Step-by-Step Coding Guide for Item Set J1900B: Falls Since Admission/Prior Assessment: Injury (Not Major)

1. Review of Medical Records

• Objective: To determine the occurrence of falls resulting in injuries (not major) since the resident's admission or the prior assessment.
• Process:
  • Review nursing notes and incident reports for entries related to falls.
  • Examine the care plan for updates following falls and associated outcomes.
  • Consult with the rehabilitation team for reports on injuries related to falls, assessing their severity.

2. Understanding Definitions

• Injury (Not Major): Includes any documented injury from a fall that does not meet the criteria for a major injury, such as minor bruises, abrasions, lacerations, or swelling.

3. Coding Instructions

• Code J1900B:
  • 0: No falls with injury (not major) since admission.
  • 1: One fall with injury (not major) since admission.
  • 2: Two or more falls with injury (not major) since admission.
• Example: If a resident fell once and suffered a minor bruise, code J1900B as '1'.

4. Coding Tips

• Clarify the severity of injuries with clinical staff to differentiate between major and minor injuries.
• Use a consistent method for recording and reviewing fall incidents and injuries to ensure accuracy in coding.

5. Documentation

• Required Documentation:
  • Detailed incident reports for each fall, specifying the nature of the injury.
  • Medical evaluations following falls to document the extent of injuries.
  • Updates to care plans reflecting any interventions implemented post-fall.
• Documentation should be clear, timely, and thorough to support accurate MDS coding.

6. Common Errors to Avoid

• Misclassifying the severity of injuries (e.g., recording a major injury as minor).
• Overlooking falls that resulted in minor injuries, thus under-reporting in J1900B.
• Failing to update the MDS when additional falls occur during the assessment period.

7. Practical Application

• Scenario: A resident who recently admitted experienced a fall while walking unassisted in the hallway, resulting in a scraped elbow. The incident was immediately reported by the staff, documented in the incident log, and the injury was assessed by the nursing team. The care plan was updated to include supervised walks and additional physical therapy. For MDS coding, based on the documentation, J1900B was accurately coded as '1', reflecting this minor injury fall.

Please note that the information provided in this guide for MDS 3.0 Item set J1900B 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.