Alert from CMS: Misdiagnosis and Coding of Schizophrenia in Nursing Homes

The Centers for Medicare and Medicaid Services (CMS) are responsible for the oversight and health and safety of nursing home residents. Over the past decade, through the work of the National Partnership to Improve Dementia Care in Nursing Homes, CMS has been monitoring antipsychotic medication use in nursing homes. Though steps have been taken to reduce the use of these drugs, there continue to be concerns that nursing home residents may be inappropriately prescribed antipsychotic medications as a result of being misdiagnosed and coded as having schizophrenia, see the Office of Inspector General report for more information. Antipsychotic medications are dangerous among the vulnerable nursing home population because of their potential side effects, including death.

To increase our focus on this issue, CMS will conduct off-site nursing home audits to assess the accuracy of Minimum Data Set (MDS) data. Specifically, to determine whether or not the facility is appropriately assessing, diagnosing, and coding schizophrenia in the MDS for residents in their facility. These efforts are aligned with the latest actions under The White House Fact Sheet: Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Home.

If the audit reveals a pattern of inaccurate coding, this practice will negatively impact a facility’s Five-Star Quality Measure Rating on Nursing Home Care Compare. In addition to CMS’ actions, we believe that some of these instances may represent actions that are inconsistent with the expectations of the board of licensure. As such, if there are instances where a practitioner has not followed the expected standards for diagnosing individuals and/or prescribing medications, we believe these practitioners should be referred to their respective state boards for investigation.


See the following resources related to reducing the use of antipsychotic medications and appropriately assessing, diagnosing, and coding schizophrenia in the MDS:

Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual (Manual (page 2 of the Errata (v2) effective July 15, 2022)

Refer to pg. 352 for the process of appropriately assessing and coding a diagnosis of schizophrenia in the MDS for residents of your long-term care facility. Specifically, you should ensure the medical record of a resident diagnosed with schizophrenia contains documentation of a comprehensive medical and psychiatric evaluation, completed by diagnosing a Medical Director or licensed psychiatric practitioner, that meets professional standards of practice (for example, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)), at the time of the initial diagnosis of schizophrenia. Listing schizophrenia as a diagnosis on a medical record (i.e., problem list) is not sufficient.

State Operations Manual Appendix PP - Guidance to Surveyors for Long-Term Care Facilities

F658 - Services Provided Meet Professional Standards F740 – Behavioral Health Services F758 - Free from Unnecessary Psychotropic Meds/PRN Use

Quality Improvement Organizations

Facilities can locate their QIO by visiting Locate Your QIO |