LeadingAge has recently heard increased concerns regarding schizophrenia audits. Members have expressed frustration in the process and seeming lack of transparency around these audits. LeadingAge has been in contact with both the Centers for Medicare & Medicaid Services (CMS) and the Center of Excellence for Behavioral Health in Nursing Facilities in an attempt to learn more.

While we have been unable to obtain data about the number of audits being conducted or rates of success and failure among nursing homes selected for audits, we hear anecdotally that few nursing homes are passing. We are told that nursing homes often have little or no documentation to show how a clinician arrived at a diagnosis of schizophrenia. We have compiled the information below to support members who may be facing audits.

What to Know About Schizophrenia

According to the American Psychiatric Association, schizophrenia is a chronic brain disorder that affects less than 1% of the U.S. population. Symptoms fall into three major categories:

• Positive symptoms, such as hallucinations and delusions.
• Negative symptoms, such as flat affect and impaired ability to engage in goal-directed behavior.
• Disorganized symptoms, such as disorganized thinking and bizarre behavior.

Symptoms usually impact multiple domains of functioning such as the ability to hold a job or maintain relationships. The average age of onset for schizophrenia is late teens / early twenties for men and twenties / early thirties for women. Individuals must display symptoms for a period of at least six months to appropriately assign diagnosis.

What to Know About Schizophrenia Audits

CMS began conducting schizophrenia audits in 2023 in an effort to identify erroneous coding of schizophrenia on the Minimum Data Set (MDS) assessment. As explained in CMS memo QSO-23-05-NH, CMS believes that providers may be erroneously diagnosing and coding nursing home residents as having schizophrenia in order to mask antipsychotic usage rates and artificially improve ratings on antipsychotic quality measures. These off-site audits are purported to target nursing homes with unusually high rates of new schizophrenia diagnoses. That is, nursing homes with high numbers of residents for which no schizophrenia diagnoses were coded on admission assessments but were later coded on subsequent assessments.

During audits, identified nursing homes are requested to provide documentation from the residents’ medical records to justify schizophrenia diagnoses. CMS is looking for a clear path from Point A to Point B. How did you arrive at a diagnosis of schizophrenia for this individual? For individuals admitted with a diagnosis, how did you confirm that this was the correct diagnosis? A simple diagnosis code on an evaluation will not work. Frankly, a checklist of symptoms on a psychiatric evaluation form will not work, even if the identified symptoms follow the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) perfectly. CMS wants to see clear evidence supporting a diagnosis and coding of schizophrenia including how the resident was assessed, symptoms and behaviors observed over a period of time, how other conditions were ruled out, and the resident’s current care plan.

Based on the documentation provided during the audit, CMS determines whether the diagnosis and MDS coding are accurate. For nursing homes that are found to have inaccurately coded schizophrenia on the MDS, ratings are downgraded and/or suppressed on Nursing Home Care Compare. CMS will continue to monitor identified nursing homes’ data after the audit to verify that identified issues have been corrected and to determine if ratings downgrades or suppressions should be lifted.

What You Can Do

Start by auditing your MDS records. Many medical record software companies have features that will allow you to run a report by diagnosis. Find out how many residents have a diagnosis of schizophrenia, then investigate those records. Don’t forget about closed records.

When investigating the medical record, confirming, or contemplating assignment of this diagnosis, remember schizophrenia is a pervasive mental illness. If you are not seeing impairment across multiple areas of the individual’s functioning and if there is no evidence of impairment spanning throughout the individual’s adult years, you may need to speak with the clinician about a differential diagnosis.

There are many reasons an individual may require the use of antipsychotic medications. The positive, negative, and disorganized symptoms of psychosis may be associated with a number of mental or physical conditions including mood disorders, cognitive disorders, delirium, and end-of-life conditions. Remember: you are not being audited on antipsychotic prescribing practices. You are being audited on the accuracy of schizophrenia diagnoses.

For more information about diagnosing and supporting individuals with behavioral health issues living in nursing homes, check out the Center of Excellence for Behavioral Health in Nursing Facilities.