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CMS Schizophrenia Audits - What You Need to Know

Background:

On January 18, 2023, in a CMS press release titled, “Biden-Harris Administration Takes Additional Steps to Strengthen Nursing Home Safety and Transparency”, it was announced that beginning in January 2023, CMS will begin conducting targeted, off-site audits on the appropriate diagnosing of schizophrenia and the use of antipsychotic medication.

The article identified that in 2016 and earlier this year, previous audits identified several issues related to inaccurate coding on the MDS of the diagnosis of schizophrenia. The current long stay quality measure for antipsychotic use excludes residents with an active diagnosis of schizophrenia, Huntington’s disease, or Tourette syndrome. Therefore, erroneously coding residents as having schizophrenia can mask a facility’s true rate of antipsychotic medication use.

Furthermore, a QSO memo regarding updates to Five Star QM Ratings (Click Here) was released on January 18, 2023 that indicated if a facility is involved in an audit that determines a pattern of inaccuracy coding residents as schizophrenia, CMS will adjust Quality Measure Ratings as follows:

  1. Overall Quality Measure and Long-Stay Quality Measure Star Rating will be downgraded to 1 star for 6 months

    1. This has the potential to drop the overall stay rating by 1 star

  2. Short-Stay Quality Measure Star Rating will be suppressed for 6 months

  3. Long-Stay Quality Measure Rating for antipsychotic use will be suppressed for 12 months, and facility will receive the minimum number of 15 points for this measure

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

Audit Requests and Process: Audits have already started coming in to selected facilities. These audit requests identify that Myers and Stauffer LC have been selected as the audit contractor and that this audit will “examine the process for appropriately assessing and coding a diagnosis of schizophrenia in the MDS for residents of your long-term care facility.” Upon receipt of the audit request, a facility only has two business days to respond to the letter and fill out the forms required to move forward. Following submission of the required information, steps are taken to schedule an entrance conference. The auditor requests remote access to the EMR to review supporting documentation. If a facility does not utilize an EMR, the records are required to be uploaded to a secure web portal. At the conclusion of the audit, an exit conference is held, and the final results are loaded onto the secure web portal.

Develop a Coordinated Plan at your SNF:  It’s best to be proactive and review your facility potential for problems prior to being involved in any type of CMS audit/review. Therefore, we have outlined the steps below you can take to review the potential risk at your facility.


1. Review and audit residents with a diagnosis of schizophrenia – Utilizing pharmacy and/or EMR reports, identify all residents who have an active diagnosis of schizophrenia in your facility. This is coded in I6000 of the MDS and includes schizoaffective and schizophreniform disorders as well.


2. If schizophrenia was diagnosed after admission, consider if it was appropriately diagnosed- NIH- National Library of Medicine identifies DSM-5 Schizophrenia diagnosing criteria that is to be followed by diagnosing practitioners. Some of the issues after medical record review identified by CMS are identified below:

Issues to look for in medical records: ​

  • Lack of comprehensive psychiatric evaluations, in accordance with professional standards of the resident’s mental, physical, psychosocial, and functional status​

  • Lack of behavior documentation​ in medical record

  • Sporadic behavior documented in the medical record, and behaviors related to dementia, rather than schizophrenia ​

  • Documentation of persistent behaviors for the time-period required ​

3. Involve the Practitioner who diagnosed the resident- If concerns are present on whether a comprehensive evaluation was conducted at the time schizophrenia was diagnosed, do not hesitate to reach out to the diagnosing Practitioner for clarification.

4. Refer resident for psychiatric consult, if applicable​


5. Make corrections/modifications to MDS, if applicable​- If it is identified that an appropriate diagnosis of schizophrenia was not supported during the review, consider making modifications/corrections to prior MDS assessments completed.

Engage With Us

If you have any questions about these changes, please do not hesitate to reach out to Engage Consulting’s Director of Clinical Consulting, Jennifer Napier at jennifern@engageconsultingpartners.com.


In case you missed it, click here to watch the recording of our latest webinar, "Outcome Drivers for Clinical, Financial and Operational Success with 2023 Changes" that highlights these changes and more to come in 2023.

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