What We Know About Nursing Home Schizophrenia Audits
(Sept. 9, 2024) LeadingAge National has recently heard increased concern from members and states about the Centers for Medicare and Medicaid Services (CMS) schizophrenia audits. They have reached out to both CMS and the Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) to learn more and have compiled information in an article found here to assist those members who may be facing these audits. While LeadingAge National has been unable to obtain data on the number of audits being conducted or rates of success and failure among nursing homes selected for audits, they are hearing that few homes are passing and that homes often have little or no adequate documentation to show how a clinician arrived at a diagnosis of schizophrenia.
Auditors are looking at things such as individuals admitted with a schizophrenia diagnosis. How was this confirmed as the correct diagnosis? A simple diagnosis code on an evaluation or a checklist of symptoms on a psychiatric evaluation form will not work. CMS wants to see clear evidence supporting a diagnosis and coding of schizophrenia, including how the resident was assessed, symptoms and behaviors observed over a period of time, how other conditions were ruled out, and the resident’s current care plan.
They recommend nursing homes start by auditing their Minimum Data Set (MDS) records. Find out how many residents have a diagnosis of schizophrenia, then investigate those records, and do not forget about closed records. When investigating the medical record, confirming, or contemplating assignment of this diagnosis, remember that schizophrenia is a pervasive mental illness. If you are not seeing impairment across multiple areas of the individual’s functioning, and if there is no evidence of impairment spanning throughout the individual’s adult years, you may need to speak with the clinician about a differential diagnosis. For more information about diagnosing and supporting individuals with behavioral health issues living in nursing homes, the COE-NF has some great free resources for homes.
Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147