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.

The issue of “reverse staging” or “backstaging” of pressure ulcers as they heal is often a cause for confusion, even for some experts.  With this blog post I hope to clarify things and explain why reverse staging is now discouraged when assessing wounds, and place the issue in context with the revised Minimum Data Set (MDS) 3.0 Section M: Skin Conditions, which went into effect October 2010.  The Minimum Data Set is a backbone of the Resident Assessment Instrument (RAI) that is required for use on all residents of Medicare certified skilled nursing facilities.

geriatrician, pressure ulcer, wound care specialist, humanistic medicine, care of elderlyThere are currently six pressure ulcer stage classifications which are based on the anatomical depth of tissue that is visualized from the surface.  Stage 1 ulcer is intact skin that has nonblanchable redness, Stage 2 is partial thickness skin loss, Stage 3 is full thickness skin loss, and Stage 4 goes into deeper tissue such as muscle or bone.  In recent years the staging system was expanded to include Unstageable, where the base of the pressure ulcer is covered by slough or eschar and the anatomical depth cannot be visualized, and suspected Deep Tissue Injury (sDTI) where the skin is intact but there is purplish discoloration in the area of a boney prominence. 

When the 1 to 4 staging system was first adapted by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989, clinicians applied it in reverse to describe healing wounds.  In other words, when a Stage 4 ulcer began to granulate, epithelialize and heal, it transformed to Stage 3, then 2, etc.  Experts, however, noted that this practice is anatomically incorrect because a healing skin defect is not filled by normal tissue, but rather is replaced by scar tissue that is composed of endothelial cells, fibroblasts, collagen, and extracellular matrix (see NPUAP).  

To describe a healing wound, it is more accurate not to reclassify it at a lower stage, but rather to use the historically deepest stage and prefix this with the term “healing.”  Therefore, a Stage 4 pressure ulcer that is almost healed is designated a “healing Stage 4” and not “downstaged” to a Stage 3, 4, or 2. 

Reverse staging is now discouraged in clinical practice – a recommendation now codified by the Centers for Medicare and Medicaid Services (CMS) in the revised MDS 3.0 Section M: Skin conditions

MDS 2.0, in use since the early 1990’s, recognized only four pressure ulcer stages and required reverse staging for wound classification.  To maintain clinical accuracy and completeness, the wound care clinician needed to describe the wound elsewhere, and perhaps differently, in the narrative section of the medical chart.  This limitation in coding of stages has changed in the new Resident Assessment Instrument (RAI) Manual, which not only recognizes Unstageable and sDTI, but explicitly prohibits reverse staging when assessing the healing wound. The clinician is still expected to document the wound in detail in another part of the medical record. 

One of the goals of MDS 3.0 was to upgrade this mandatory assessment tool to correct outdated assessment standards and incorporate more clinically relevant language.  CMS has accomplished this in Section M: Skin Condition by incorporating the expanded staging system and abolishing reverse staging. 

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To download essential resources for MDS 3.0 Section M click here.

To download my recent paper on Essentials of MDS 3.0 Section M: Skin Condition click here

For the NPUAP position paper on reverse staging of pressure ulcers click here.

To purchase a copy of the Document Dermis™ Pocket Guide to Pressure Ulcers click here.

To access the Blog Archive on my Document Dermis™ Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN, PhD click here.



  • Gay Mashburn
    04/13/2016, 8:44 am  Reply

    I’ve understood that an ulcer that heals becomes a healed (whatever it was staged) ulcer.

    For Oasis purposes, can a stage II PU be described as a stage I ulcer after it has healed?

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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.