I understand that CMS will be conducting audits of schizophrenia coding in the MDS data and potentially adjusting the long-stay residents who are receiving antipsychotic drugs QM ratings when inaccurate coding is found. What are the criteria for diagnosing Schizophrenia?



The DSM-5 outlines 5 primary criteria for diagnosing schizophrenia:

  • The patient must exhibit 2 or more of the following:
      • Delusions
      • Hallucinations
      • Disorganized speech (such as speaking incoherently, losing track of thoughts)
      • Disorganized or catatonic behavior
      • Negative symptoms
  • Level of functioning has declined
  • Criterion A symptoms have been present for a minimum of 6 months
  • Schizoaffective disorder, major depression, and bipolar disorder have been ruled out
  • Substance use/abuse has been ruled out as a cause

To be diagnosed, a group of these symptoms and features must be exhibited—experiencing only one or two is insufficient.  For a schizophrenia diagnosis, the patient must have the following at a minimum:

      • At least two symptoms from Criteria A
      • One of those two must be delusions, hallucinations, or disorganized speech.
      • These must have been present for at least one month.

In addition, symptoms must impair life activities (e.g. work, relationships, self-care) and be exhibited as a new problem that is a decline in prior status. Additionally, symptoms must have a duration of at least a month with symptoms present at least some of the time for six consecutive months.

In July 2022, CMS released an Errata document to the RAI MDS 3.0 User Manual that clarifies the need for a detailed evaluation and appropriate diagnostic information to support a diagnosis, such as for a mental disorder, prior to coding the diagnosis on the MDS.  The RAI manual update further clarifies that in situations where a resident has been potentially misdiagnosed, a referral by the facility and/or the survey team to the State Medical Boards or Boards of Nursing may be necessary. In the update, the following example was provided related to coding of a schizophrenia diagnosis in section I:

The resident was admitted without a diagnosis of schizophrenia. After admission, the resident is prescribed an antipsychotic medication for schizophrenia by the primary care physician. However, the resident’s medical record includes no documentation of a detailed evaluation by an appropriate practitioner of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for six months prior to the start of the antipsychotic medication in accordance with professional standards.

Coding: Schizophrenia item (I6000), would not be checked.

Rationale: Although the resident has a physician diagnosis of schizophrenia and is receiving antipsychotic medications, coding the schizophrenia diagnosis would not be appropriate because of the lack of documentation of a detailed evaluation, in accordance with professional standards (§483.21(b)(3)(i)), of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for the time period required.

Written by: Proactive Consultant

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