CMS updates to the QM manual that changes how the long-stay antipsychotic medication measure is calculated.
CMS recently released updates to the Quality Measure (QM) manual that significantly change how the Long-Stay Antipsychotic Medication measure is calculated. While the goal of reducing inappropriate antipsychotic use has not changed, the way CMS identifies residents receiving antipsychotics has.
Under the updated methodology, CMS continues to use MDS data to define the long-stay resident population and applicable exclusions. However, antipsychotic use is now identified using both assessment data and claims/encounter data, including Medicare fee-for-service claims, Medicare Advantage encounters, and Medicaid claims. This allows CMS to capture prescriptions and administrations that occur outside the MDS 7-day lookback window.
As a result, facilities may see higher antipsychotic rates even when prescribing practices have not changed. The increase reflects improved detection, not necessarily increased use.
CMS has also strengthened validation of exclusion diagnoses such as schizophrenia, Huntington’s disease, and Tourette’s syndrome. Exclusions reported on the MDS may now be evaluated against claims history, making unsupported or inconsistently documented diagnoses more visible.
The updated Long-Stay Antipsychotic measure is used in the Nursing Home Five-Star Quality Rating System, and CMS has established new national cut points based on the revised methodology. Facilities may see shifts in Quality Measure scores or star ratings even if clinical practice remains stable.
Operationally, this reinforces the importance of strong psychotropic stewardship. Facilities should ensure antipsychotic use is supported by clear clinical rationale, accurate diagnosis coding, documentation of non-pharmacologic interventions, and regular interdisciplinary review. Reconciling pharmacy claims with MDS reporting is now essential.
The updated measure reflects CMS’s broader shift toward data validation across settings. Facilities that understand how the measure works—and prepare proactively—will be better positioned to maintain compliance while continuing to meet residents’ clinical needs.
Polaris Group is helping organizations get ahead of these changes by identifying where claims data, MDS coding, and clinical documentation may be misaligned—before they affect Five-Star ratings. Our targeted antipsychotic risk reviews help facilities validate exclusions, strengthen non-pharmacologic documentation, and prepare interdisciplinary teams for the new claims-informed measure logic.
If you want to understand how this update may impact your quality scores—and what to fix now—Polaris Group can help.
