02/25/2026
Continuing in our series this week, let’s talk about when a heel wound is NOT a pressure injury.
A heel wound may be coded outside Section M only when:
• Pressure has been clearly ruled out
• Documentation supports a primary alternate etiology (e.g., severe PAD)
• Objective vascular evidence is present (ABI/TBI)
• Appropriate pressure offloading was implemented and documented!!!
Even in cases of severe PAD or skin failure, pressure injury must first be considered and excluded. Also see F684-Other Wound Etiologies
So, what can we take from this series? Here’s a few survey-proof takeaways to keep in your back pocket:
You cannot code or document your way out of pressure!!
Mislabeling a heel pressure injury as a diabetic foot ulcer:
• Does not prevent an F686 citation
• Often leads to additional deficiencies (assessment, care planning, QAPI)
• Undermines clinical credibility during survey
Correct identification, documentation, and offloading of heels in mobility impaired patients/residents protect the resident, the facility, and the staff from survey and legal ramifications.
References:
1. Centers for Medicare & Medicaid Services. State Operations Manual (SOM), Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev. 225, Issued August 8, 2024; effective updates April 28, 2025).
2. CMS, Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual, Version 1.20.1, Chapter 3 – Section M: Skin Conditions. Final version effective October 1, 2025
