QSO Memo: Audit of Schizophrenia Diagnosis & Antipsychotic Use; Posting Citations Under IDR/IIDR

On January 18th, CMS posted QSO-23-05-NH and there are several key areas to highlight:
  • Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding: The quality measure for long-stay residents who are receiving antipsychotic drugs allows for an exclusion of any residents with a diagnosis of schizophrenia, Huntington's disease, or Tourette syndrome. CMS is concerned that facilities are erroneously coding residents as having schizophrenia, to exclude residents from counting towards the metric. CMS will be conducting audits of schizophrenia coding in the Minimum Data Set data and, based upon the results, adjust the Nursing Home Care Compare quality measure star ratings for facilities whose audits reveal inaccurate coding.
If CMS finds inaccurate MDS coding, the facility star rating will be negatively impacted:
  • The overall QM and long stay QM ratings will be downgraded to one star for six months (this drops the facility's 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.
  • CMS will monitor audited data to identify if facilities with coding inaccuracies have addressed the issues. Follow up audit may be conducted to confirm issue is corrected.
What do we know about the audits?
  • Audits will be conducted offsite.
  • Facilities selected will receive a letter explaining audit purpose, process, instructions for providing supporting documentation.
  • Facility has opportunity to ask questions and seek any clarification needed.
  • CMS is examining evidence for appropriately documenting, assessing and coding diagnosis in MDS (Such as, comprehensive psychiatric evaluation(s), Behavior documentation).
  • At conclusion of audit, facility will have opportunity to discuss audit results with CMS.
  • Facilities have the opportunity to forgo audit by admitting errors and committing to correct the issue. If done prior to start of audit, CMS will consider lesser action related to their star ratings, such as suppression of QM ratings (rather than downgrade).
  • Posting Citations Under Informal Dispute Resolution and Independent Informal Dispute Resolution (IDR/IIDR):
    • Beginning on January 25, 2023, CMS will post deficiency citations under IDR/IIDR in each section of Nursing Home Care Compare that currently displays citations, and will indicate if a citation is under dispute.
    • CMS cites that the resolution process can take up to 60 days therefore the consumer is unaware of this information until after the process is complete. CMS also states that this will provide transparency to consumers, especially when deficiencies are identified as Immediate Jeopardy.
    • The results will not be included in the star rating calculation until the IDR/IIDR is resolved.
    • If, based on the results of the IDR/IIDR process, the citations are upheld, they will remain posted and will be included in the calculation of the facility's star rating if applicable.
    • If the citations are overturned (i.e., removed), they will be removed from the website.
    • If the level of scope or severity of a citation is reduced, the citation will be displayed at the reduced level.
To read the full QSO-23-05-NH click here.  
Staff contact: