Audit or Admit: CMS Provides Clarification on Five-Star Penalties and Schizophrenia Audits

The Centers for Medicare and Medicaid Services (CMS) recently provided detailed information on the penalties that will be assigned to nursing homes that fail a schizophrenia Minimum Data Set (MDS) audit or admit to miscoding prior to the start of the audit. This clarification provides valuable information so that facilities selected for the audit can make the right decision – undergo the audit or admit to miscoding.

When a facility admits to miscoding MDS data in a schizophrenia audit, the following will occur:

• The long-stay antipsychotic quality measure (QM) will be suppressed (not displayed on the Nursing Home Care Compare website) for six months.
• The long-stay QM star rating and overall QM star rating will be suppressed (not displayed on Care Compare) for six months, and the following footnote will be displayed for both the long-stay QM and overall QM star rating:

• The other long-stay QM values (aside from the long-stay antipsychotic measure) will be displayed on Care Compare.
• The short-stay QM values will be displayed on Care Compare with a short-stay star rating, but that will not be used to calculate the overall QM star rating, since it will be suppressed.

CMS also provided additional information on the penalties that will be assigned to facilities that fail an audit. CMS began conducting audits of schizophrenia coding in the MDS data and based upon the results will adjust the Care Compare QM star ratings for facilities whose audits reveal inaccurate coding. Facilities that have coding inaccuracies identified through the schizophrenia MDS audit will have their QM star ratings adjusted as follows:

• The overall QM and long-stay QM star ratings will be downgraded to one star for six months (this could potentially drop the facility’s overall star rating by one star).
• The short-stay QM star rating will be suppressed for those same six months.
• The long-stay antipsychotic QM will be suppressed for 12 months, and the facility will receive the minimum number of points (15) for this measure for months 7-12.

The lifting of the downgrade and/or suppression at the timeframes above are subject to CMS verification that the issues have been corrected.

Contact: Susan Chenail, schenail@leadingageny.org, 518-867-8383 ext. 116