Step-by-Step Coding Guide for Item Set J1900A: Falls Since Admit/Prior Assessment: No Injury

1. Review of Medical Records

• Objective: Gather accurate information regarding any falls the resident has experienced since admission or the prior assessment, specifically those that resulted in no injury.
• Steps:
  1. Collect Information: Review the resident's medical records, including incident reports, nursing notes, and previous assessments.
  2. Identify Falls: Look for documented instances of falls, noting the date and circumstances of each fall.
  3. Confirm No Injury: Verify that the falls identified resulted in no injury to the resident.

2. Understanding Definitions

• Fall: An unintentional change in position resulting in coming to rest on the ground, floor, or lower level.
• No Injury: The fall did not result in any injury to the resident, including bruises, cuts, or pain.

3. Coding Instructions

• Steps:
  1. Identify Falls with No Injury: Confirm instances of falls from the resident’s medical records and ensure they resulted in no injury.
  2. Verify Documentation: Ensure the falls and the absence of injuries are well-documented in the incident reports and nursing notes.
  3. Code Appropriately: Code J1900A as follows:
     • 0: No falls
     • 1: One fall with no injury
     • 2: Two or more falls with no injury

4. Coding Tips

• Accurate Identification: Ensure all falls since admission or the last assessment are identified and verified as resulting in no injury.
• Consistent Terminology: Use consistent terminology when documenting and coding falls and the absence of injury.
• Consult Staff: If there is any uncertainty, consult with the nursing staff or other relevant healthcare providers for clarification.

5. Documentation

• Required:
  • Incident Reports: Detailed reports of all falls, including circumstances and outcomes.
  • Nursing Notes: Document any falls and confirm the absence of injuries.
  • Assessment Notes: Include notes from any assessments that mention falls and their outcomes.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification of the number of falls and the absence of injuries.
• Incomplete Documentation: Make sure all relevant details about falls and their outcomes are thoroughly documented.
• Assumptions: Do not assume the absence of injury without proper documentation.

7. Practical Application

• Example:
  • Resident Profile: Tom, an 80-year-old resident, experienced two falls since his last assessment.
  • Steps:
    1. Review Records: The nurse reviews Tom’s medical records, including incident reports and nursing notes documenting the falls.
    2. Identify Falls: It is confirmed that both falls resulted in no injury.
    3. Document and Code: The nurse documents the falls and codes J1900A as "2".
  • Outcome: Tom’s falls with no injury are accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set J1900A 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.