The much anticipated changes to the Long Stay Antipsychotic quality measure have finally been posted.
The new specifications are sweeping with claims based data headlining the revisions.
Now, in addition to the MDS, certain claims data from Medicare Part D, Medicaid RX (Pharmacy), Medicaid OT (Other Services), Medicare OP (Outpatient) and other claims, will be used determine antipsychotic use and diagnostic related exclusions in the long stay resident population.
By itself, these changes may not seem so dramatic. However, a closer examination of the actual technical specifications reveals a significant overhaul of this measure.
Here’s the down and dirty. The numerator for this new quality measure now contains 2 parts instead of just 1.
Numerator: Long-stay residents with a selected target assessment who received antipsychotic medication(s). This condition is defined as follows:
1. For assessments with target dates within the target period: N0415A1 = [1]. OR
2. The resident has a claim or encounter record for antipsychotic medication during the target period while the resident is in the facility.
2.1 Resident has a Medicaid RX (Pharmacy) or Medicare Part D claim/encounter record for antipsychotic medication during the NH stay. The timing of the record is determined by the fill date field in the claim/encounter record. OR
2.2 Resident has Medicaid OT (Other Services) claim or Medicare OP (outpatient)/PB (physician/carrier) claim/encounter record for physician-administered antipsychotic medication with a beginning service date/service date during the NH stay. The timing of the record is determined by the beginning service date or the service date field in the claim/encounter record.
In other words, in addition to MDS data, if an antipsychotic is located on a claim during the nursing home stay, it will cause this measure to trigger, unless there is a denominator exclusion. That’s a huge change.
The denominator exclusion list has expanded as well to include specific timeframes for continuous enrollment in specific Medicare and Medicaid programs, Diagnostic criteria found on the MDS and Medicare or Medicaid claims and Hospice.
In QSO-25-20 CMS indicated that the national percentage of residents receiving antipsychotic medication will increase from 14.64% to 16.98% because of the changes to this measure. This will have an impact on star rating come the January care compare refresh even though, undoubtedly, CMS will adjust the 5-star related scoring cut points for this measure to account for the new national trend distributions.
Bottom line is providers will need to heighten their awareness of antipsychotic use among their patient populations and pay attention to residents that show up as triggering for this measure that may not have triggered in the past, once this measure goes into effect January 1st.
My hope is that these new specifications will open up fresh dialogue with CMS to find more equitable ways to address current antipsychotic use among the LTC resident population. We should at least be advocating for more diagnostic exclusions like Bipolar Disorders and Schizoaffective Disorder.
In recent posts, both McKnight’s LTC News and Skilled Nursing News detailed a recent study by the Alliance for Aging Research, that looked at the negative impact the LS Antipsychotic measure is having on appropriate applications of these medication in the LTC setting for diagnoses other than schizophrenia like certain neurodegenerative diseases associated with Alzheimer’s Dementia, even calling for CMS to discontinue this measure altogether.
Only time will tell the impact this new quality measure will have on our clinical practice and the 5-star ratings. Let’s hope that more reasoned heads will prevail as we begin to evaluate the fallout in 2026.
