Step-by-Step Coding Guide for Item Set J1700B: Fall History: Fall 2-6 Months Before Admission

1. Review of Medical Records

• Objective: To gather accurate information about the resident’s fall history.
• Steps:
  1. Collect Information: Review the resident's medical records, including previous assessments, physician notes, and hospital records.
  2. Look for Documentation: Identify any documented falls within the 2-6 months prior to admission.
  3. Family and Caregiver Reports: Review reports from family members or previous caregivers that mention falls.

2. Understanding Definitions

• Fall: An unintentional change in position coming to rest on the ground, floor, or lower level.
• Fall 2-6 Months Before Admission: Any fall that occurred within the timeframe of 2 to 6 months prior to the resident's admission to the facility.

3. Coding Instructions

• Steps:
  1. Identify Falls: Confirm if any falls occurred in the specified timeframe.
  2. Verify Dates: Ensure the falls fall within the 2-6 months before the admission date.
  3. Code Appropriately: Code J1700B as "1" if there was at least one fall, and "0" if there were no falls.

4. Coding Tips

• Accurate Timing: Pay attention to the exact dates of falls to ensure they fit within the specified period.
• Consistent Terminology: Use consistent terminology when documenting and coding falls.
• Consult Records: Check multiple sources if needed, including hospital records and caregiver notes, to confirm falls.

5. Documentation

• Required:
  • Fall Incident Reports: Include detailed reports of any falls, including dates and circumstances.
  • Medical Records: Ensure physician notes and hospital records reflect the fall incidents.
  • Admission Assessment: Document any falls reported during the initial admission assessment.

6. Common Errors to Avoid

• Incorrect Time Frame: Ensure falls are within the 2-6 months period before admission, not outside it.
• Incomplete Documentation: Document all relevant details about the falls to support coding.
• Assumptions: Do not assume falls occurred without documentation or reliable reports.

7. Practical Application

• Example:
  • Resident Profile: Tom, an 80-year-old resident, was admitted to the facility. During the review, it was noted that he had a fall four months before admission.
  • Steps:
    1. Review Records: The nurse reviews Tom’s medical records and notes a fall incident documented in the hospital records four months ago.
    2. Verify Dates: The fall is confirmed to be within the 2-6 months timeframe before admission.
    3. Document and Code: The nurse codes J1700B as "1" and documents the fall details in Tom’s records.
  • Outcome: Tom’s fall history is accurately documented and coded, aiding in proper care planning.

Please note that the information provided in this guide for MDS 3.0 Item set J1700B 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.