ICD-10 codes qualify: 41 Body mass index (BMI) 40.0-44.9, adult, 42 Body mass index (BMI) 45.0-49.9, adult, 44 Body mass index (BMI) 60.0-69.9, adult, 45 Body mass index (BMI) 70 or greater, adult, 01 Morbid (severe) obesity due to excess calories, 2 Morbid (severe) obesity with alveolar hypoventilation, Cross-train. Verify coding, dont assume. The general method for calculation of any NTA category is as follows: The Fiscal Year (FY) 2021 PDPM ICD-10-CM Mappings file includes the NTA Comorbidity to ICD-10-CM Mapping, which maps comorbidities in the NTA component captured in item I8000 to allowable ICD-10 codes. CMS Perhaps the most "transformative" component relates to Non-Therapy Ancillary (NTA) Services. For example, Mr. Steve is a long term care resident due to Parkinson's Disease. Each component has its case mix index to determine the component rate. 0000003037 00000 n 0000003793 00000 n PDPM Chart Audit Simple and Easy: Winning in PDPM Payment and Regulatory Strategies . To ease some of this burden, AAPACN developed the Sample Task List for the Nurse Assessment Coordinator tool . Remember, a diagnosis has to be active and documented by a physician or nonphysician extender to qualify as an NTA item. This could be a difference of $29.23 per day for Urban and $27.93 per day for a Rural facility. In this fourth webinar of our six part series, learn which items on the MDS or Medicare claim will be used to determine the NTA score and its impact on payment. The patients NTA comorbidity score is the sum of the points associated with each relevant comorbidity. var divElement = document.getElementById('viz1528375166404'); var vizElement = divElement.getElementsByTagName('object')[0]; vizElement.style.width='100%';vizElement.style.height=(divElement.offsetWidth*0.75)+'px'; var scriptElement = document.createElement('script'); scriptElement.src = 'https://public.tableau.com/javascripts/api/viz_v1.js'; vizElement.parentNode.insertBefore(scriptElement, vizElement); Use the rate filter to show only the highest or lowest NTA rates. A Knowledgeable and Compassionate partner. The NTA component, together with the nursing and non-case mix components, make up the total reimbursement for a patient day under Medicare Part A. NTA classification is based on the presence of certain comorbidities or use of certain extensive services. Hopefully I dont lose my blogging privileges, but I looked at a years worth of Part A admissions to every SNF in the country and found, gasp, not all codes occur that often. All about coding rehabilitation for joint replacements: Its important to know the reason for the joint replacement since coding a joint replacement due to a fracture is different than when a joint replacement is due to an elective surgery. Continuous training is the key and implementation of what was learned in coordination with the facility team members will ensure success in providing skilled care for the patients and maximizing facility reimbursement. There must be a reason for it, right? Patients are assigned a clinical category based on the primary diagnosis for SNF stay. NF is the lowest grouper with a score of 0, while NA is highest with a score of 12+. Variable Per Diem Adjustment Factors and ScheduleNTA. 0000006770 00000 n Reimbursement for these services is covered under the. (Nursing, Social Services, Dietary and Activity Staff). The AHCA Patient Driven Payment Model (PDPM) Resource Center provides AHCA provider members with a suite of original content, tools, and training options and resources to assist providers in how to be successful in implementing the new Medicare Part A PDPM SNF PPS, effective October 2019. Learn more about Jessica, Eleisha, and the rest of the Proactive team. Primary reason for SNF care or PDPM diagnosis coded on Section I00200B (ICD-10 code) of the MDS assessment, Functional status coded on Section GG of the MDS assessment, Cognitive Status: BIMS score coded on the Section C of the MDS assessment, presence of a swallowing disorder or mechanically altered diet coded on Section K of the MDS assessment, other SLP-related comorbidities coded on Section I of the MDS assessment, Extensive services received coded on Section of the MDS assessment such as Tracheostomy, Ventilator, and Isolation, Presence of Depression coded on Section D: PHQ9 on the MDS assessment, Restorative nursing services coded on Section O of the MDS assessment, Comorbidities present coded on Section I of the MDS assessment, Extensive services received coded on Section O of the MDS assessment: Tracheostomy, Ventilator and Isolation. As we prepare for the transition to the Patient-Driven Payment Model (PDPM), which is expected to occur on October 1, 2019, we have been reviewing the primary components that make up the Case Mix Index (CMI) for reimbursement. Our wound certified educators train, educate, and guide our providers and client facilities on the most efficacious wound care treatments and follow up. Based on that, we can calculate the rate. MDS Item Field rows in tan represent MDS item groups identified in CMS PDPM documentation and do not have data entry fields. CMS 100-2 Chapter 8 Series Part I: Access to Medicare Part A Benefits In a SNF. The patients functional score which is coded on Section GG of the MDS form is derived by assessing the patients usual self-performance in the ADL task areas during the first three days of facility stay. 2 &r}p")|@ O&]LpLk| Mvl(Pv[C0AMfxYp&NymfJXdO@QhCec*2-K8P3Tjp6'+Q :~_%`n/[w}_,0-|:%?h6'#%?7?\o(@Ln 9w9Fhe`P8B09@(@DT\QG+ (CQ {dX r4`H*B4,&0hl3()%zI[)jCN8{SNa%PED~ eT T(m:l] 43FH&"@`BN`Kk(f Share our insider knowledge and tips! Just 1 NTA point can have an average worth of anywhere from $18 to $55 per day. In this post Im going to take a deeper look at it and calculate the average NTA payment by state and facility. I believe that this payment method acknowledges not only the skilled rehabilitation services provided to the patient, but also the complexity of skilled nursing services rendered to the patient and appropriately incorporated in the PDPM rate calculation. ,: >i*S7O=X8ZA'ic2+(!olVz`zz_"K@I The PDPM program has six payment components. Ill also compare urban versus rural facilities when it comes to NTA case-mix. last. The correct coding for NTA will require a team effort and diligent review of coding and supporting documentation to ensure 100% accuracy. Facilities must ensure efficient processes are in place when selecting the primary diagnosis. Hover over a facility to see the name, NTA Rate, NTA case-mix index and whether the facility is urban or rural. Facilities that work to establish these best practices associated with the NTA component will increase revenue and see other benefits such as improved Quality Measures, reduced readmission rates, and improve skilled documentation. Start (and continue) the conversation. Do not be apprehensive to query the physician if a diagnosis is not clear or is suspected and not documented. Its interesting to note that the data CMS provided, that I am using here, came from some assessments that we no longer will be doing. You can see in the histogram that not only are there a lot fewer rural facilities, but they also appear to have lower average case-mix. As a result, client facilities realize improved wound healing results, improved survey scores and NTA reimbursement under PDPM. Whats in it for me? Previous articles in this series outlined the physical and occupational therapy component and the speech language pathology component. Good talk. 0000006001 00000 n We earn 1 NTA point and qualify for Nursing Category Special Care Low for a Stage IV Pressure Ulcer when coded in M0300. These maps look significantly different from a lot of the others weve seen. and the grouper software will pick it up from I8000. It is not clear why this would be the case. background-color: #2c4a88; 0 DetI Rloh,mJLEo(DA"pd#Se.e)6d;[+I=R^2rcZ'F6C"x=*!J&[KL~^ogN3#)LNb}:QOd 0}pE` )S If the 25% is exceeded, a non-fatal warning will appear on the final validation report during the MDS submission process. CMS 100-2 Chapter 8 Series Part I: Access to Medicare Part A Benefits In a SNF. These residents may have a significant number of inaccurate or resolved diagnoses if a facility doesnt have a process for ongoing diagnosis reconciliation. A SANE nurse is an RN who has been trained to examine and assess clients who have a reported a sexual assault. the design of the PDPM case-mix system implemented in FY 2020. The map below shows every SNF in the US that accepted Medicare Part A patients in 2017. Admittedly, thats a lot to look through. All disciplines should complete all their assessments ON TIME to CAPTURE all skilled services and accurately calculate residents daily rate PRIOR TO completion and transmission of the MDS 5-day assessment. Comorbidities associated with higher increases in NTA costs are grouped into higher point tiers, while those that are associated with lower increases in NTA costs are grouped into lower point tiers. These conditions may warrant completion of an Interim Payment Assessment (IPA) thus increasing the NTA component score and potentially the total per diem. Other diagnoses will affect the Non-therapy Ancillary (NTA) component. Under PDPM, Section GG drives PT and OT, and nursing which affects reimbursement. As a result, client facilities realize improved wound healing results, improved survey scores and NTA reimbursement under PDPM. If a resident is admitted into a Part A stay within 30 days after major surgical procedure (as a hospital inpatient) that carried some degree of risk to life or had the potential for severe disability, then J2100 (recent surgery requiring active SNF care) is checked "yes". Under PDPM, there are six payment components. Non-Therapy Ancillary (NTA) classification in PDPM is determined by the presence of certain conditions or the use of certain extensive services that were found to be correlated with increases in NTA costs for SNF patients. Non-Therapy Ancillary (NTA) classification in PDPM is determined by the presence of certain conditions or the use of certain extensive services that were found to be correlated with increases in NTA costs for SNF patients. How often will the items on this list be available to you when you are doing the 5 day assessment? The individual NTA conditions have points ranging from 1 to 8. It is highly recommended for the MDS nurse to make calculations which can determine the highest acceptable reimbursement rate for the facility. The NTA case-mix groups are based on NTA score ranges: 0 (NF), 1 2 (NE), 3 5 (ND), 6 8 (NC), 9 11 (NB), or 12+ (NA), according to table 17, NTA Case-Mix Groups, in chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 Users Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html, Center for Medicare and Medicaid Services. Contact us now and sign up to receive our newsletters here. This is to offset the high cost of medications and supplies that would be required to support the patient characteristics with these NTA conditions upon admission. The NTA comorbidity score is a weighted count of certain comorbidities that a SNF patient has, which is then used to classify the patient into an NTA component payment group. We earn 2 NTA points if Diabetes is coded in MDS item I2900. 437 0 obj <> endobj To assist in ensuring that you can capture all diagnoses and pertinent information to maximize facility reimbursement, I suggest doing the following (which most MDS nurses I am sure are already doing): Request for Hospital History & Physical, Progress Notes, and consults. color: white; Prior to October 1, 2019, all SNFs which participate under the Medicare program are paid under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) based primarily on the type and intensity of therapy services provided to the patients regardless of their acuity, unique characteristics, specific needs, or goals. Custodial care does not require the assistance of a licensed staff. Yes, I get that is bad. These components for classification and payment include: Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Non-therapy Ancillary (NTA) as well as Nursing. 0000003961 00000 n With this component being paid at a 3x rate for 1st 3 days of . CMS identified a . In it, youll find the 1,612 codes that map to the different comorbidities. MDS 3.0 RAI Manual. Just 1 NTA point can have an average worth of anywhere from $18 to $55 per day. When reviewing the CMI components driving PDPM reimbursement its important to consider the critical role of the Non-Therapy Ancillary (NTA) score. Also, there is a 25% combined limit on concurrent and/or group therapy. Under PDPM there are 161 Minimum Data Set (MDS) item fields. } To account for changes in resource PT, OT, and NTA utilization over the course of a SNF stay, PDPM utilizes a variable per-diem adjustment factor that adjusts the per-diem payment for these components over the course of the resident stay. Points are added together for all conditions. h2430Q0P0430S0 0000001690 00000 n endstream endobj 451 0 obj <>stream |Pa(E8BNJA!-tUiX%:h~GJ?J.H% kZ*qyXjBy@C(zHhzQhhlL2cO`.$p6_[3R^IrHrr6#eq7**2uWytb$HyZi[F2_ GBM*.`k@/9cO9R*^fo_MOK6_xg,eM'jv}5E|SWNH0$z|.WL7y9 ;4H*h;H8H"*RW l? The required MDS data would be entered in the sub-items listed below the item group identifier. Comorbidities are assigned points based on the cost in care associated with the condition or service, with points ranging from 1 to 8. Additionally, PDPM applies variable per diem payment adjustments to three components, PT, OT, and NTA, to account for changes in resource use over a stay. But if discharged on 10/01/19, it must be included on the claim. Le^#N"TaAKTt Preparedness for coding changes will be the key to a smooth transition. You can view either rural, urban or both. The Centers for Medicare and Medicaid Services (CMS) have provided the SNFs with a list of ICD-10-CM codes mapping to one of the clinical categories: These clinical categories are used as the Primary PDPM diagnosis giving weight to the calculation of PDPM rates for PT, OT, SLP and Nursing components. 26 11.4 Will section I0020B override section I0020, 1-13 for the primary reason for SNF admission since 0 PDPM and Non-Therapy Ancillaries The non-therapy ancillary (NTA) part of the patient driven payment model (PDPM) is considered by most people I've talked to as being better than what we're currently doing. With several big changes ahead, the margin for error slim for most providers. Highlights: Securely download your document with other editable templates, any time, with PDFfiller. Understanding the Value of the MDS Nurse Under PDPM, Psoriatic Arthropathy & Systemic Sclerosis, Myelodysplastic Syndromes and Myelofibrosis. A} 2?d`aYW!3,8h|J/K\J:s&Ve>1|9WiixusVo\sGP8saBT!+(z$lYnAZZp@6Y1m`[ jKeMQ5i.7HCGIC1iGIc' At the start of 2019, 63% of respondents to SNN's annual outlook survey identified a greater emphasis on coding as a a key PDPM strategy. PDPM HIPPS Coding Crosswalk In order to accommodate the new payment groups, the PDPM HIPPS algorithm is . The provider will report on the Minimum Data Set (MDS) each of the comorbidities that a person has. Under PDPM, long-term care facilities will receive reimbursement based on services that each resident receives. View D0AD3F24-D6BD-4273-B139-8FCA97487E6A.jpeg from NURSING MISC at St. Clair County Community College. Note that for the first 3 days of the stay you get 3 times the rate shown on the map. 1=BY)#CT 'a7bA(XdHE ? Item I0020 and I0020B: Item I0020 (primary medical condition category that best describes the primary reason for admission lists several options. The Primary Diagnosis in I0020B and the Principal Diagnosis should match. With supportive documentation, it can be coded in I5600. 5!!!!!May!be!used!by!permission!only!Proactive!Medical!Review,!LLC!!!!!www.proactivemedicalreview.com!!!! They are assisted by certified nursing assistants (. Diligent review of the medical history and clinical record is essential. - Corrected typo in minimum point value thresholds used to ify patients into groups "NA" and "NB" under the NTA component. 18% of the Nursing adjustment factor is multiplied to the Nursing rate only patients with diagnosis of AIDS. Conduct interview assessments for the Brief Interview for Mental Status (BIMS), and Mood ON ASSESSMENT REFERENCE DATE (ARD) OR A DAY PRIOR TO ARD. Coding of these areas will affect the, Postpartum Preeclampsia Diagnosis and Management, Hyperemesis Gravidarum: More Than Just Morning Sickness. This list of options is not used for PDPM payment, but is used as risk adjustments for some of the QRP Quality Measures. The decision to change the definition was because CMS believes that therapists, using their clinical judgment, will allow for more flexibility and that residents often benefit from the psychosocial aspects of group therapy. endstream endobj 1698 0 obj <>stream CMS stated in the final rule for FY 2023 that they intend to take a more cautious approach to mitigate the potential negative impacts on the nursing home industry with this parity adjustment by spreading it across a two-year period. Involve the Interdisciplinary Team. Luckily, code diving is a lot of fun, right? Below is the full listing of conditions and services used for NTA classification and the associated number of points for that comorbidity. With the transition from Resource Utilization Group Version IV (RUG-IV) to the Patient-Driven Payment Model (PDPM) on October 1, 2019, the MDS nurse requires an analytical mind and financial knowledge to determine the highest allowable reimbursement for the facility. For the NTA component, the CMI is multiplied against the applicable per diem adjustment factor and is then applied to determine the case-mix adjusted payment associated with each of these payment components for each utilization day under PDPM. When expanded it provides a list of search options that will switch the search inputs to match the current selection. Skilled nursing facilities now have more than a year of experience with the Patient-Driven Payment Model (PDPM), the updated case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) that includes five case-mix-adjusted payment components: physical therapy (PT), occupational therapy PDPM Series Part 4: Non-Therapy Ancillaries Case Mix Groups. Section I8000 alone has 27 of these conditions, while sections K, M, N, and O also have items that can contribute to the NTA score. The PDPM Rate is derived from the sum of all the PDPM component rates: PT base rate x PT case mix index (CMI) x VPD adjustment factor, OT base rate x OT CMI x VPD adjustment factor, NTA base rate x NTA CMI x VPD adjustment factor, Nursing base rate x Nursing CMI x 18% Nursing adjustment factor (only for AIDS patients). Points (1-8) are assigned to specific conditions. This PDPM model aims to utilize the individual patient's characteristics and needs based on diagnosis as opposed to the RUG-IV system relying on volume of services. THURSDAY JUNE 23, 2022 2 PM EASTERN - 90 MINUTES, OHIO HEALTH CARE ASSOCIATION- Virtual Webinar, COST $35 FOR OHCA MEMBERS, $90 FOR NON-MEMBERS, https://webinars.ohca.org/?pg=semwebCatalog&panel=showLive&seminarid=16339, 6/23/22 Capturing Non-Therapy Ancillary (NTA) in PDPM. .com NTA Diagnosis Tool CMS identified a list of 50 conditions and extensive services associated with increases in NTA costs.
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