Pressure ulcer staging and support surfaces

When treating patients with deeper pressure ulcers, pressure redistribution with specialty beds and cushions is an integral part of the treatment plan. This discussion presents CMS guidelines for selecting specialty beds for all stages of pressure injuries.

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According to the NCUAP guidelines for staging pressure injuries, the wound in the attached photo would be classified as:

  • Stage 2
  • Stage 3
  • Stage 4
  • Unstageable

Answer: B

Stage 3 pressure ulcers are defined as the following:  Full thickness tissue loss.  Full-thickness loss of skin in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.  Slough and/or eschar may be visible.  The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling may occur.  Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed.  If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. 

When assessing the wound in this photo, one may be debating between Stage 3 and Unstageable.  However, the definition says eschar may be visible, and the eschar in this wound looks thin and superficial, which would not preclude one from determining that the depth is not beyond the subdermal tissue and no fascia, muscle, tendon, etc. are involved.  Thus, Stage 3 would be appropriate documentation.

Treatment of Stage 3 wounds involves debridement of all necrotic tissue, moist wound dressings (depending on the amount of drainage), treatment of infection if present, and PRESSURE REDISTRIBUTION.  The question then becomes what type of specialty bed is covered by this patient.  A review of Medicare guidelines indicates that it is not just the staging of the wound that is considered, but also the patient’s mobility, nutritional status, co-morbidities, etc.  Coverage is described in the following three groups:

  • GROUP 1 - A group 1 support surface is covered if the patient is completely immobile. Otherwise, he or she must be partially immobile, or have any stage pressure ulcer and demonstrate one of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier. 
  • GROUP 2 - A group 2 support surface is covered if the patient has a stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included the use of an appropriate group 1 support surface for at least one month), and has sores which have worsened or remained the same over the past month. A Group 2 support surface is also covered if the patient has large or multiple stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent mycutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a group 2 or 3 support surface. 
  • GROUP 3 – A group 3 support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one (1) month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with patient care, and all other alternative equipment has been considered and ruled out.[i] 

Group 1, 2, and 3 support surfaces are defined as follows:

  • Group 1 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include mattresses, pressure pads, and mattress overlays (foam, air, water, or gel). 
  • Group 2 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses.
  • Group 3 support surfaces are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads.1 

Needless to say, accurate and complete documentation of the patient’s medical history, medications, co-morbidities, nutritional status, continence, functional status, prognosis, response to treatments that have been rendered, sensory perception, and circulatory status (especially if the pressure ulcer is on an extremity).  In addition, there must be documentation on patient education and adherence to the treatment plan.

These guidelines support the premise that when we are treating a patient with a pressure ulcer, we are not treating a wound, we are treating a PATIENT with a wound, and all aspects of the patient’s well-being are to be considered when developing a treatment plan and requesting specialty beds through third-party payers. 

 [1] Center for Medicare and Medicaid Services.  Medicare Policy Regarding Pressure Reducing Support Surfaces – JA1014.  Available at  Accessed August 31, 2019. 

Further information on selection of specialty surfaces for patients with pressure injuries/ulcers can be found at the following:

Garcia AD, Sprigle S. Pressure injuries and ulcers. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 171-198.  Available at

Rose Hamm

Physical Therapy, University of Southern California