For years, the MDS largely controlled the antipsychotic quality story in skilled nursing facilities.
If antipsychotic medication use was documented on the assessment, it counted toward the quality measure. If it was not captured during the assessment window, CMS visibility was limited.
That is changing quickly.
Beginning in 2026, CMS is re-specifying the Long-Stay Antipsychotic Quality Measure to include Medicare and Medicaid claims data alongside traditional MDS assessments.
The result is a major shift in how antipsychotic utilization is identified, validated, and publicly reported.
More importantly, it signals something much bigger: CMS is continuing its transition away from relying solely on self-reported assessment data and toward claims-validated quality measurement.
Why CMS Is Expanding Beyond the MDS
CMS and the Office of Inspector General have raised concerns for years that the MDS does not always fully capture antipsychotic utilization patterns.
In many situations:
- medications may fall outside the MDS look-back window
- injections may occur during care transitions
- pharmacy claims may not align with assessment timing
- physician-administered medications may only appear through billing data
As a result, CMS determined that relying exclusively on MDS coding may not provide a complete picture of resident medication utilization.
The updated methodology now combines:
- MDS assessment data
- Medicare Part D pharmacy claims
- Medicaid prescription claims
- physician-administered medication claims
- outpatient and carrier encounter data
CMS is essentially widening the lens.
And that wider lens allows the agency to identify medication use far more comprehensively than before.
The MDS Is No Longer the Only Trigger
Under the updated methodology, residents may now trigger inclusion in the quality measure through multiple pathways.
Traditional MDS Coding Still Applies
If antipsychotic use is coded on the MDS in Section N, the resident will continue to trigger into the measure as expected.
That part remains familiar.
Claims Data Can Now Independently Trigger the Measure
This is where the change becomes much more significant.
Even if antipsychotic use is not coded on the MDS, claims data alone may still place the resident into the quality measure.
Examples include:
- pharmacy fills billed during the target period
- physician-administered antipsychotic injections
- outpatient or carrier claims identifying medication utilization
In other words: CMS can now identify utilization patterns even when the MDS itself does not reflect antipsychotic use.
This dramatically reduces the ability to manage quality outcomes through MDS coding practices alone.
Why Exclusions Are Becoming More Difficult to Defend
The updated methodology also changes how exclusions are validated.
Historically, exclusions such as schizophrenia or hospice status were often driven primarily through MDS coding.
Now, many exclusions require supporting claims data in addition to assessment documentation.
Diagnoses Must Be Supported Across Systems
Conditions such as:
- schizophrenia
- Huntington’s disease
- Tourette’s syndrome
must now be supported through qualifying ICD-10 diagnosis codes found within Medicare or Medicaid claims history.
Simply checking the diagnosis on the MDS may no longer exclude the resident from the measure.
Hospice Exclusions Have Also Shifted
CMS is now validating hospice exclusions through:
- hospice claims
- enrollment indicators
- supporting utilization records
rather than relying solely on assessment documentation.
The operational implication is significant: documentation alone is no longer enough.
The entire data trail must align.
Why Facilities May Suddenly See Higher Rates
One of the biggest concerns for providers is how these changes may affect publicly reported outcomes.
Because claims data often captures utilization more comprehensively than the MDS alone, many facilities are expected to see higher antipsychotic quality measure rates even if prescribing practices themselves have not changed.
CMS simply has greater visibility than before.
This may directly impact:
- Care Compare reporting
- Five-Star Quality Measures
- referral relationships
- payer perception
- public transparency
Facilities that previously appeared low-risk under MDS-only reporting may discover that claims data tells a very different story.
What Skilled Nursing Facilities Should Be Doing Now
The facilities best positioned for success will move beyond siloed MDS processes and focus on system-wide alignment.
Preparation should include:
- aligning Section N coding with pharmacy claims
- reviewing Section I diagnosis accuracy
- validating physician documentation consistency
- monitoring Medicare and Medicaid enrollment continuity
- improving communication during care transitions
- strengthening interdisciplinary medication oversight
Facilities should also begin reviewing quality measures through a broader operational lens.
Because CMS is no longer evaluating only what appears on the assessment.
It is evaluating how the entire clinical and claims record aligns together.
The Bigger Trend Behind This Change
The updated antipsychotic measure is not an isolated adjustment.
It reflects a much larger CMS strategy focused on:
- claims-based quality validation
- external data verification
- reimbursement integrity
- public reporting transparency
- audit readiness
This same direction is appearing across:
- the SNF Validation Program
- hybrid quality measures
- falls with major injury reporting
- future reimbursement oversight initiatives
For skilled nursing facilities, quality reporting is becoming increasingly interconnected across systems, documentation, billing, and utilization data.
The Bottom Line
The way CMS evaluates antipsychotic use in skilled nursing facilities is fundamentally changing.
The MDS no longer controls the entire quality narrative.
Claims data, pharmacy utilization, physician billing, and enrollment history are now becoming part of how CMS evaluates facility outcomes and publicly reported performance.
For providers, this raises the importance of:
- interdisciplinary communication
- documentation accuracy
- claims awareness
- medication oversight
- operational alignment
Facilities that proactively strengthen these systems now will be far better prepared as CMS continues moving toward claims-validated quality measurement.
How MDS Solutions Supports Facilities
At MDS Solutions, we help skilled nursing facilities strengthen interdisciplinary documentation practices, reimbursement strategy, quality oversight, and operational alignment in an increasingly data-driven regulatory environment.
As CMS continues expanding claims-based quality validation, our focus remains helping facilities build systems that support defensible documentation, accurate reporting, and stronger operational confidence.
Because today, quality measures are no longer shaped by one assessment alone.
They are shaped by the entire clinical story CMS can now see.