1900C: Falls Since Admission/Prior Assessment: Major Injury, Step-by-Step
Step-by-Step Coding Guide for Item Set J1900C: "Falls Since Admission/Prior Assessment: Major Injury"
1. Review of Medical Records
- Objective: Ensure the accurate documentation of falls that resulted in a major injury since the resident's admission or last MDS assessment.
- Actions:
- Review the resident's incident reports, physician notes, nursing notes, and hospital reports to determine if any falls occurred and the resulting level of injury.
- Confirm that medical documentation identifies if the fall caused a major injury, such as fractures, joint dislocations, or head injuries with altered consciousness.
2. Understanding Definitions
- J1900C: Falls Since Admission/Prior Assessment: Major Injury: This item records the number of falls resulting in major injury (e.g., fractures, joint dislocations, or head injuries).
- Major Injury: Defined as any injury such as fractures, dislocations, closed head injuries with altered consciousness, or subdural hematomas resulting directly from a fall.
3. Coding Instructions
- Step-by-Step:
- Step 1: Identify the number of falls that resulted in a major injury during the look-back period.
- Step 2: Code based on the number of falls resulting in a major injury:
- Code 0: No major injury falls since admission or the last assessment.
- Code 1: One fall with a major injury.
- Code 2: Two or more falls with major injuries.
- Step 3: Ensure that each fall is recorded only once, and code the fall based on the most severe injury sustained.
4. Coding Tips
- Accurate Injury Classification: Ensure that only injuries meeting the "major injury" definition are coded in J1900C.
- Retrospective Review: If a fall-related injury is identified after the Assessment Reference Date (ARD) and changes the injury level (e.g., a fracture discovered later), modify the assessment to update the injury level.
5. Documentation
- Objective: Maintain clear and accurate documentation of all falls and the resulting injuries.
- Actions:
- Record the circumstances of each fall, including the date, time, and nature of the injury.
- Document medical assessments and diagnoses, especially for fractures or other major injuries.
- Update the care plan based on the resident’s risk for falls and any injury sustained.
6. Common Errors to Avoid
- Incorrect Classification: Avoid coding falls without clear documentation of a major injury. Minor injuries like bruises or abrasions should not be coded in J1900C.
- Missed Injury Identification: Ensure all documentation (e.g., hospital reports) is reviewed to identify injuries that may not have been apparent immediately after the fall.
7. Practical Application
- Example 1: A resident fell, sustained a hip fracture, and was hospitalized for surgery. J1900C is coded as "1" to indicate one fall with a major injury.
- Example 2: A resident experienced two falls, one resulting in a closed head injury with altered consciousness and another causing a fracture. J1900C is coded as "2" to indicate two falls with major injuries.
Please note that the information provided in this guide for MDS 3.0 Item set J1900C was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
