Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

I recently gave another training session for nursing home professionals for MDS 3.0 Section M: Skin Conditions.  In the audience were nurses, directors of nursing, administrators, MDS coordinators and a smattering of physical therapists, doctors, and social workers.  After the didactic I fielded questions and decided to share the most common ones with my blog readers. 

Question 1:  How do I code Section M0700 when a resident’s pressure ulcer presents as a blister?

Answer:  Pressure ulcers sometimes present as blisters, particularly in the heel area.  Blisters that are filled with clear serous fluid are coded in M0300B: Stage 2.  Pressure ulcers that present as a blood-filled blister are coded as Suspected Deep Tissue Injury in M0300G. 

Section M0700 asks for “Most severe tissue type,” and gives the following four choices:

     1.  Epithelial tissue
2.  Granulation tissue
3.  Slough
4.  Necrotic tissue (Eschar)

Epithelial tissue refers to the closely packed cells that cover the entire surface of the body, and separated from underlying tissue by a thin sheet of connective tissue which provides structural support and binds to neighboring structures.  Wound healing is characterized in part by the process of epithelialization, which occurs when fresh epithelial cells proliferate and spread over the open wound bed, providing cover for the wound and forming new skin. 

When coding a blister in Section M0700, the correct answer is 1. Epithelial tissue. 

Question 2:  How do I code a superficial re-opening of a healed Stage 4 ulcer?

Answer:  The RAI Manual prohibits “back staging” (also called reverse staging or downstaging) of pressure ulcers as they heal.  Therefore, when a Stage 4 pressure ulcer heals, it is documented as a “healed Stage 4.”  If this ulcer reopens, even if the reopened area is superficial and looks like a Stage 2 ulcer, it should be documented as a “reopened stage 4.” 

If this ulcer were coded as a Stage 2 ulcer, you would be effectively downstaging from a “healed Stage 4” to a stage 2, which is prohibited by CMS. 

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These answers were verified with Elizabeth Ayello RN, PhD, who developed the education program for MDS 3.0 Section M for CMS, and co-authored our book, Pocket Guide to Pressure Ulcers

Related posts:

Straight Talk on Reverse Staging of Pressure Ulcers


  • 05/31/2018, 8:16 pm  Reply

    I would still code it as a stage 4 pressure ulcer.Just because it’s healed in the middle,the ulcer is still considered not healed and it is still only 1 ulcer .

  • Jeanett Vergara
    07/20/2016, 8:57 pm  Reply

    what skin type do you put for a stage 1 non blanchable skin, options are epithelial, granulation, slough, eschar , or none of above.
    I put epithelial is this correct? the MDS coordinator who used to code sec M would put none of the above for a stage 1. Just double checking.. Thank you for your response

  • Karen
    04/26/2016, 1:52 pm  Reply

    I have a stage IV ulcer that healed in the middle and now it is counted as 2 separate stage IVs. How do I code that in the section that asks about if these were present on the previous assessment. Now I have 2 stage IV when before there was one. But the area was present and not new.

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.