Effective October 1, 2025 | CMS RAI Manual v1.20.1
The Centers for Medicare & Medicaid Services (CMS) has released the final version of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual v1.20.1, posted on August 29, 2025. This version includes several critical updates that Skilled Nursing Facilities (SNFs) must implement by October 1, 2025. Access the latest manual HERE.
Among the most impactful changes is the updated guidance in Section J: Health Conditions, which directly affects:
- Quality Measures (QMs) – Falls with Major Injury is a publicly reported measure
- Total Quality Score (TQS) – Falls with Major Injury influences reimbursement in Indiana
Updated Definition: Falls with Major Injury
The RAI Manual now provides refined guidance on what constitutes a Major Injury resulting from a fall. According to the manual (p. J-37):
MAJOR INJURY: Includes, but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries.
Further clarification (p. J-39) states:
“Fractures confirmed to be pathologic (vs. traumatic) are not considered a major injury resulting from a fall.”
Why This Matters for Indiana SNFs
SNFs serve a population with high rates of osteoporosis and other bone diseases. Under the new guidance, if a physician documents that a fracture was pathologic—for example, due to osteoporosis—it should not be coded as a Fall with Major Injury.
Implications:
- Quality Measure Accuracy: Percentage of Long-Stay Residents experiencing one or more falls with major injury is a publicly reported measure that can influence a facility’s reputation and quality ratings.
- Financial Impact: In Indiana, this measure also affects the TQS, which directly impacts reimbursement. Accurate coding can help ensure appropriate reimbursement:
- Quality Payments under Indiana Medicaid’s UPL Supplemental Payment Program are tied to a facility’s TQS
- Falls with Major Injury is one of the measures used to calculate TQS (along with Pressure Ulcers, Rehospitalizations, ED visits, and Nurse Staffing)
- Capturing all TQS Point for this measure through accurate coding, could increase current reimbursement by almost 2% of the facility’s base Medicaid Rate and have an even bigger impact in future years.
Action Steps for Facility Leadership
- Educate Your Team: Begin training all clinical and MDS staff on the updated RAI guidance, especially those involved in fall documentation and coding.
- Review Section J1900 Coding: Ensure your team understands the distinction between traumatic and pathologic fractures and how to apply the new definitions. Physician documentation must be present to support a pathological fracture.
- Establish Audits: Establish internal audits to verify that physician documentation supports the correct classification of fractures.
Conclusion
The updated RAI Manual v1.20.1 presents an opportunity for Indiana SNFs to improve the accuracy of fall-related reporting and receive appropriate Medicaid reimbursement. By aligning documentation and coding practices with the new guidance, facilities can enhance both clinical integrity and financial performance. Our team of post-acute care experts can help your facility navigate the updated CMS guidance, ensure accurate fall injury coding, and maximize your Total Quality Score (TQS) for optimal reimbursement. Contact us today to align your documentation practices with the new guidelines and unlock the full potential of Indiana’s Medicaid UPL Supplemental Payment Program.
Landon Hackett, CPA, MSA, Director
