CMS to Audit Schizophrenia Coding – and Adjust QMs – Based on Results

In a media release issued this morning, “Biden-Harris Administration Takes Additional Steps to Strengthen Nursing Home Safety and Transparency: CMS to increase oversight of inappropriate antipsychotic use,” the Centers for Medicare and Medicaid Services (CMS) announced some important changes that providers need to be aware of.

As you are likely aware, CMS recently indicated that it is aware of situations where residents have been coded as having a diagnosis of schizophrenia in order to have them excluded from the Quality Measure related to Long Stay residents receiving an antipsychotic. Schizophrenia, Tourette’s and Huntington’s disease are the three diagnoses that are excluded from this QM. As such, CMS believes that some nursing homes have coded residents as having schizophrenia in order to “mask” their actual rate of antipsychotic use for the QM on Care Compare.

 Let’s look at a key section of today’s press release as it relates to potentially inappropriate coding of schizophrenia in nursing home residents:

“Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medications. Antipsychotic medications are especially dangerous among the nursing home population due to their potential devastating side effects, including death. This action advances the Biden-Harris Administration’s goal of reinforcing safeguards against unnecessary medications and treatments that was outlined in President Biden’s State of the Union Action Plan for Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes.

We have made significant progress in decreasing the inappropriate use of antipsychotic medications in nursing homes, but more needs to be done,” said CMS Administrator Chiquita Brooks-LaSure. “People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications.”

This action furthers the Administration’s objective to improve the accuracy of the quality information that is publicly reported and the nursing home Five-Star Rating System. The use of antipsychotic medications among nursing home residents is an indicator of nursing home quality and used in a nursing home’s Five-Star rating, however it excludes residents with schizophrenia. If an audit identifies that a facility has a pattern of inaccurately coding residents as having schizophrenia, the facility’s Five-Star Quality Measure Rating on the Care Compare site will be negatively impacted. For audits that reveal inaccurate coding, CMS will downgrade the facility’s Quality Measure ratings to one star, which would drop their Overall Star Rating as well. CMS will monitor each facility’s data to determine whether they have addressed the identified issues. After that, CMS will decide whether any downgrades should be reversed.”

In a companion QSO Memo also released today, January 18, 2023, CMS provides information for discussion related to how the Agency will adjust Quality Measures if it identifies erroneous coding during these offsite audits. These audits come on the heels of the 2016 onsite focused schizophrenia surveys and pilot offsite audits conducted recently. Those surveys and audits identified concerns, so CMS is now taking additional steps to ensure appropriate coding – and adding repercussions.

The Process

CMS will be auditing accuracy of the MDS offsite to determine if providers have appropriately documented, assessed and coded a diagnosis of schizophrenia for their residents. Facilities that are selected for auditing will receive a notification letter. That letter will include information on the process and instructions for providing documentation to CMS. The QSO Memo notes that providers will be able to ask questions during the process and once the audit is concluded, will also be able to discuss the audit results with CMS.

Any facility that has been identified with a pattern of coding inaccuracies identified will have CMS monitor and audit its information submitted to determine if it has addressed the identified issues. This data will also be audited to determine if the changes the temporary changes made to the star ratings should be changed (discussed below). CMS may also conduct a follow-up audit to confirm the corrections have been made.

The Agency is also offering providers an opportunity to admit that they have made coding errors and commit to correcting the identified issues in lieu of CMS conducting the audit. If a provider chooses this option and CMS has not started its audit process yet, then a lesser action will be taken related to a provider’s Five-Star Quality Rating.

Let’s look at what can happen to your star rating if an audit identifies inaccuracies.

Audit Findings (and their impact on QM Ratings)

Five Star Rating

CMS plans to take some pretty drastic actions if it identifies MDS coding inaccuracies related to schizophrenia.

If a provider has inaccurate coding identified, the following will occur:

  • Overall Quality Measure rating will be downgraded to 1 star for 6 months and the Long-Stay Quality Measure rating will be downgraded to 1 star for the same time period. The result is the facility’s Overall star rating is reduced by one star.
  • Short-Stay Quality Measure rating will be suppressed for 6 months
  • Long-Stay Antipsychotic Quality Measure will be suppressed for 12 months

The QSO Memo does not indicate what happens if a provider does not correct the identified coding issues within these timeframes. As mentioned above, CMS will be monitoring and auditing the information provided by facilities to determine when the ratings changes could be lifted.

For full details, view the CMS QSO Memo “Updates to the Nursing Home Care Compare Website and Five Star Quality Rating System: Quality Measure Ratings Based on Erroneous Schizophrenia Coding and Posting Citations Under Dispute (Ref: QSO-23-05-NH). You can view our recent CMSCG Blog post related to the second part of this QSO Memo (IDR/IIDR), here.

Reach out today and let's get started!

Urgent Compliance Concern? Call CMSCG

(631) 692-4422
cmscg podcast. five-star quality

Contact CMS Compliance Group

© 2011-2024 CMS Compliance Group, Inc. All Rights Reserved. Privacy Policy