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Pressure Ulcer Staging - Best Practices for Completing OASIS C2 M1324

Posted by Nathan Hope on Nov 28, 2017

Medicare Guidelines for Pressure Ulcer Staging and Completing M1324 - Stage Problematic Pressure Ulcer.

MyHomecareBiz recommends including the following pressure ulcer staging policies and procedures for documenting OASIS C2 M1324 --Stage of Most Problematic Unhealed Pressure Ulcer:

What is the purpose of M1324?

Identifies the stage of the most problematic stageable pressure ulcer. Please note; ulcers that have healed are not considered for this item.

When is the assessment performed?

Download the Pressure Ulcer  Careplan for Skilled Nursing

  • Start of Care, Discharge from agency—not to an inpatient facility, Follow-up, Resumption of Care



  • Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”. Recognize, however, that Stage 1 pressure ulcers and Suspected Deep Tissue Injury (sDTI), although closed (intact skin), would not be considered healed.
  • Unstageable pressure ulcers, whether covered with a non-removable dressing or eschar or slough, would not be considered healed


Determine Which Pressure Ulcers are Stageable and Unstageable

  • A pressure ulcer is considered Unstageable if:
    • it is covered with a non-removable dressing/device, such as a cast, that cannot be removed, it is a suspected deep tissue injury in evolution, or
    • the wound bed is obscured by some degree of necrotic tissue AND no bone, muscle, tendon, or joint capsule (Stage 4 structures) are visible. Note that if a Stage 4 structure is visible, the pressure ulcer is reportable as a Stage 4 even if slough or eschar is present.


Dpressurce-ulcer-prevention-I.jpgetermine the Most Problematic Pressure Ulcer

  • “Most problematic” may be the largest, the most advanced stage, the most difficult to access for treatment, the most difficult to relieve pressure, etc., depending on the specific situation.
  • If the patient has only one stageable pressure ulcer, that ulcer is the most problematic.


Describe the Stage of the most Problematic Pressure Ulcer

  • Enter the response that most accurately describes the stage of the most problematic stageable pressure ulcer using the definitions of Stage in M1311 that were derived from the National Pressure Ulcer Advisory Panel (NPUAP) staging system.
  • Enter “NA” if the patient has NO pressure ulcers or only has pressure ulcers that are Unstageable as defined above.
  • Do not reverse stage pressure ulcers as a way to document healing as it does not accurately characterize what is physiologically occurring as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Clinical standards require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has healed.
  • If a pressure ulcer is Stage 4 at SOC and is granulating at the Follow-up Assessment, the ulcer remains a Stage 4 ulcer.

Further Clarification on Stages:


Newly epithelialized:

  • Wound bed completely covered with new epithelium.
  • No exudate.
  • No avascular tissue (eschar and/or slough).
  • No signs or symptoms of infection.


Fully granulating:

  • Wound bed filled with granulation tissue tthe level of the surrounding skin.
  • No dead space.
  • No avascular tissue (eschar and/or slough).
  • No signs or symptoms of infection.
  • Wound edges are open.


Early/partial granulation:

  • ≥ 25% of the wound bed is covered with granulation tissue.
  • < 25% of the wound bed is covered with avascular tissue (eschar and/or slough).
  • Nsigns or symptoms of infection.
  • Wound edges open.


Not healing:

  • Wound with ≥ 25% avascular tissue (eschar and/or slough) OR
  • Signs/symptoms of infection OR
  • Clean but non-granulating wound bed OR
  • Closed/hyperkeratotic wound edges OR
  • Persistent failure timprove despite appropriate comprehensive wound management.


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