CMS found something concerning while reviewing fall data in skilled nursing facilities:
Nearly half of major fall injuries identified through hospital and emergency department claims were not being captured on the MDS.
According to CMS-reviewed research, only about 57.5% of claims-identified falls with major injury were reflected in MDS reporting.
That finding is driving one of the biggest upcoming changes to skilled nursing quality measurement.
CMS is re-specifying the Falls With Major Injury quality measure to include both MDS assessments and claims data, creating what is known as a hybrid quality measure.
And while this methodology has not yet been adopted into the Five-Star Quality Rating System, it signals a major shift in where CMS quality reporting is headed.
Why CMS Is Changing the Falls With Major Injury Measure
Historically, the Falls With Major Injury quality measure relied almost entirely on MDS documentation.
If the fall and injury were not coded correctly on the assessment, the event often did not impact the measure.
CMS identified a major gap in that process.
Hospital claims, emergency department records, and observation data frequently identified serious fall-related injuries that never appeared within MDS reporting.
As a result, CMS redesigned the measure to capture events using multiple data sources rather than relying solely on assessment documentation.
The updated methodology now incorporates:
- MDS assessments
- hospital claims
- emergency department claims
- observation claims
- ICD-10 diagnosis coding
- external cause-of-injury coding
The goal is to create a more accurate representation of actual resident outcomes across the continuum of care.
CMS Can Now Identify Falls in Multiple Ways
The updated hybrid measure significantly expands how falls with major injury are identified.
Traditional MDS Coding Still Counts
If a facility documents a fall with major injury on the MDS through Section J coding, the resident will continue triggering into the measure as before.
That process remains unchanged.
Claims Data Can Upgrade the Severity of a Fall
CMS is now comparing claims data against MDS documentation.
For example:
- a resident fall may be documented on the MDS
- the injury itself may not be coded as “major”
- hospital claims may later identify fractures or traumatic brain injuries tied to that fall
If claims data supports a qualifying injury diagnosis, the event may still count as a fall with major injury.
Claims Data Alone Can Trigger the Measure
This is where the methodology changes most dramatically.
If a hospital or emergency department claim contains:
- a fall-related external cause code
- and a qualifying major injury diagnosis
the resident may trigger into the quality measure even if the fall never appeared on the MDS.
That means CMS can now identify fall-related injuries independently through claims validation.
The measure is no longer dependent on MDS documentation alone.
What Counts as a “Major Injury” Is Also Expanding
CMS has broadened the clinical definition of major injury within the updated methodology.
Qualifying injuries now include:
- traumatic fractures
- joint dislocations
- traumatic brain injuries
- spinal cord injuries
- internal organ injuries
- crush injuries
- traumatic amputations
These diagnoses are identified through ICD-10 coding found within claims data.
This broader definition significantly increases the likelihood that fall-related injuries will be captured and reported.
Why Facilities May See Their Rates Increase
When CMS tested the hybrid methodology, facility-level results changed substantially.
Using traditional MDS-only reporting:
- the average Falls With Major Injury rate was approximately 3.7%
After incorporating claims data:
- the average rate increased to more than 9%
Perhaps even more striking:
- the percentage of facilities reporting zero falls with major injury dropped from over 11% to less than 2%
This does not necessarily mean resident care worsened.
It means CMS now has broader visibility into outcomes occurring across hospitals, emergency departments, and post-acute settings.
For providers, this creates an important operational reality: future publicly reported rates may appear higher even if clinical practices remain unchanged.
What This Could Mean for Five-Star Ratings
At this time, the Five-Star Quality Rating System still relies on the traditional MDS-based Falls With Major Injury measure.
However, CMS frequently introduces updated methodologies into:
- quality reporting programs
- technical specifications
- validation systems
- pilot reporting structures
before eventually transitioning them into public reporting and Five-Star calculations.
While CMS has not formally announced implementation timing, many industry experts anticipate that the hybrid methodology may eventually become part of the Five-Star framework.
Facilities that wait until implementation occurs may find themselves reacting too late.
What Skilled Nursing Facilities Should Focus on Now
This shift places greater emphasis on actual fall prevention systems rather than documentation practices alone.
Facilities should focus on:
- strengthening fall risk assessment processes
- improving environmental safety programs
- enhancing interdisciplinary care planning
- conducting stronger post-fall root cause reviews
- monitoring hospitalization and emergency department trends
- improving communication during care transitions
Facilities should also begin evaluating claims-related hospitalization data more proactively, since those claims may increasingly shape future quality outcomes.
Because in this new environment, quality measures are no longer isolated to what happens inside the facility walls.
CMS is evaluating resident outcomes across the broader healthcare continuum.
The Bigger Trend Behind the Hybrid Measure
The updated Falls With Major Injury methodology reflects a much larger CMS strategy.
Across skilled nursing, CMS is increasingly moving toward:
- claims-validated quality measures
- external data verification
- real-world outcome tracking
- reimbursement integrity initiatives
- broader audit oversight
This trend aligns closely with:
- the SNF Validation Program
- claims-based antipsychotic quality measures
- expanding audit activity
- increased focus on operational data integrity
For providers, quality reporting is becoming less about isolated assessment coding and more about whether the entire clinical story aligns across systems.
The Bottom Line
The future of quality measurement in skilled nursing facilities is changing rapidly.
The updated Falls With Major Injury measure demonstrates that CMS is no longer relying solely on the MDS to evaluate outcomes.
Hospital claims, emergency department records, and utilization data are becoming part of the quality story.
For facilities, this raises the importance of:
- true fall prevention systems
- interdisciplinary coordination
- hospitalization tracking
- operational alignment
- claims awareness
- outcome-focused care planning
Organizations that strengthen these systems now will be far better positioned as CMS continues evolving toward claims-based quality measurement.
How MDS Solutions Supports Facilities
At MDS Solutions, we help skilled nursing facilities strengthen interdisciplinary systems, improve documentation accuracy, and prepare for the future of claims-validated quality reporting.
From reimbursement strategy and quality measure analysis to operational education and clinical alignment, our focus is helping facilities build sustainable systems that support both compliance and resident outcomes.
Because in today’s environment, quality reporting is no longer defined by documentation alone.
It is increasingly defined by the outcomes CMS can validate across the continuum of care.