Step-by-Step Coding Guide for Item Set J1700A: Fall History: Fall During Month Before Admission

1. Review of Medical Records

• Objective: To determine if the resident experienced any falls in the month prior to admission to the facility.
• Process:
  • Review transfer documents and admission notes that might include fall history mentioned by previous caregivers or healthcare facilities.
  • Examine initial assessments and interviews where the resident or family might have reported recent fall incidents.
  • Check any available hospital or clinic notes received with the resident that may document recent falls.

2. Understanding Definitions

• Fall: An unintentional change in position coming to rest on the ground, floor, or other lower level.

3. Coding Instructions

• Code J1700A:
  • 0: No — if there was no fall in the month before admission.
  • 1: Yes — if there was at least one fall in the month before admission.
• Example: If a resident fell once two weeks before being admitted to the facility, code J1700A as '1'.

4. Coding Tips

• Clarify the exact timing of falls to ensure they occurred within one month before the admission.
• Obtain information from multiple sources if possible, such as the resident, family, and transferring healthcare providers.

5. Documentation

• Required Documentation:
  • Documentation of the fall event(s) in the medical records, including any clinical notes or reports from the time of the fall.
  • Statements or assessments that include details of the fall, such as date, time, circumstances, and any injuries sustained.
• Ensure all reported falls are documented clearly with corroborative details to support coding accuracy.

6. Common Errors to Avoid

• Overlooking falls that occurred close to the admission date.
• Failing to document verbal reports of falls from residents or family members.
• Misinterpreting other types of mobility incidents (like sliding from a chair) as falls.

7. Practical Application

• Scenario: During the admission process, the nurse conducts an initial interview where the resident mentions a fall that occurred three weeks prior, resulting in a bruised arm. This information is cross-verified with hospital discharge summaries provided upon admission, which also note the fall. The nurse documents this in the resident's medical record under fall history. For MDS coding, J1700A is accurately coded as '1', indicating this fall before admission.

Please note that the information provided in this guide for MDS 3.0 Item set J1700A  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.