Dementia and Schizophrenia and Five-Star, Oh My!

The Centers for Medicare and Medicaid Services (CMS) released a memo for nursing homes, QSO-23-05-NH, on Jan. 18, 2023, with updates to Care Compare, Five-Star ratings, and adjusting quality measure (QM) ratings based on erroneous schizophrenia coding.

One of the QMs used to calculate the QM star rating is the percentage of long-stay residents who receive antipsychotics. This is a Minimum Data Set (MDS)-based measure that has several exclusions. The one exclusion that CMS is concerned with is residents with a diagnosis of schizophrenia and accuracy of coding it on the MDS.

CMS will immediately begin offsite auditing of schizophrenia coding. The auditing process will examine evidence that the facility documented, assessed, and coded a diagnosis of schizophrenia appropriately. Issues found on past pilot audits were the absence of comprehensive psychiatric evaluations, behavior documentation, and identifying behaviors related to schizophrenia versus dementia with behaviors and psychological symptoms of psychosis (BPSP), which include agitation, delusional beliefs, repetitive questioning, hallucinations, and wandering. Facilities selected for the audit will receive a letter explaining the process and instructions for providing supporting documentation. There will be a penalty for facilities with inaccurate coding:

• The overall QM and long-stay QM star ratings will be downgraded to one star for six months, dropping the overall star rating by one star;
• The short-stay QM rating will be suppressed for six months; and
• The long-stay antipsychotic QM will be suppressed for 12 months.

There will be a lesser action option for facilities selected for the audit. Facilities that admit to miscoding prior to the start of the audit and commit to correcting the issue will have their QM ratings suppressed rather than downgraded. This is a facility choice, and there are several actions that you can take to identify miscoding so that you can make that decision once it is presented to you. First, work with your pharmacist to ascertain antipsychotic use. Do a medical record review for residents on antipsychotics for supporting documentation. There are several resources that leadership and MDS Coordinators can use, including the MDS 3.0 Resident Assessment Instrument (RAI) User’s Manual (v1.17.1R) Errata (v2) (page 2) released in July 2022 and Appendix PP released in October 2022. The errata provides guidance to assessment coordinators for accurately coding a diagnosis of schizophrenia on the MDS, and Appendix PP provides guidance for documentation contained in the medical record that supports the use of antipsychotics. Ensure that your psychiatric providers and medical directors are using the appropriate standards for providing a schizophrenia diagnosis. The professional standards for diagnosing schizophrenia are in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM – 5). The final step in the decision process is to review your Five-Star Report to ascertain the implications of the penalty versus suppression if you identified coding issues during your medical record review. Only you can decide what is best. If you need assistance in understanding your Five-Star implications, LeadingAge NY offers its members free Five-Star consults.

Another valuable resource is the National Partnership to Improve Dementia Care in Nursing Homes. Consider dementia training for caregivers, review your trauma-informed care policies, and implement and monitor the effect of therapeutic interventions for behaviors prior to using, while using, and instead of using antipsychotics, including music therapy, aroma therapy, art therapy, bright light therapy, therapeutic touch, reality orientation, activities, and physical exercise.

For more information or to learn more about Five-Star consults, please contact Susan Chenail.

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