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Did You Know? Updated Long-Stay Antipsychotic Use Quality Measure

Mar 10, 2026 | Clinical Insight

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CMS’ Hybrid Long-Stay Antipsychotic Measure is Live

In response to long-standing concerns from the Office of Inspector General (OIG) and other stakeholders about the unnecessary use of antipsychotic medications and potential for underreporting via the MDS dataset, CMS has revised (in effect January 1, 2026) how it calculates the long-stay antipsychotic use quality measure for nursing homes.

The new methodology includes:

  • Medicare Fee-for-Service (FFS) claims
  • Medicaid claims
  • Medicare Advantage (MA) encounter data

These data sets supplement the MDS, reportedly allowing CMS to more accurately capture antipsychotic use, particularly for prescriptions not falling within the MDS’s 7-day lookback window.

MDS-reported exclusion diagnoses (i.e. schizophrenia, Tourette’s syndrome and Huntington’s disease) are also being validated with claims and encounter data to reduce the likelihood of errant exclusion reporting.

We first communicated on this methodology change in June of 2025 with additional updates to Nursing Home Compare and the 5-Star Rating System as announced by CMS. See the below article for additional information:

https://www.hdrxservices.com/did-you-know-updates-to-nursing-home-care-compare/

Key Impacts of the Hybrid Antipsychotic Use Measure

The updated ‘hybrid’ long-stay antipsychotic medication measure begin public reporting on Care Compare on Medicare.gov in January and used 07/01/2025 – 09/30/2025 (Q3 2025) as the initial data collection period. Subsequent updates will follow a quarterly schedule. Resident-level quality measure results will be provided in iQIES prior to public reporting.

In reflection of the updated data collection methods, many facilities have seen their antipsychotic Quality Measure (QM) rate rise. There are steps providers can take to ensure the accuracy of their data prior to public reporting, and we have included some information on how to audit and improve antipsychotic usage rates at your community.

Action Steps for Facilities

To audit and improve your Long-Stay Antipsychotic Use measure before the next Care Compare publication, focus on reconciling MDS coding and medication order(s) accuracy with documentation in your resident’s medical record.

Step 1: Analyze Resident-Level Reports in iQIES

  • Pull Your QM Package Reports: Access the Internet Quality Improvement and Evaluation System (iQIES) to pull both facility-level and resident-level quality measure reports.
    • Check iQIES during the third week of each new quarter (e.g., April 22, 2026) for your preview report.
    • Conduct chart audits and make corrections within allowable timeframes.
  • Identify Claims-Only Triggers: Look for residents who are not coded for antipsychotic use on the MDS but are still triggering the measure.
    • Antipsychotic medications like prochlorperazine (Compazine) may trigger, even when used for nausea.
    • As needed (PRN) antipsychotic medication orders will trigger, even when used sparingly or not at all.

Step 2: Validate Exclusionary Diagnoses

CMS will use claims data to verify the three allowed exclusions: Schizophrenia, Huntington’s Disease and Tourette’s Syndrome.

  • Audit Schizophrenia Documentation: Ensure there is a formal diagnosis from a qualified practitioner (psychiatrist or neurologist) with supporting history in the available medical record.
  • Review Coding Accuracy: Verify that ICD-10-CM codes in your electronic medical record (EMR) match the diagnoses submitted on Medicare / Medicaid claims. Discrepancies can lead to “erroneous coding” audits and a one-star rating downgrade.

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.

Step 3: Audit Antipsychotic Orders and Supporting Documentation

  • Monthly Medication Regimen Review (MRR): Have your consultant pharmacist flag any antipsychotic orders that lack an appropriate ICD10 diagnosis code or lack documentation for clinical rationale in the medical record.
  • Hospital Transfer Audit: Review incoming admissions for new antipsychotic orders. Have providers evaluate the resident and their medical history to determine if the medication should be continued or deprescribed.
  • PRN Orders: Verify that all PRN antipsychotics have a 14-day expiration and a physician evaluation if required beyond that timeframe.
  • Gradual Dose Reductions: Ensure that gradual dose reductions are being attempted, and that documentation supports antipsychotic use per CMS definitions and regulations.

Important Clarifications on Timing

  • 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

References:

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Paul Nolan

As a Clinical Coordinator, Paul focuses on improving care coordination using best practices to reduce rehospitalizations.

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