New CMS guidance increases scrutiny of MDS coding. Learn how to avoid F641 citations and ensure accurate assessments at your facility.
The Centers for Medicare & Medicaid Services (CMS) has issued significant revisions to surveyor guidance for F641 – Accuracy of the MDS, effective April 28, 2025. These updates increase scrutiny of MDS coding practices and introduce new protocols for addressing assessment inaccuracies during surveys
F641 cites that the MDS assessment must “accurately reflect the resident’s status”, including physical, cognitive, emotional and behavioral conditions, as well as diagnoses, medications, interventions, functional status and care needs.
Surveyors are now directed to closely examine the accuracy of MDS assessments. If they determine a pattern of inaccurate coding, defined as three or more residents with MDS discrepancies, the surveyors are instructed to refer the case to the Office of the Inspector General (OIG) for investigation of falsification and potential fraud.
Industry reports indicate that in prior years, 45% of deficiencies cited during MDS-focused surveys were related to MDS inaccuracies. Additionally, between 2015-2019, there was a 194% increase in the number of residents reported on the MDS as having schizophrenia but who did not have a corresponding schizophrenia diagnosis in their medical claims. CMS is targeting unsupported schizophrenia diagnoses as a result of this pattern.
What steps can your facility take to ensure you are not at high risk for citations related to MDS inaccuracies?
- Conduct regular comprehensive audits to identify and correct MDS inaccuracies proactively. Focus on high-risk areas such as schizophrenia diagnosis and psychotropic medication use. Ensure all diagnoses coded on the MDS are active, as per RAI Guidelines at the time of the assessment.
- Ensure that your facility’s policies reflect current standards, particularly concerning diagnosis and medication practices.
- Enhance staff training to ensure understanding of accurate and timely documentation practices and the importance of aligning MDS assessments with clinical evidence.
- Strengthen your interdisciplinary collaboration and communication, ensuring strong processes between MDS Coordinators, the physician team and clinical staff, so to ensure timely and accurate documentation and MDS coding.
- Provide focused training and audits on Section GG to ensure interdisciplinary assessment and accurate coding of resident’s usual performance.
- Review behavioral care plans regularly to ensure agreement with MDS entries.
- Prepare for surveys by conducting mock surveys and preparing documentation that demonstrates compliance with MDS accuracy standards.
- Create a documented QAPI review for MDS Accuracy.
Contact the Polaris Group to have our team of expert consultants analyze your facility’s compliance with F641 by conducting a focused review of your facility’s MDS accuracy. We also identify high-risk areas such as unsupported diagnoses, inconsistent functional coding, and discrepancies between MDS coding, and the required support in medical records. Learn how a partnership with Polaris Group can help to optimize your facility’s compliance with F641.
