Is concussion related to fall considered a fall with major injury that would be coded In section JJ1900C of the MDS?




The RAI Manual defines a fall with major injury as follows:

Major injury: includes bone fractures, joint dislocations, closed head injury with altered consciousness, subdural hematoma.

A concussion meets the definition of a closed head injury. Depending on the level/grade of the concussion it could include an altered level of consciousness. In the case to determine whether the MDS coding should reflect a fall with major injury or a fall with injury except major additional information is needed to determine whether an altered level of consciousness is associated with the concussion.

In some cases, individuals who suffer a concussion may lose consciousness for a period and if the documentation indicates this occurred associated with the fall it would meet the definition of a major injury as noted above. In addition, it is important to note the RAI manual definition above does not specify that there must be a loss of consciousness to meet the criteria of major, but instead specifies “altered level of consciousness.” By definition, an altered level of consciousness is any deviation from the normal state of alertness and awareness, such as experiencing increased lethargy.  If this altered consciousness is associated with a concussion related to a fall this would meet the definition of a major injury.

Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant

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