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.

Another guest post by Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN.

I was pleased with the response to my first guest post on Dr. Levine’s healthcare blog.  One question in particular regarding suspected deep tissue injury (sDTI), written by Laura DiGiulio CWOCN, particularly deserves comment.  Laura asked:

“I would like some guidance 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 ulcers 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”

Thanks Laura for your question, many wound care clinicians are grappling with the same issues.  You are required to follow the CMS regulations for your care setting.  So for long-term care you must follow the CMS adapted pressure ulcer definitions for coding on MDS 3.0.  The CMS manual on Section M will be very helpful as it gives several examples.  This can be downloaded from here.  CMS also has posted questions from the training sessions held in April 2010  (see MDS 3.0 Q&A from Training sessions  April 12, 2010 at this link)  which along with my coauthored article with Dr. Levine and Sharon Roberson were the basis for my previous blog.  CMS continues to post updates and additional resources so I suggest you check the CMS website for new or revised information.

You might consider attending the second CMS training session on MDS 3.0 which will be held in Las Vegas August 9-13, 2010. For more information and registration (which closes July 8) please follow this link

As far as the situation you described at your facility please contact your state CMS office as I cannot speak for them.  CMS expects LTC to follow the manual for MDS 2.0 until MDS 3.0 becomes effective with proposed implementation date of October 1, 2010. (See CMS Implementation Timeline May 25 2010 that gives the dates for Transition from MDS 2.0 to MDS 3.0 on the CMS website).  Please refer to another article that I co-wrote with Sharon Roberson and Dr. Levine entitled, Clarification of pressure ulcer staging in long-term care under MDS 2.0. Advances in Skin & Wound Care. May 2010 23(5):206-10.  Under MDS 2.0, the only options you have for coding pressure ulcers are Stage 1, 2, 3, or 4. There is no place on section M to code a suspected deep tissue injury on MDS 2.0, but remember this will change with MDS 3.0 as suspected deep tissue injury will now be coded in section M under subsection 300 G.

Keep up the good work Laura!  The struggle to prevent and heal skin ulcers never ends.

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

Related posts:

Pressure Ulcer Regulations in the Nursing Home: Introduction to Revised F-Tag 314

How CMS Views Pressure Ulcers in Hospitals

Elizabeth Ayello PhD, RN,  former President of the National Pressure Ulcer Advisory Panel, is now consultant to CMS regarding development of education and policy regarding MDS 3.0 Section M: Skin Condition. 



  • Susie Lee
    10/13/2010, 3:46 pm  Reply

    I was at your 0600 talk at the recent Wound Care Symposium in Orlando and would like a soft copy of the slides of “Essentials of MDS 3.0 Section M- Skin Conditions” to supplement training of my staff.

    If ever in Hawaii give me a call and I’ll buy you a Mai Tai!

    Susie Lee RN, BSN, WCC

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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.