The First Hybrid Quality Measure Is Here, And Yes, It’s Going to Shake Things Up
What MDS Coordinators need to know (and do) right now.
If you’ve heard the buzz about CMS’ first-ever hybrid quality measure, the Long-Stay Antipsychotic Medication QM, you’re probably wondering:
“How will this impact our quality scores? And why does it feel like half the data will come from places I don’t even control?”
You’re not alone. Facilities across the country are asking the same thing.
This new measure blends MDS data with claims data from Medicare, Medicaid, Medicare Advantage, pharmacy claims, and physician-administered claims. In other words, it captures antipsychotic prescriptions from any place they could appear. CMS’ goal is very clear: reduce unnecessary antipsychotic use nationwide.
For MDS Coordinators, a measure that pulls data from sources outside your building can feel unsettling.
“How did this resident trigger?”
“Where did that claim come from?”
“Why is this showing up when our MDS is clean?”
Let’s walk through what counts, who’s included, and most importantly, what you can control.
What Actually Counts in This New QM
A resident will trigger the measure if antipsychotic use appears at any point in the target period. That includes the following:
✔ Coded on the MDS
Specifically, in N0415A1= 1 → Antipsychotic received in last 7 days.
✔ OR Appears in claims
Including Medicare (includes Medicare Advantage) and Medicaid claims: Pharmacy claims (Part D or Medicaid RX), Physician-administered claims (Medicare or Medicaid).
❌ Does not count
If the medication was given while the resident was discharged.
Who’s Included
Any long-stay resident (101+ cumulative days) with a valid target MDS is included unless they qualify for an exclusion:
- The resident was not continuously enrolled in:
- The required Medicare or Medicaid coverage:
- Medicare Part A, B, and D or
- Medicare Advantage with Part D or
- Medicaid only
- During the lookback:
- The entire target period, and
- The 12-month exclusion lookback window, and
- (If age 65+ and newly admitted) The 12 months before admission
- The required Medicare or Medicaid coverage:
- The resident has a diagnosis of schizophrenia, Huntington’s, or Tourette’s that is supported in both MDS and claims.
- The resident was in hospice, identified through claims, at any time in the target window.
The Real Challenge for MDS Coordinators
This measure forces facilities to think beyond the MDS. You may see the following issues:
- Physician documentation that doesn’t line up
- Pharmacy claims you were never aware of
- New admissions with unclear histories
- Diagnoses coded without active documentation
- Residents triggering from outside claims even when the MDS looks perfect
It feels out of your control because, in some cases, it is.
The good news is that the areas you can control make a meaningful difference.
What You Can Do: Five Quick Wins for Accuracy
These steps give you the most influence over the measure:
1. Code N0415A1 correctly every time.
Consistency here is crucial.
2. Confirm psychiatric diagnoses are only coded when they are active and clinically documented.
If it is not supported, do not code it.
3. Confirm hospice status.
If hospice involvement appears in claims, the resident is excluded. A quick review can prevent an unnecessary trigger.
4. Review new admissions closely.
Pay attention to physician documentation. You need the diagnosis description and condition status before coding the first MDS.
These small actions can prevent confusion, inaccurate triggers, and unnecessary numerator hits.
5. Don’t let PRN antipsychotics trip you up.
Review all residents with ordered PRN antipsychotics and evaluate for discontinuing the medication. This will avoid refills that would show on pharmacy claims and therefore trigger the QM even if the medication was not administered.
Still unsure what’s actually driving your scores
You are not expected to be an expert in Medicare Part D claims, pharmacy billing, and physician-administered medication codes. You are an expert in the MDS, and this hybrid measure brings all of these data sources together.
If you are looking at your antipsychotic measure and asking,
“Why is this resident in the numerator?”
We can help.
Celtic can analyze the data behind your scores, show you where triggers are coming from, and help your team strengthen documentation, coding, and processes so your team builds the skills and systems needed for this and future measures.
👉 Need help deciphering your scores? Reach out and we will walk through it with you.
