In this episode of Heart to Heart with HealthCap, Angie Szumlinski sits down with Jane Schoof, Director of Utilization at Atrium Living Centers, to discuss the most significant changes to the MDS 3.0 RAI Manual (v1.20.1), focusing on falls and injuries. Together, they review how CMS has redefined what constitutes a fall, including incidents caused by “overwhelming external forces,” and explain what should now be coded as an intercepted fall. The discussion sheds light on how these updates are designed to close reporting gaps between hospital claims and MDS coding, improve accuracy, and strengthen resident care.

Jane also provides insight into the revised definitions of major injury and injury except major, sharing how clinicians can apply clinical judgment, documentation, and teamwork to code consistently. The conversation emphasizes the importance of clearly documenting every fall, whether it occurs in therapy or during routine care, to ensure coding accuracy and regulatory compliance.

To help you implement these new standards, HealthCap has created two companion resources: the Comprehensive Reference Guide: Understanding the 2025 MDS 3.0 Changes and the Falls and Injuries Quick Reference Handout. Both documents offer examples, practical tips, and operational insights to help your community align its coding and training practices with the 2025 updates.