N0450: Antipsychotic Medication Review
N0450: Antipsychotic Medication Review
Item Rationale
Health-related Quality of Life
The use of unnecessary medications in long term care settings can have a profound effect on the resident’s quality of life.
Antipsychotic medications are associated with increased risks for adverse outcomes that can affect health, safety, and quality of life.
In addition to assuring that antipsychotic medications are being utilized to treat the resident’s condition, it is also important to assess the need to reduce these medications whenever possible.
Planning for Care
Identify residents receiving antipsychotic medications to ensure that each resident is receiving the lowest possible dose to achieve the desired therapeutic effects.
Monitor for appropriate clinical indications for continued use.
Implement a system to ensure gradual dose reductions (GDR) are attempted at recommended intervals unless clinically contraindicated.
Steps for Assessment
Review the resident’s medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent.
If the resident received an antipsychotic medication, review the medical record to determine if a gradual dose reduction has been attempted.
If a gradual dose reduction was not attempted, review the medical record to determine if there is physician documentation that the GDR is clinically contraindicated.
Coding Instructions for N0450A
Code 0, no: if antipsychotics were not received: Skip N0450B, N0450C, N0450D and N0450E.
Code 1, yes: if antipsychotics were received on a routine basis only: Continue to N0450B, Has a GDR been attempted?
Code 2, yes: if antipsychotics were received on a PRN basis only: Continue to N0450B, Has a GDR been attempted?
Code 3, yes: if antipsychotics were received on a routine and PRN basis: Continue to N0450B, Has a GDR been attempted?
Coding Tips and Special Populations
Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used.
Coding Instructions for N0450B
Code 0, no: if a GDR has not been attempted. Skip to N0450D, Physician documented GDR as clinically contraindicated.
Code 1, yes: if a GDR has been attempted. Continue to N0450C, Date of last attempted GDR.
Coding Instructions for N0450C
Enter the date of the last attempted Gradual Dose Reduction.
Coding Tips and Special Populations (N0450B and N0450C)
Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating that a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated. Information on GDR and tapering of medications can be found in the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (see F758). The State Operations Manual can be found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs-Items/CMS1201984.
In N0450B and N0450C, include GDR attempts conducted since the resident was admitted to the facility, if the resident was receiving an antipsychotic medication at the time of admission, OR since the resident was started on the antipsychotic medication, if the medication was started after the resident was admitted.
Do not include gradual dose reductions that occurred prior to admission to the facility (e.g., GDRs attempted during the resident’s acute care stay prior to admission to the facility).
If the resident was admitted to the facility with a documented GDR attempt in progress and the resident received the last dose(s) of the antipsychotic medication of the GDR in the facility, then the GDR would be coded in N0450B and N0450C.
If the resident received a dose or doses of an antipsychotic medication that was not part of a documented GDR attempt, such as if the resident received a dose or doses of the medication PRN or one or two doses were ordered for the resident for a specific day or procedure, these are not coded as a GDR attempt in N0450B and N0450C.
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Prior to discontinuing a psychoactive medication, residents may need a GDR or tapering to avoid withdrawal syndrome (e.g., for medications such as selective serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs], etc.).
Discontinuation of an antipsychotic medication, even without a GDR process, should be coded in N0450B and N0450C as a GDR, as the medication was discontinued. When an antipsychotic medication is discontinued without a gradual dose reduction, the date of the GDR in N0450C is the first day the resident did not receive the discontinued antipsychotic medication.
Do not count as a GDR an antipsychotic medication reduction performed for the purpose of switching the resident from one antipsychotic medication to another.
The start date of the last attempted GDR should be entered in N0450C, Date of last attempted GDR. The GDR start date is the first day the resident received the reduced dose of the antipsychotic medication.
In cases in which a resident is or was receiving multiple antipsychotic medications on a routine basis and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C.
If multiple dose reductions have been attempted since admission OR since initiation of the antipsychotic medication, record the date of the most recent reduction attempt in N0450C.
Federal requirements regarding GDRs are found at 42 CFR 483.45(d) Unnecessary drugs and 483.45(e) Psychotropic drugs.
Coding Instructions for N0450D
Code 0, no: if a GDR has not been documented by a physician as clinically contraindicated. Skip N0450E Date physician documented GDR as clinically contraindicated.
Code 1, yes: if a GDR has been documented by a physician as clinically contraindicated. Continue to N0450E, Date physician documented GDR as clinically contraindicated.
Coding Instructions for N0450E
Enter date the physician documented GDR attempts as clinically contraindicated.
Coding Tips and Special Populations (N0450D and N0450E)
In this section, the term physician also includes physician assistant, nurse practitioner, or clinical nurse specialist.
In N0450D and N0450E, include physician documentation that a GDR attempt is clinically contraindicated since the resident was admitted to the facility, if the resident was receiving an antipsychotic medication at the time of admission, OR since the resident was started on the antipsychotic medication, if the medication was started after the resident was admitted to the facility.
Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rationale for why an attempted dose reduction is inadvisable. This decision should be based on the fact that tapering of the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident’s function, well-being, safety, and quality of life.
