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DiraChart MDS item reference
J1900ASection Jv1.20.1Manual page J-37
Falls since admit/prior assessment: no injury
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
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Response format: Coded response
1
one
Manual page J-372
two or more
Manual page J-37Item-specific instructions
Coding Guidance
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Steps for Assessment
1. If this is the first assessment (A0310E = 1), review the medical record for the time period
from the admission date to the ARD.
2. If this is not the first assessment (A0310E = 0), the review period is from the day after the
ARD of the last MDS assessment to the ARD of the current assessment.
3. Review all available sources for any fall since the last assessment, no matter whether it
occurred while out in the community, in an acute hospital, or in the nursing home. Include
medical records generated in any health care setting since last assessment. All relevant
records received from acute and post-acute facilities where the resident was admitted during
the look-back period should be reviewed for evidence of one or more falls.
4. Review nursing home incident reports and medical record (physician, nursing, therapy, and
nursing assistant notes) for falls and level of injury.
5. Ask the resident, staff, and family about falls during the look-back period. Resident and
family reports of falls should be captured here, whether or not these incidents are
documented in the medical record.
6. Review any follow-up medical information received pertaining to the fall, even if this
information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results),
and ensure that this information is used to code the assessment.
Coding Instructions
for J1900
Determine the number of falls that occurred since admission/entry or reentry or prior
assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code
each fall only once. If the resident has multiple injuries in a single fall, code the fall for the
highest level of injury.
Coding Instructions for J1900A, No Injury
•
Code 0, none: if the resident had no injurious fall since the admission/entry or reentry
or prior assessment (OBRA or Scheduled PPS).
•
Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry
or prior assessment (OBRA or Scheduled PPS).
•
Code 2, two or more: if the resident had two or more non-injurious falls since
admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).
Coding Instructions for J1900B, Injury (Except Major)
•
Code 0, none: if the resident had no injurious fall (except major) since admission/entry
or reentry or prior assessment (OBRA or Scheduled PPS).
•
Code 1, one: if the resident had one injurious fall (except major) since admission/entry
or reentry or prior assessment (OBRA or Scheduled PPS).
J1900: Number of Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
•
Code 2, two or more: if the resident had two or more injurious falls (except major)
since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).
Coding Instructions for J1900C, Major Injury
•
Code 0, none: if the resident had no major injurious fall since admission/entry or
reentry or prior assessment (OBRA or Scheduled PPS).
•
Code 1, one: if the resident had one major injurious fall since admission/entry or
reentry or prior assessment (OBRA or Scheduled PPS).
•
Code 2, two or more: if the resident had two or more major injurious falls since
admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).
Coding Tips
•
If the level of injury directly related to a fall that occurred during the look-back period is
identified after the ARD and is at a different injury level than what was originally coded
on an assessment that was submitted to the Internet Quality Improvement and Evaluation
System (iQIES), the assessment must be modified to update the level of injury that
occurred with that fall.
•
Fractures confirmed to be pathologic (vs. traumatic) are not considered a major injury
resulting from a fall.
MDS item matrixAssessment Applicability
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Assessment Applicability
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