Revised Ftag of the Week – F658 Services Provided Meet Professional Standards (Pt. 2)

In Part 1 of our revised Ftag of the Week for F658, we reviewed the significant guidance addition to the tag related to documentation requirements to support mental health diagnoses. The revised Interpretive Guidance in Appendix PP includes long lists of examples of what would be considered insufficient documentation to support a new or existing mental health diagnosis. So, while schizophrenia and related diagnoses would fit into these lists already reviewed, the Centers for Medicare & Medicaid Services (CMS) decided that there needed to be even more guidance for surveyors to help them understand if a diagnosis has been validated with sufficient supporting documentation.

The revised guidance comes from the DSM-5, which is the “Bible” for diagnosing mental disorders. Even if you’re not familiar with it, you need to ensure your diagnosing practitioner is, because if all the boxes aren’t being checked, then there’s going to be a problem validating the diagnosis.  

Let’s Start with Schizophrenia

The Interpretive Guidance notes that CMS is “aware” that residents have been given a diagnosis without enough supporting documentation to meet the DSM diagnostic criteria for the condition. Let’s review the diagnostic criteria for schizophrenia, and while you’re reading, consider how schizophrenia presents differently than your residents who are diagnosed with dementia present.

First, remember that Schizophrenia is usually early onset, so when there are droves of individuals with this new diagnosis added later in life (when they’re more likely to be diagnosed with dementia), it’s not surprising that it set off alarm bells at CMS. Now let’s look at what needs to be present to meet the diagnostic criteria.

1. Symptoms – Two or more of these, with each present for a “significant” portion of time during a time frame of 1 month, or less if successfully treated: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior or negative symptoms. At least one of the symptoms must be delusions, hallucinations or disorganized speech.
2. Functioning – Since the onset of the disturbance and for a significant part of the time, the individual’s level of functioning in one or more major areas is markedly below the prior level achieved before onset. Major areas of functioning include interpersonal relations, self-care or occupation. If the onset occurs in childhood/ adolescence, then the benchmark would be that the expected level of functioning in areas such as academics or interpersonal relations is used instead.
3. Persistence of disturbance – Over a 6-month period, there must be continuous signs of the disturbance since its onset. This must include at least one more of the symptoms (or less if successfully treated) as indicated above. Periods of prodromal or residual symptoms may occur during this period where the only signs of disturbance exhibited may be only negative symptoms or lesser versions of two or more of the symptoms listed above.
4. Rule–out of other key disorders – Schizoaffective disorder and depressive disorder or bipolar disorder with psychotic features must be ruled out as part of the diagnostic process. This means that there have been no major depressive or manic episodes which occurred concurrently during the active phase of the episodes or if these have occurred, they have only been present for a minority of the total duration of the illness. Complex, right? That’s why a comprehensive psych eval should be completed to validate this diagnosis – and something that those CMS auditors will definitely look for.
5. Disturbance is not related to other events – The episode also can’t be due to the physiological effects of a substance, whether a medication or from an illicit substance, or due to another medical condition.
6. Link to Autism Spectrum or Communication Disorder – This is an interesting element that more facilities should pay attention to since a gap is sometimes observed in validating that symptoms are actually schizophrenia versus behavioral manifestations of one of these concerns. Per the DSM, if there is a history of autism spectrum disorder or a childhood-onset communication disorder, then the additional diagnosis of schizophrenia would only be made if the required symptoms of schizophrenia, including prominent delusions or hallucinations have been present for at least one month (or less if significantly treated).

Then There’s Schizophreniform and Schizoaffective Disorder . . .

The revised guidance also addresses the DSM-5 criteria for schizophreniform disorder and schizoaffective disorders.

• Schizophreniform is characterized by symptoms which are similar to those present for schizophrenia, but there are two differences. First, there does not need to be a decline in functioning. Second, there does not need to be as long of a duration (6 months) to make the diagnosis. That means that an episode would be at least 1 month, but less than 6. The other diagnostic criteria from #4 and #5 above apply here as well.

Schizoaffective disorder, on the other hand, has different criteria.

• It includes an uninterrupted period of illness where a major depressive or manic mood episode occurs concurrent with the criteria set out in #1 above. There must also be a depressed mood.
• In the absence of a major mood episode during the lifetime duration of the illness, there must be evidence of delusions or hallucinations for 2 or more weeks.  
• There must be symptoms present which meet the criteria of a major mood episode for the majority of the total duration of the illness (both active and residual).
• The effects of another medical condition or a substance have been ruled out.

Note that since the surveyors are likely to not be medical practitioners, they are guided to review if the documentation shows how the practitioner arrived at a particular diagnosis using the DSM criteria. Since they have given them the criteria in Appendix PP, the hope is that they can just follow right along.

The surveyor is also guided to ask if other underlying conditions were ruled out prior to diagnosing the individual with schizophrenia. There should also be documentation from the physician indicating what medical and other pertinent information has been reviewed for the resident regarding the diagnosis decision.  This is the time for the physician to write a comprehensive assessment progress note.

The revisions for F658 seem like a lot, but remember, noncompliance with this tag is based on not providing or arranging for services, particularly related to diagnosing a resident, which did not adhere to accepted standards of quality – aka the DSM-5 criteria. Time to review these requirements with your medical staff to ensure that they understand what is expected of them.