‘We’re Not Through’: More Hybrid QM Data Collection Likely Ahead for Nursing Homes
•February 17, 2026
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Why It Matters
Hybrid data collection raises compliance stakes, directly influencing reimbursement, star ratings, and regulatory penalties for nursing homes.
Key Takeaways
- •CMS adopts hybrid MDS‑claims method for quality measures
- •Antipsychotic and fall injury QMs now require claim validation
- •Audits will affect star ratings and financial penalties
- •Interdisciplinary teams must align nursing, billing, and physicians
- •Facilities must meet tight MDS correction deadlines
Pulse Analysis
CMS’s shift toward a hybrid quality‑measure framework reflects a broader regulatory push to tighten oversight in post‑acute care. By linking MDS assessments with Medicare claim data, the agency aims to close reporting gaps highlighted in OIG investigations of antipsychotic prescribing and fall‑related injuries. This integration not only improves the fidelity of public quality metrics but also creates a more granular data set for policymakers evaluating facility performance. For nursing homes, the change signals a move away from isolated reporting toward a unified, data‑driven accountability model.
The immediate impact is felt in two high‑visibility measures: antipsychotic medication use and falls with major injury. CMS now cross‑checks MDS entries against pharmacy and physician claims, meaning discrepancies can trigger audit findings that lower five‑star ratings and trigger financial penalties. The 2023 focused audit on schizophrenia diagnoses already caused rating drops for facilities with incomplete documentation. As the hybrid method expands, providers can expect more frequent validation checks, tighter F‑tag enforcement, and heightened scrutiny of claim‑based indicators, all of which translate into heightened financial risk exposure.
Operationally, nursing homes must adopt a coordinated approach that brings together admissions staff, nursing leadership, billing departments, and external physicians. Accurate MDS coding, timely claim submissions, and proactive correction of errors before the monthly data pull are essential to avoid adverse QM calculations. Facilities should institute regular cross‑functional reviews, leverage analytics to flag mismatches, and train staff on ICD‑10 and external cause coding requirements. By aligning interdisciplinary processes with CMS’s hybrid expectations, providers can safeguard star ratings, reduce audit fallout, and position themselves competitively in an increasingly data‑centric market.
‘We’re Not Through’: More Hybrid QM Data Collection Likely Ahead for Nursing Homes
Regulatory changes to the nursing home industry for this year may seem small individually, but together, they reflect broader initiatives sought by the Centers for Medicare and Medicaid Services (CMS) to tighten oversight, accountability and performance measurement.
Changes are expected to increase financial risk exposure and require tighter interdisciplinary coordination. Notably, CMS is increasingly combining Minimum Data Set (MDS) data and Medicare claims data when calculating quality measures (QMs) in a process known as the “hybrid method,” according to Pat Newberry, clinical reimbursement consultant for software platform SimpleLTC.
Reports from the Office of the Inspector General (OIG) on the use of antipsychotic medications and falls with major injury propelled the hybrid method, she said, and suggestions made to CMS indicates more QMs may be subject to hybrid data collection as well.
“We’re not through with these new hybrid claims measures. We’re going to start seeing these become more and more prevalent,” Newberry said, referring to OIG comments.
Newberry on Tuesday provided a deep dive into quality measure changes for this year and beyond, including insights on thenew, hybrid QMs that combine the MDS and claims, and increased audit activity through PDPM and MDS validation, among other regulatory hurdles.
Antipsychotic medication QM
The antipsychotic medication quality measure, for example, was updated following a 2021 OIG study which found that the MDS did not accurately reflect the number of residents receiving antipsychotic medications. CMS agreed with OIG that information collected needed to be enhanced and that MDS reports need to be validated, and that supplemental data was needed to monitor use of such medications, Newberry said.
CMS made these changes in phases: 2022 marked an initiation of survey regulations with new F-tags introduced, and 2023, CMS led an MDS focus audit of schizophrenia diagnosis. In 2025, CMS consolidated and updated F-tags tied to antipsychotic medications, Newberry said.
“If you guys weren’t involved in that, good for you, because that was a really tough audit,” Newberry said of the 2023 focused audit. “It did impact a lot of people’s five-star quality measure, because they did drop some star ratings depending on what CMS found.”
The hybrid collection of MDS data and claims data is the agency’s most recent solution to OIG findings, she said. Antipsychotic use can be captured through pharmacy or physician claims even if it’s not coded in the MDS.
“This is really going to have to be an interdisciplinary team effort: the business office, nursing admissions. You need to get with your physicians, and you need to also work with the hospitals,” Newberry said of the hybrid data collection. “You want to make sure that you’re really looking at how you can validate continuous enrollment and how you can validate some of these other claims measures that you’re going to be looking at.”
Exclusion diagnoses like schizophrenia need to appear on both the MDS and claims to qualify, noted Newberry.
Falls with major injury QM
The falls with major injury QM is also getting the hybrid treatment, Newberry said, which is included under the SNF QRP. The decision also came from more OIG reports, which found many major injuries documented in hospital claims weren’t reflected in the MDS. CMS also revised the criteria for how facilities are selected for the Special Focus Facility (SSF) program, adding falls in place of adequate staffing as part of the selection process.
Nearly 60% of claims of falls with major injury identified by the hospital or physician office were reported on the MDS – meaning 40% of falls with major injury never made it to the MDS, according to OIG findings.
Moving forward, CMS is requiring hospital and emergency department claims along with ICD-10 diagnosis and external cause codes to identify qualifying falls. Newberry suggested nursing homes should ensure accurate MDS coding and may need to modify assessments if hospital documentation later confirms a major injury.
Diagnoses that would indicate a major injury includes” traumatic fracture, traumatic joint dislocation or subluxation, injury to the head with and without loss of consciousness, other non-fracture bone injury, organ trauma, crush injury, spine injury involving the cord or disc, and traumatic amputation.
Newberry also mentioned key data submission deadlines for nursing homes to ensure that quality measure data collection is accurate – CMS pulls MDS data on the last Sunday of the month following the end of a quarter, and nursing homes need to submit corrections before the pull date for corrections to be included in QM calculations.
Late modifications might still need to be made for compliance, but won’t impact published QM results, she said.
The post ‘We’re Not Through’: More Hybrid QM Data Collection Likely Ahead for Nursing Homes appeared first on Skilled Nursing News.
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