LeadingAge participated in a call with the Centers for Medicare & Medicaid Services (CMS) on February 2 to learn more about the recently announced schizophrenia audits. CMS has initiated these audits, announced on January 18 in QSO-23-05-NH, in an attempt to identify instances of erroneous coding and diagnosing of schizophrenia for the assumed purpose of justifying antipsychotic usage. Erroneous coding will result in penalties on Nursing Home Care Compare. Read on to learn more.

Schizophrenia Audit Selection and Notification

CMS will utilize Minimum Data Set (MDS) data to identify patterns of potentially erroneous coding. Nursing homes identified for audit will be notified by certified letter with additional information describing the process. The certified letter will contain information about audit timelines, the kinds of documentation that will be reviewed in the audit process, and how this information will be accessed. The certified letter will also include an attestation form for nursing homes that choose to attest to erroneous coding and forego the audit process.

Attestation to Forego Audit

Nursing homes selected for audit may choose to forego the audit process by completing an attestation form to admit to erroneous coding of schizophrenia on the MDS. Nursing homes attesting to erroneous coding will provide information to CMS on the circumstances leading to coding error and how the nursing home plans to correct these errors and processes.

Penalties for Erroneous Coding

Nursing homes identified to have erroneously coded schizophrenia on the MDS will be penalized through the Quality Measures domain on Nursing Home Care Compare. Nursing homes that “fail” audit, meaning the schizophrenia diagnoses could not be verified, will have their ratings adjusted as follows:

• Overall Quality Measure domain rating and long stay Quality Measure ratings will be downgraded to one star for 6 months. This will result in the nursing home’s overall Five Star Quality Rating being downgraded by one star.
• The short stay Quality Measure ratings will be suppressed for 6 months.
• The long stay antipsychotic measure will be suppressed for 12 months.

Nursing homes that choose to forego an audit and attest to coding errors will receive lesser penalties on Nursing Home Care Compare.

Monitoring and Follow Up

CMS will continue to monitor all facilities identified for an audit, regardless of the outcome of the audit. The length of follow up will vary and is intended to confirm process change. CMS will also share this information with the state survey agency for all nursing homes identified for audit.

For resources that may be helpful in identifying coding inaccuracies and addressing ineffective processes, visit the LeadingAge RoPs Tools and Resources page.