New guidance for nursing home surveyors set to go into effect in February heightens the stakes for employees whose coding work is linked to repeat inaccuracies.

The Centers for Medicare & Medicaid Services is directing surveyors to examine more closely the accuracy of assessments captured in the Minimum Data Set, a complex set of forms that guide providers as they identify patient needs, develop care plans and bill for services.

That includes referring some cases of suspected non-compliance to state boards of nursing, and for the first time, the Health and Human Services Office of the Inspector General.

“Surveyors are expected to focus on MDS coding accuracy but are not expected to investigate possible falsification of the resident assessment instrument,” the guidance states. “If the surveyor identifies a pattern (i.e., three or more residents) of inaccurate MDS coding by staff who completed, signed, and certified to the accuracy of the portion of the assessment they completed, and there are indications or concerns that the individual who completed the section(s) in question knew the coding was inaccurate, a referral should be made to the Office of Inspector General for investigation of falsification.”

Surveyors are then instructed to use the OIG’s Submit a Hotline Complaint link under the agency’s fraud-reporting site.

Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance with Zimmet Healthcare Services Group, said the strong language and directions are a change from existing guidance. That currently calls for possible referrals to the State Agency Regional Office and Medicaid Fraud Control Unit.

“I think surveys will focus on this more,” Cantinieri told McKnight’s Long-Term Care News Wednesday. “Still, there is also potential for audits by outside oversight and audits that look at the supporting documentation for any psychotropic medication and not leave it solely in the hands of the surveyors, who have many other issues that they need to investigate during visits.”

Schizophrenia still key focus for agency

Much of the new language related to MDS reporting inaccuracies reflects the industry’s ongoing efforts to understand when and why providers are diagnosing schizophrenia.

In 2022, an OIG report found that schizophrenia diagnoses among nursing home residents had climbed 194% between 2015 through 2019. One possible reason, federal officials said: Nursing home residents diagnosed with that specific mental disorder would be excluded from a quality measure designed to track the use of psychotropic drugs.

CMS has since then ramped up its scrutiny of inappropriate diagnoses and antipsychotic and anticonvulsant use, including with prior guidance adopted in October of that year. In early 2023, the agency launched audits of certain providers’ use of schizophrenia diagnosis, with some facilities still facing penalties associated with audit findings.

The new surveyor guidance, which also addresses other aspects of antipsychotic management in a 900-page document published Monday, is the latest evolution in the agency’s attempt to reign in diagnoses that lack documentation. Other changes also push surveyors to hold medical directors more accountable for their role in prescribing and, potentially, diagnosing patients using antipsychotics.

But it also could be used more broadly by surveyors who are newly empowered to look for more patterns in the MDS data itself.

“A pattern within a nursing home of clinical documentation or of MDS assessment or reporting practices that result in higher Patient Driven Payment Model (PDPM) scores, untriggering Care Area Assessments (CAAs) or unflagging Quality Measures (QMs), where the information does not accurately reflect the resident’s status, may be indicative of payment fraud or attempts to avoid reporting negative quality measures,” the guidance states.

“One or two assessments with inaccurate MDS diagnosis coding should be cited as isolated. If the surveyor identifies a pattern (i.e., three or more) of inaccurate coding for any new diagnosis (such as schizophrenia) with no supporting documentation by a physician, the surveyor should cite the scope of the non-compliance at a minimum of pattern or widespread as appropriate,” CMS adds.The new guidance falls under F641 for Accuracy of Assessment. An existing tag, F642 for Coordination/Certification of Assessments, will be eliminated when the new guidance goes into effect Feb. 24, 2025.