For years, nurse assessment coordinators (NACs) managed the long-stay (LS) antipsychotic quality measure largely through section N of the Minimum Data Set (MDS). Accurate 7-day look-back coding was the primary lever that facilities could pull to reflect their quality efforts. But that approach is no longer enough. Recently, the Centers for Medicare & Medicaid Services (CMS) re-specified this measure in the MDS 3.0 Quality Measures User’s Manual V18.0 to include claims and encounter data with the MDS data.
NACs now sit at the crossroads of MDS assessment, claims data, pharmacy workflows, and enrollment logic when attempting to understand the LS measure Percent of Residents Who Received an Antipsychotic Medication. This article will help NACs understand what has changed, how the different data sources and time periods work together, and how to adapt daily practices to manage this measure effectively.
From MDS-Only to a Hybrid Measure
Historically, the LS antipsychotic measure relied solely on MDS data. If antipsychotic use was coded on the target assessment (N0415A1 = 1 [checked]), the resident triggered. If it did not, the resident did not. Exclusions were also driven by the MDS, based on diagnosis coding for schizophrenia, Tourette’s syndrome, or Huntington’s disease.
In a Quality, Safety & Oversight memo (QSO memo), CMS identified two persistent problems with the previously established approach. First, antipsychotic use that occurred outside the 7-day look-back window but still occurred during the nursing home stay was not captured. Second, diagnoses such as schizophrenia were sometimes overreported on the MDS, excluding residents who should have remained in the measure calculation (CMS, 2025b).
In response, CMS re-specified the measure to address the two issues just described by introducing a hybrid approach that uses both MDS and claims data. The measure now combines data from the following sources:
- MDS
- Medicaid RX (Pharmacy) or Medicare Part D claim/encounter
- Medicaid OT (Other Services) claim or Medicare OP (outpatient)/PB (physician/carrier) claim/encounter
- Medicare Advantage encounter
- Enrollment files (Medicare, Medicare Advantage, and Medicaid)
For NACs, this re-specification means the measure no longer just reflects a snapshot in time. Instead, it indicates medication management across the entire target period, validated by multiple data sources.
Understanding the Numerator
At its core, the numerator answers one question: Was there evidence that the resident received or had filled an antipsychotic medication during the target period while residing in the facility? And there are two distinct pathways to trigger:
Pathway 1: A resident meets the numerator condition if N0415A1 is checkedon a qualifying target assessment.
This pathway still relies on the standard 7-day look-back window tied to the assessment reference date. Accurate section N coding remains essential, but it is no longer the whole story.
Pathway 2: A resident also meets the numerator condition if claims or encounter data show antipsychotic use during the target period while the resident is in the facility, even if the MDS does not reflect use.
This pathway includes these items:
- Pharmacy claims (Medicare Part D or Medicaid RX) based on the fill date, and
- Physician-administered antipsychotics identified through Medicare outpatient, physician/carrier, or Medicaid other services claims, based on the service date.
A critical nuance is timing. If an antipsychotic is filled during the target period (e.g., calendar quarter) and while the resident resides in the facility (i.e., was not discharged), the resident triggers, even if the medication was never actually administered or was discontinued quickly.
For NACs, this junction is where transitions of care matter. Hospital readmissions, emergency department visits, and standing pharmacy orders can all generate a fill that affects the measure.
Monitoring Throughout the Quarter
The updated measure evaluates antipsychotic use across the entire target period, typically a calendar quarter. This represents a significant shift from focusing on the narrow 7-day look-back period. Under the new logic, the following situations are pertinent:
- One antipsychotic fill captured on a pharmacy claim at any point in the quarter can cause the resident to trigger.
- Discontinuation later in the quarter does not remove the trigger for that quarter.
- Quality improvement efforts may not appear on Care Compare until a future quarter with no fills.
It is key for NACs and facility leadership to recognize this delay in the public reporting of their quality improvement efforts.Even when the clinical team acts timely and appropriately, the public data may lag behind their efforts.
Understanding the Denominator and Exclusions
The denominator remains unchanged with the re-specification. It still includes LS residents with a qualifying target assessment, except for those who meet exclusion criteria. However, the exclusion criteria did undergo a major change, expanding to consider enrollment status, claims and encounter data, and hospice claims. The changes also introduced two new look-back periods: the preadmission look-back window and the measure exclusion look-back window.
| Preadmission look-back window: The same date one year prior to the day before admission date, until one day before admission date. Measure exclusion look-back window: The same date one year prior to the target date until the target date. |
(Adapted from CMS, 2025a, pp. 48 – 49)
Enrollment-based exclusions
Depending on the scenario, CMS reviews enrollment during these periods of time:
- Each month of the target period,
- Each month of the one-year measure exclusion look-back window, or
- Each month of the one-year preadmission look-back window for residents who were 65 years or older at the time of admission and admitted within one year of the end of the target period.
If the resident was not continuously enrolled in one of the specified programs, as noted here, the resident is excluded from the measure. CMS notes the following exclusions for the denominator in the MDS 3.0 Quality Measure User’s Manual v18.0:
| The resident is not continuously enrolled in either (i) Medicare Part A&B&D or Medicare Part C&D (Medicare Fee-For-Service or Medicare Advantage with Part D enrollment) or (ii) Medicaid only during each month from the beginning of the target period until the end of the episode.The resident is not continuously enrolled in either (i) Medicare Part A&B or Medicare Part C (Medicare Fee-For-Service or Medicare Advantage), or (ii) Medicaid only during each month of the measure exclusion lookback window. The resident is aged 65 or older at admission and is admitted within one year prior to the end of the target period, but is not continuously enrolled in either (i) Medicare Part A&B or Medicare Part C (Medicare Fee-For-Service or Medicare Advantage), or (ii) Medicaid only in each month of the pre-admission lookback window. |
(Adapted from CMS, 2025a, pp. 48 – 49)
Although enrollment status is not visible on the MDS, NACs may see residents excluded, even though the medication was received on the MDS due to this exclusion criteria. This situation may occur when a resident is in private pay and not enrolled in a Medicare program or has a payer such as Veterans Affairs.
Diagnosis-based exclusions
Similar to the original measure, the re-specified measure retains the same three exclusion diagnoses of schizophrenia, Tourette’s syndrome, and Huntington’s disease. However, for a diagnosis to exclude the resident, the diagnosis must be coded accurately on the MDS on the target or prior assessment and validated by a claim. For Tourette’s syndrome and Huntington’s disease, the supporting claim must be within the measure exclusion look-back period.
But for schizophrenia, the supporting claim depends on the resident’s age at admission and if the resident admitted within one year of the end of the target period. If the resident was 65 years of age or older at the time of admission and admitted within a year of the end of the target period, the supporting claim or encounter data must occur during the one-year preadmission period. But if the resident is younger than 65 or admitted more than a year before the end of the target period, the one-year measure exclusion period is used.
Hospice-based exclusion
Under the re-specification, hospice is now an exclusion, but it is determined solely through claims and eligibility data, not MDS coding. A resident is excluded if hospice services overlap with the target period, based on the following:
- Medicare Part A hospice claims,
- Medicaid hospice claims, or
- Medicaid hospice eligibility group coding.
Changes to Workflow and Quality Improvement Efforts
The re-specified measure fundamentally changes how NACs and facility teams must approach antipsychotic quality management. The team can no longer wait until the look-back period of the target assessment to understand if the resident will trigger this measure. Ongoing medication management must be in place with a detailed focus during care transitions when order changes are more likely. These transitions may include returns from a brief hospital stay, emergency department visits, or physician or psychiatrist visits.
Quality assurance and performance improvement efforts should include transition-related prescribing, pharmacy fills during the quarter, and ensuring physicians or psychiatrists address antipsychotics and the associated diagnosis during visits.
Conclusion
The re-specified LS antipsychotic quality measure reflects the push by CMS for validation of data beyond nursing facility reporting. By understanding how MDS data, claims data, enrollment files, and time periods intersect, NACs can anticipate risks, guide interdisciplinary practice, and ensure that quality scores truly reflect resident-centered care. Facility teams that recognize this measure as a process issue, rather than a coding issue, and manage antipsychotic use proactively across the stay will be better prepared to achieve sustained success under the new specifications.
Note: For more information on this measure, watch AAPACN’s latest on-demand webinar New Year, New Measure: Making Sense of the Long-Stay Antipsychotic Re-Specification
References:
Centers for Medicare & Medicaid Services. (2025a). MDS 3.0 quality measures user’s manual V18.0. https://www.cms.gov/medicare/quality/nursing-home-improvement/quality-measures Centers for Medicare & Medicaid Services. (2025). REVISED: Updates to nursing home care compare. Memorandum, QSO-25-20-NH REVISED, September 10, 2025. https://www.cms.gov/files/document/qso-25-20-nh-revised-2025-09-10.pdf
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