Short and Long-Term Antipsychotic Quality Measures and Behavior Quality Measure

Overview

The Antipsychotic Drug Use QMs are of great concern to CMS and surveyors. The exclusions to these measures include the diagnoses of Schizophrenia, Schizoaffective Disorder, and Schizophreniform Disorder. These diagnoses are often coded without sufficient documentation to support that the diagnoses are accurate for that resident. The surveyors will be reviewing documentation to identify whether QMs were incorrectly not triggered due to coding these diagnoses in MDS item I6000 (Schizophrenia). This presentation will discuss the documentation requirements that must be met prior to coding a mental health diagnosis per the updated Appendix PP guidance to surveyors that became effective April 28, 2025. CMS has initiated Schizophrenia Audits that are continuing that focus on whether there was sufficient documentation present prior to MDS coding of Schizophrenia diagnoses in MDS item I6000. Even one record identified during an audit where Schizophrenia was coded in I6000 without sufficient documentation would be considered a failed audit. CMS conducts audits of schizophrenia coding in the MDS. Facilities that have coding inaccuracies identified through these audits have their QM ratings adjusted as follows:

• The overall QM and long-stay QM ratings are downgraded to one star for six months (Note that this drops the facility’s overall star rating by one star).
• For months 7-12, the facility will receive the minimum number of points for the long-stay antipsychotic QM.
• The short-stay QM rating is suppressed for six months.
• The long-stay antipsychotic QM is suppressed for 12 months.

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

This presentation will focus on the difference between long and short stay QM criteria, look-back scan measures and how they differ from regular QMs. The short-stay Antipsychotic Drug use QM utilizes a look-back scan. The presentation will carefully walk the attendees through each of the 3 Quality Measures—intent—numerator (those who have the triggering issue), the denominator (those who could have had the issue which includes all residents who were not excluded from the QM calculation), the exclusions and the risk adjustment. The presenter will also share the best practices for care planning for residents who do trigger the Quality Measures. The regulations related to psychotropic drug use will also be covered during this presentation.