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.

Guest Post by Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN.

Are you ready for the changes in MDS 3.0, Section M: Skin Condition? Having just developed the slide materials and provided the instruction on this for the CMS “Train the Trainer” programs in April 2010, I strongly believe that because section M is expanded to three pages, now is the time for clinicians, MDS coordinators, administrators and facilities to get ready for the CMS projected October 2010 implementation date of MDS 3.0.

Criteria used to evaluate pressure ulcer risk (section M0100) as well as the clinical decision as to whether a resident is at risk for a pressure ulcer (M0150) are now part of section M of MDS 3.0. Documentation must make it possible to determine which pressure ulcers were present on admission to the facility, the date of the oldest stage 2 pressure ulcer (M0300B3) as well as the dimensions (M0610) and most severe type of tissue present (M0700) in the largest pressure ulcer.

Reverse staging in long term care is finally gone!!! Accurate ability to stage according to CMS adapted definitions of pressure ulcer classification is required. If you need help with pressure ulcer staging, one educational resource is the Document Dermis™ Pocket Guide to Pressure Ulcers which is published and distributed by the New Jersey Hospital Association.  For each pressure ulcer stage, the number of pressure ulcers present must be recorded (M0300 A-G). MDS 3.0 includes a place to record unstageable pressure ulcers due to either a non-removable dressing or device (M0300E), slough and/or necrotic tissue (M0300F) or intact skin from deep tissue injury ((M0300G). Just as in MDS 2.0, any pressure ulcer that presents as a blister regardless of what it is filled with, is documented on MDS 3.0 as a stage 2.

These are just some of the highlights of revised section M of MDS 3.0. You can read more about MDS 3.0 Section M Skin Conditions in my article which I co-authored with Dr. Jeffrey Levine, a practicing internist, geriatrician, and wound care specialist and Sharon Roberson RN, the Northeast Consortia Technical Lead, Survey and Certification from the Centers for Medicaid and Medicare Services entitled “Essentials of MDS 3.0 Section M: Skin Conditions” pubished in this month’s issue of Advances in Skin and Wound Care.

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Reference for this post was Levine, Roberson, Ayello.  Essentials of MDS 3.0 Section M: Skin Conditions.  Advances in Skin & Wound Care.  June 2010, 23(6), pp 273-284.

See also Roberson, Ayello, Levine.  Clarification of Pressure Ulcer Staging in Long-term Care under MDS 2.0, Advances in Skin & Wound Care.  May 2010, 23(5), pp 206-210.

Order your Pocket Guide to Pressure Ulcers using this Order Form.   

To view all blog posts on revised Minimum Data Set 3.0 click on the MDS 3.0 blog archive.

See related posts: 

New Pocket Guide to Pressure Ulcers.

Clinicians Love the Pressure Ulcer Guide.



  • Inge Luce
    08/18/2010, 7:20 pm  Reply

    I am looking for some guidance as to what Emergency Nurses need to document upon admission to the hospital. Inge

    • 09/06/2010, 10:58 am

      Reply written by Dr. Jeffrey Levine:

      Thanks for the note Inge. The standard of care for ER nurses is the same for any nurse inspecting skin. Indeed, being mindful of the issues related to Present on Admission (POA) documentation, it is even more important for ER nurses to perform thorough skin assessment. The assessment should include examination of all dependent boney prominences for redness and/or evidence of skin break, with staging if applicable and narrative description. For more information on POA issues please read my blog post from January 13th, 2010 entitled How CMS views pressure ulcers in hospitals.

  • Laura DiGiulio
    06/15/2010, 10:17 am  Reply

    Good morning Dr. Ayello, I am a newly certified WOCN practicing as wound care nurse since 2005 in the long term care setting. I have been trying to follow all the news and updates regarding documentation of sDTI pressure injury and the upcoming MDS 3.0, and teaching it to our staff. Needless to say this has been a challenge; specifically in explaining the difference in classification between the acute care setting and MDS coding requirements. I have been teaching and urging staff to follow the revised classification instructions by the NPUAP, but confusion arises when MDS coding is done. In some cases MDS coding is more forgiving or lenient’ (staging blood filled blisters as Stage 2) and I am asked why we have to follow the NPUAP guidelines if it is not supported by CMS which regulates long term care. I don’t know the answer to that question. But this is almost water under the bridge, more importantly I would like some guidence about how to integrate the new MDS3.0 guidelines related to staging SDTI with clinical documentation done by nursing staff. The article which you co-authored: Essentials of MDS 3.0 Section M: Skin Conditions in Figure 4 compares the new MDS classification with Acute Care setting. When MDS 3.0 is implemented do we still follow the acute care staging system based on NPUAP or the revised LTC MDS3.0 system? I had assumed we would continue to follow the NPUAP recommendations, but I am now wondering what is expected or accepted by CMS. I would also like to add that my efforts to teach and have nurses quickly identify sDTI placed our facility in unfavorable circumstances during our annual DOH inspection. Pressure injury initially coded as sDTI that later turned out to be only stage 1 or 2, was interpreted as knowledge deficit in staging and higher numbers of p.u. DISCOVERED at greater stages of injury. This was quite disheartening; we erred on the side of caution for the patient’s benefit, we tried to explain without success. Any clarity you can provide would be greatly appreciated. Best regards, Laura DiGiulio, CWOCN

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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.