The calculation for the Quality Measure for Falls with Major Injury has been revamped with the update to the definition of falls. This updated calculation currently impacts the SNF Quality Reporting Program (QRP).
The definition of Falls with Major Injury (FMI) was revamped based on a study by HHS’ Office of the Inspector General, which found a substantial underreporting of FMI events. The definition has been expanded to “Unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident).”
In addition, Major Injury was further clarified - “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.” Injury (vs. Major Injury) includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that causes the resident to complain of pain.
The new Falls with Major Injury (FMI)measure is a hybrid measure utilizing claims and assessment data for the numerator. It is triggered if a resident experiences one or more falls with major injury on one or more of the assessments/claims during the look-back scan. The numerator is determined as follows:
There are claims’ numerator exclusions for this measure:
The denominator for this measure uses a typical assessment-based measure calculation. It includes all resident stays with one or more look-back scan assessments, except those meeting the exclusion. The exclusion for this measure is if a resident expired during the SNF stay (Type 2 stay with PPS 5-day Assessment MDS items A0310B = [01] AND A0310F= [12] on the Death in Facility tracking record).
The look-back scan is a 12-monthtarget. The entire Medicare Part A SNF stay specific to a resident, including all SNF Part A stays, in the 12-month target are included. For Part A SNF stays an entire stay, or Type 1 SNF stay, is defined as a matched pair with a PPS 5-day Assessment and PPS discharge assessment with no Death in Facility tracking record.
For the updated FMI measure, a comprehensive set of diagnoses is utilized to identify ICD-10 codes from the claims data. The set includes:
A list of the ICD-10 Major Injury Diagnostic Codes and the External Cause of Injury Codes is available in Skilled Nursing Facility - Falls with Major Injury Respecification Technical Specification Report from RTI International. This is available at the following link: https://www.cms.gov/files/document/fmi-technicalspecificationsreport-snf.pdf.
As indicated above, this report only discusses respecification in relation to the Quality Reporting Program. Poor performance or a high percentage can lead to financial repercussions in relation to the SNF QRP with the annual percentage update (APU). It is therefore key we understand the measures new specifications to avoid significant financial impact.