RAI Manual v1.20.1Steps for Assessment
1. 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.
2. If the resident received an antipsychotic medication, review the medical record to determine
if a gradual dose reduction has been attempted.
3. 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.
Manual page N-13RAI Manual v1.20.1Coding 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?
N0450: Antipsychotic Medication Review (cont.)
Manual page N-13RAI Manual v1.20.1Coding 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)
•
Compliance with the requirement to perform a GDR may be met if, for example, 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 attempts 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. 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 in accordance with 42 CFR 483.45 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.
N0450: Antipsychotic Medication Review (cont.)
•
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.
DEFINITION
GRADUAL DOSE
REDUCTION (GDR)
Step-wise tapering of a dose
to determine whether or not
symptoms, conditions, or
risks can be managed by a
lower dose or whether or not
the dose or medication can
be discontinued.
N0450: Antipsychotic Medication Review (cont.)
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.
Manual page N-13