Wow! What a new year.
Wait… I don’t mean that I partied hard. No, I was in bed fast asleep well before midnight. Yes, I’m that guy. “Auld Lang Syne” was sung to swaying champagne glasses while I happily snoozed in the new year.
I mean, where did 2022 go? And, hang on for the wild ride 2023 will be. So much lies ahead of us and we need to be prepared.
In a late 2022 Open Door Forum, the Centers for Medicare & Medicaid Services indicated that we should expect the revised RAI Manual sometime early Q2 2023 and that training videos will be available by May. I am eagerly awaiting this as much as you are.
As we wait, there is still MDS v1.17.2 that we are required to complete accurately via the guidelines in the RAI manual v1.17.1 which, incidentally, has been updated with two errata documents since 2019.
In July 2022, CMS issued the second of these documents as a result of language that was added to the State Operations Manual (SOM) Appendix PP related to the qualifications for diagnosing someone with schizophrenia. Here’s the sequence.
SOM Appendix PP
F641 and F658 — “CMS is aware of situations where practitioners have potentially misdiagnosed residents with a condition for which antipsychotics are an approved use (e.g., new diagnosis of schizophrenia) which would then exclude the resident from the long-stay antipsychotic quality measure. For these situations, determine if non-compliance exists for the facility’s completion of an accurate assessment. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing.”
F740 — “Schizophrenia must be diagnosed by a qualified practitioner, using evidence-based criteria and professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders – Fifth edition (DSM-5), and documented in the resident’s medical record.”
RAI Manual (Errata p. I-12)
“In situations where practitioners have potentially misdiagnosed residents with a condition for which there is a lack of appropriate diagnostic information in the medical record, such as for a mental disorder, the corresponding diagnosis in Section I should not be coded, and a referral by the facility and/or the survey team to the State Medical Boards or Boards of Nursing may be necessary.”
RAI Manual (Errata p.I-16 supporting example)
“The resident was admitted without a diagnosis of schizophrenia. After admission, the resident is prescribed an antipsychotic medication for schizophrenia by the primary care physician. However, the resident’s medical record includes no documentation of a detailed evaluation by an appropriate practitioner of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for six months prior to the start of the antipsychotic medication in accordance with professional standards.”
Misdiagnosing schizophrenia in an attempt to circumvent a quality measure hit is clearly on CMS’ radar screen. Not only are there survey non-compliance consequences, but referrals to outside agencies for assessment inaccuracies that result are also on the table.
Remember that the Short Stay percent of residents who newly received an antipsychotic medication quality measure is one of two measures affecting the Five-Star rating where more than 20% of nursing homes have a QM value of 0%, and so CMS has set a strict benchmark of 0% in order to receive 100 points. This is a high bar making it a challenge for providers to achieve 100 points.
MDS accuracy is also in the bull’s-eye when it comes to coding item I6000. Let’s not forget the attestation statement at the beginning of section Z0400 that states, in part, “I certify that the accompanying information accurately reflects resident assessment information for this resident,” and that, “I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information.”
Looking to the future, with the implementation of MDS 3.0 v1.18.11 in October 2021, section N will require that an indication be present for any of the high-risk drug classes listed there, including antipsychotics. If the new item N0415A, “Antipsychotic,” is checked and a diagnosis of schizophrenia is the indication for this medication, it (schizophrenia) must meet diagnostic criteria such as is indicated in the MDS Errata example.
The SOM Appendix PP also indicates that for F756, an example of noncompliance that demonstrates severity at Level 4 includes, “On the MRR, the pharmacist identified that a resident was prescribed an antipsychotic medication without a clinical indication. This placed the resident at likely risk for harm such as experiencing a fall, mental status changes, or sustained negative psychosocial outcomes. The medical record did not show evidence that the attending physician had reviewed and responded to the identified irregularity.” The irregularity here is lack of an indication for an antipsychotic. The likelihood that a misdiagnosed schizophrenia may rise to this type of irregularity seems implicit.
And then there is the whole antipsychotic reduction process recorded in section N as well. The current RAI Manual as well as appendix PP of the SOM lay out explicit guidelines that are expected to be followed relative to the items coded at MDS item N0450. Physician involvement is imperative, and documentation is key.
The snowball of compliance requirements related to a diagnosis of schizophrenia and the appropriate use of antipsychotic medication has grown large. MDS coordinators are the fulcrum, balancing accurate coding of the MDS that reflects compliant diagnosing and appropriate medication use. Much is on the line for non-compliance.
Here’s a funny New Year’s Eve quip I heard recently, “Youth is when you’re allowed to stay up late on New Year’s Eve. Middle age is when you’re forced to.” I guess I relate to the middle age part. That’s OK. I’m resolved to make the most and best of this stage of my life, snoozing in the new year notwithstanding.
Did you know that the Scottish phrase “auld lang syne” means times long past? Here in this new year, as we face a new MDS and continued compliance requirements related to antipsychotic medication and schizophrenia diagnoses, let’s reminisce and resolve to continue to place the resident at the center of everything.
Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.