A Big Change Is Showing Up in Your QM Reports: Hybrid Long-Stay Antipsychotic Measure
The new Hybrid Long-Stay Antipsychotic Quality Measure is now live and visible on MDS 3.0 QM reports resulting in dramatic shifts in scoring for some facilities. If you haven’t already, now’s the time to run both your facility-level and resident-level QM reports to review the following…
Where to Find the New Measure
On the facility-level QM report, scroll all the way to the bottom of the page to locate the new Hybrid Long-Stay Antipsychotic Measure. The long-stay antipsychotic measure has undergone a fundamental change in how CMS determines whether a resident triggers this quality measure.
What’s Changed? Claims Data Now Counts — Even Without Administration
Historically, the Long-Stay Antipsychotic QM relied primarily on MDS look-back coding. Under the new hybrid methodology, CMS now uses a combination of MDS data and claims data to determine measure inclusion. This means that a resident can trigger the measure even if no antipsychotic medication was administered during the MDS look-back period. How does that happen? If a Medicare, Medicaid, or pharmacy claim shows that an antipsychotic medication was ordered and billed during the resident’s stay, the resident will count in the numerator — regardless of whether a dose was ever given.
Real-life example:
A physician orders a PRN antipsychotic.
The pharmacy fills the prescription and submits a claim.
The resident never actually receives a dose.
The quality measure still triggers.
This is one of the biggest reasons I’m seeing unexpected changes in facility scores.
Diagnosis Exclusions Are Now Being Double-Validated
CMS is also using claims data to validate exclusionary diagnoses, including:
- Schizophrenia
- Tourette’s Syndrome
- Huntington’s Disease
If one of these diagnoses is coded on the MDS but does not appear on the Medicare or Medicaid claim, the resident will NOT be excluded from the measure. In short:
- An MDS diagnosis alone is no longer enough to stop the resident from triggering
- The diagnosis must be supported by claims data
Timing Matters: What Counts (and What Doesn’t)
A few important clarifications from the updated MDS 3.0 Quality Measure User’s Manual:
- CMS is reviewing claims that occur after SNF admission
- Hospital claims prior to admission should not be included in the antipsychotic look-back
- This remains a long-stay quality measure
- New residents will not trigger this QM during the first 100 days of their stay
What’s Next: Public Reporting
This re-specified Long-Stay Antipsychotic Medication Quality Measure is not just an internal reporting change. The hybrid long-stay antipsychotic measure will begin public reporting on Care Compare (Medicare.gov) in January 2026
- The initial data collection period was July 1, 2025 – September 30, 2025 (Q3 2025)
- Quarterly updates will follow after the initial release
- Resident-level quality measure results will also be available in iQIES
What you are seeing now in your internal QM reports is essentially a preview of what will become publicly visible on Care Compare.
How Should You Prepare?
There are several proactive steps facilities can take now to avoid surprises when this measure appears on Care Compare.
- Monitor Five-Star Preview Reports
Closely review your Five-Star Preview Reports when they become available in iQIES.
- The preview report for the January 2026 refresh is expected around the third week of January 2026
- This preview allows you to see how the measure is calculated before public posting
- Use this time to identify unexpected triggers and validate the data
- Keep ICD-10-CM Coding Up to Date
Because this updated measure incorporates claims data, accurate ICD-10-CM coding is more important than ever.
- Exclusionary diagnoses must be supported not only on the MDS, but also on claims
- Outdated, inactive, or unsupported diagnosis codes may result in residents being incorrectly included in the measure
- Pull and Review QM Package Reports in iQIES
Regularly pulling your QM package reports allows you to:
- Validate the accuracy of the data being used for calculation
- Identify residents triggering due to claims activity
- Conduct targeted chart audits
- Make corrections when appropriate, within allowable timeframes
Being proactive here allows facilities to address issues before scores are publicly posted.
Final Thoughts
This hybrid antipsychotic measure represents a significant shift in how CMS evaluates antipsychotic use in long-stay residents. It reinforces the importance of strong communication between nursing, providers, pharmacy, and the MDS team — and the need to monitor quality measures continuously, not just at survey time. If you haven’t already, now is the time to:
- Run your facility-level and resident-level QM reports
- Understand what’s driving your scores
- Prepare for what will soon be visible on Care Compare
Next Steps:
Need help reviewing reports, auditing residents, or walking through next steps? Contact Proactive to learn more about our QM support services.
Join us starting February 4, 2026 for the new webinar series Roadmap to 5-Star Wins! A 6-week series focused on key insights to develop a stepwise action plan to achieve and sustain 5-Star success in 2026.
Source: mds-qm-users-manual-v18-0
Written By:
Sarah Becker, RN, RAC-CT, DNS-CT, QCP
Director of Clinical Reimbursement
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