Section I and Schizophrenia

by | Oct 4, 2022 | MDS Data Elements

Explore More Posts from MDS Consultants

Changes to Section I and Schizophrenia

In July 2022, CMS released an erratum to the RAI (Resident Assessment Instrument) Manual that included more detailed guidance on the use of diagnoses for section I, including the schizophrenia diagnoses that have been used as exclusion criteria for psychotropic medication use.

You may be wondering why was this change made?

When it comes to schizophrenia specifically, CMS monitored the use of this exclusion diagnosis – especially as its use increased gradually after the development of the psychotropic use quality measure. The rate of schizophrenia occurrence in nursing homes is as high as 11% in some areas, while the diagnosis occurs at a rate of less than 1% in the general population (CMS, 2021; Thomas, 2021). This gap suggested to CMS that there may be an overuse of the schizophrenia diagnosis in Skilled Nursing Facilities.

The new RAI Erratum addressed the trend, stating,

In situations where practitioners have potentially misdiagnosed residents with a condition for which there is a lack of appropriate diagnostic information in the medical record, such as for a mental disorder, the corresponding diagnosis in Section I should not be coded, and a referral by the facility and/or the survey team to the State Medical Boards or Boards of Nursing may be necessary.”

Therefore we see that CMS is increasing their requirement for diagnostic documentation across the board.  CMS added the following example that specifically applies to schizophrenia,

The resident was admitted without a diagnosis of schizophrenia. After admission, the resident is prescribed an antipsychotic medication for schizophrenia by the primary care physician. However, the resident’s medical record includes no documentation of a detailed evaluation by an appropriate practitioner of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for six months prior to the start of the antipsychotic medication in accordance with professional standards. 

Coding: Schizophrenia item (I6000), would not be checked. 

Rationale: Although the resident has a physician diagnosis of schizophrenia and is receiving antipsychotic medications, coding the schizophrenia diagnosis would not be appropriate because of the lack of documentation of a detailed evaluation, in accordance with professional standards (§483.21(b)(3)(i)), of the resident’s mental, physical, psychosocial, and functional status (§483.45(e)) and persistent behaviors for the time period required.”

Item I6000 on the MDS (MINIMUM DATA SET), labeled as “Schizophrenia” includes schizoaffective and schizophreniform disorders. It does not include unspecified psychosis, delusional disorder, or schizotypal personality disorder. This means that the Diagnosis and Statistical Manual of Mental Disorders, 5th Edition criteria for either schizophrenia, schizoaffective, or schizophreniform must be met as determined by a psychiatric provider.

To meet the criteria the patient must experience at least 2 of: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms for at least one month (APA, 2022). Schizoaffective disorder is recognized when there are also symptoms of depression or mania (APA 2022). For schizophrenia, there also must be a dysfunction in functioning at work, relationships, self-care, or school related to the above symptoms (APA, 2022).

If the nursing home feels that a resident meets the criteria for a mental health diagnosis, nursing and social work staff can document symptoms to assist the psychiatric provider in diagnosing and writing the diagnostic formulation. From the erratum wording, it seems like CMS will be looking for this documentation. Once the documentation and official diagnosis is in place, item I6000 may be checked on the MDS assessment!


American Psychiatric Association (2022). Diagnostic And Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)

Centers for Medicare and Medicaid Services. (2021). MDS 3.0 Frequency Report.

MDS 3.0 RAI User’s Manual (v1.17.1R) Errata (v2) (

Thomas, K. (2021). Phony Diagnoses hide high rates of drugging at nursing homes. The New York Times.,a%20Times%20investigation%20found.%20Give%20this%20article%201004

Explore More Posts from MDS Consultants

Get ready for October 1

Transportation – New Item A1250

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See An additional item we will see in the upcoming MDS 3.0 v.1.18.11 in October 2023 is A1250 - Transportation. This is included in a new subset of...

New 3-day Lookbacks | Assessment Periods

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of March 24, 2023 What You Can Expect to See New 3-day lookback/assessment periods are coming to the MDS world. There are different sections of the MDS that the Nurse Assessment Coordinators...

New Pain Interview in Section J

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of February 22, 2023 What You Can Expect to See The most noticeable changes to Section J are evident in the pain interview, specifically questions J0510, J0520 and J0530. The RAI Manual has...

Section B – Hearing, Speech and Vision Changes

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section B on the MDS is a component of the Standardized Patient Assessment Data Elements (SPADEs), which is utilized across post-acute care...

Race and Ethnicity – Changes in Section A

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section A, Identification Information for Race/Ethnicity has expanded. One of the major changes is the deletion of section A1000 Race/Ethnicity....

Read more on Toolbox Essentials

Focused Infection Control Surveys and Directed Plan of Correction

It's a dreary Monday morning, and the state surveyors walk into your facility to conduct a Focused Infection Control survey. You and your team have been trying your hardest to comply with infection control procedures throughout the pandemic. At the end of the survey,...

New Advanced Beneficiary Notice

Is your facility using the proper ABN form? The Centers for Medicare & Medicaid Services (CMS) recently updated the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The new ABN will be mandatory for use on 1/1/2021, but the new form can be...

Covid-19 and Skilled Status

In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed. ...

Mind Your PHQs

Some skilled nursing facilities (SNFs) are concerned about accurate payment when a resident unexpectedly discharges and the Brief Interview for Mental Status (BIMS) has not yet been completed.However, they should be just as concerned about the PHQ-9. The PHQ-9...

MDS in the Emergency Preparedness Plan

The COVID-19 pandemic has highlighted the need for skilled nursing facilities to have an effective Emergency Preparedness Plan - one that includes sheltering-in-place. The Centers for Medicare and Medicaid Final Rule requires that participating providers have an...

MORE from MDS Experts

Schizophrenia Diagnosis Audits

On January 18th, 2023, CMS announced they will be conducting off-site audits in nursing homes for assessment accuracy and coding of residents with a diagnosis of Schizophrenia. Along with auditing for appropriate diagnosis, the audits will review appropriate use of...

OSA or PDPM? A State-Level Decision

As of Oct. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) has retired the A0300 Optional State Assessment (OSA) from the federally required MDS 3.0 v1.18.11 that is submitted by nursing facilities. The OSA is now a separate optional MDS assessment...

The Physician and “I”

The physician’s role in the nursing facility is essential to delivering skilled, quality care for Skilled and Long-Term Care residents. Physicians are our lead in providing clinical decision making and properly defining, clarifying, and verifying diagnoses. Only the...

Coding UTIs on the MDS 3.0

Urinary Tract Infections (UTIs) are a commonly miscoded data element on the MDS. Are you over coding UTIs? Are you not coding them at all? Should you? Shouldn’t you? The MDS has historically left data collectors asking themselves these questions. What happens if I do...

Achieving Accurate ADLs with the OSA

Section G of the MDS 3.0 was retired October 1, 2023, yet the MDS nurse may still need to use the knowledge of accurately coding ADLs with an assessment called the Optional State Assessment (OSA).  State-Optioned OSA Although the option to choose an OSA from the...

Webinars & Training

Grow your knowledge with our MDS education

MDS Guides & Forms

Exclusive resources & tools we use every day

Ask an Expert Forum

Members can get 1:1 advice from our MDS experts

Let's Meet in Person

Get more info on our training & conference schedule

News for MDS Experts

Browse our blog & get news alerts on MDS changes

MDS Completion

Get your MDS' done ASAP with short-term, expert help

Remote Floater

Fill gaps on your team when & where you need

Case Mix Index

Improve your complex case mix calculations

MDS System Mgt

Best practices for MDS schedules & workflow

+ More Services

Get help on PDPM, ICD-10, quality, schizoph. audits ++