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CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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Stage 4 Pressure Ulcers
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What this item is
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When to use it
Use this item when the facility is completing content tied to Section M and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page M-19
- CMS exact locator: Manual page M-19
- This item does not yet have governed answer rows attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page M-19
CMS exact locator
Manual page M-19
Full CMS Text
Item Rationale
Health-related Quality of Life
Pressure ulcers affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes.
DEFINITION
STAGE 4 PRESSURE ULCER Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Planning for Care
Pressure ulcers at more advanced stages typically require more aggressive interventions, including more frequent repositioning, attention to nutritional status, more frequent dressing changes, and treatment that is more time-consuming than with routine preventive care. An existing pressure ulcer may put residents at risk for further complications or skin injury. If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the resident’s overall clinical condition should be reassessed.
Steps for Assessment
1. Perform head-to-toe assessment. Conduct a full body skin
assessment focusing on bony prominences and pressure- bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being
assessed is primarily related to pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.
3. Identify all Stage 4 pressure ulcers currently present.
4. Identify the number of these pressure ulcers that were
present on admission/entry or reentry.
Coding Instructions for M0300D
M0300D1 Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 4. Enter 0 if no Stage 4 pressure ulcers are present and skip to M0300E, Unstageable – Non-removable dressing. M0300D2 Enter the number of these Stage 4 pressure ulcers that were first noted at Stage 4 at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, enter the number of Stage 4 pressure ulcers that were acquired during the hospitalization (i.e., the Stage 4 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital). Enter 0 if no Stage 4 pressure ulcers were first noted at the time of admission/entry or reentry.
DEFINITIONS
TUNNELING A passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. UNDERMINING The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface.
Coding Tips
The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be shallow. Stage 4 pressure ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone/tendon/muscle is visible or directly palpable. Cartilage serves the same anatomical function as bone. Therefore, pressure ulcersthat have exposed cartilage should be classified as a Stage 4. Assessment of the pressure ulcer for tunneling and undermining is an important part of theof the complete pressure ulcer assessment. Measurement of tunneling and undermining is notis not recorded on the MDS, but should be assessed, monitored, and treated as part of the comprehensive re plan.
Matrix Applicability
Matrix values will appear here after they are imported into the governed matrix tables.