Step-by-Step Coding Guide for J1700. Fall History on Admission/Entry or Reentry

1. Review of Medical Records

Begin by thoroughly reviewing the resident's medical records, including hospital discharge summaries, physician notes, nursing notes, physical therapy notes, and any incident reports. Look for mentions of falls that occurred in the 180 days prior to the current admission/entry or reentry.

2. Understanding Definitions

• Fall: An unexpected event where the resident comes to rest on the ground, floor, or lower level.
• Intercepted Fall: An event where the fall was intercepted, preventing the resident from hitting the ground, documented as a fall in the medical record.

3. Coding Instructions

• J1700A - History of Falls: Code "Yes" if the resident had any falls in the last 180 days. Code "No" if there were no falls documented.
• J1700B - History of Falls with Injury: Code "Yes" if any of the falls resulted in an injury. Code "No" if none of the falls resulted in an injury.
• J1700C - History of Falls with Major Injury: Code "Yes" if any falls resulted in major injuries (e.g., fractures, hospitalizations). Code "No" if no falls resulted in major injuries.

4. Coding Tips

• Ensure accuracy by cross-referencing information from different sections of the medical record.
• Document any discrepancies or lack of information and how it was resolved.
• Remember that an intercepted fall is considered a fall for coding purposes.

5. Documentation

• Clearly document in the MDS assessment the source of information for each fall, including dates and outcomes.
• Note any discrepancies and actions taken to clarify the resident's fall history.

6. Common Errors to Avoid

• Failing to review the entire 180-day period prior to admission.
• Overlooking intercepted falls.
• Misclassifying the severity of injuries from falls.

7. Practical Application

Example: A resident was admitted to the nursing home from the community. Review of the medical records and interview with the family revealed two falls in the past 180 days. The first fall did not result in injury, while the second fall resulted in a wrist fracture.

• J1700A would be coded "Yes" for history of falls.
• J1700B would be coded "Yes" for history of falls with injury.
• J1700C would be coded "No," assuming the wrist fracture is not considered a major injury according to the facility's policy or clinical judgment.

The Step-by-Step Coding Guide for item J1700 in MDS 3.0 Section J is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.