If you’re running a Medicare-certified home health agency, you already know wounds can make or break your patient outcome. Nothing slows down care like a pressure injury that won’t heal, or worse, one that was staged incorrectly from the start. Misstaging can lead to delayed interventions, higher infection risk, avoidable hospitalizations, and survey deficiencies that no agency owner wants to face.
But with the right professionals, pressure wound staging doesn’t have to be confusing when you understand the system and the common pitfalls.
*This article was written in consultation with Mariam Treystman & Dr. Robert Goldberg.
At The Home Health Consultant, we’ve guided hundreds of agencies through survey prep, staff education, and compliance reviews. Our co-founder Mariam Treysman sat down with Dr. Robert Goldberg, a cardio-thoracic surgeon turned wound care specialist.
By the end of this article, you’ll have clear, plain-English answers on how to stage pressure wounds correctly in the home setting.
Who Is Dr. Robert Goldberg and Why Did He Join This Conversation?
Dr. Robert Goldberg is a thoracic surgeon and wound care specialist practicing in Los Angeles, California. After years of training in cardiothoracic surgery, he transitioned his expertise into advanced wound care.
He trained with Vohra Medical Group, the nation’s largest physician-led wound management organization, before establishing his own independent practice, Goldbro MD Professional Medical Corporation. Today, he brings expert wound care directly into patients’ homes across Los Angeles.
Dr. Goldberg knows firsthand how hard it is for homebound and bedbound patients to access specialized care: “These patients are often homebound or bedbound… there’s very limited care they can get at home.”
That perspective is exactly why he sat down with us, to walk through pressure wound staging and the pitfalls that agencies should avoid. Let’s dive in.
Why Doesn’t This Article Mention Wound Staging for Hospice?
If you’ve been following our content (thank you, by the way!), you may be wondering why this article doesn’t cover hospice like so many of our others. The reason comes down to the definition of hospice itself: hospice is palliative care.
Palliative care isn’t about improving a patient’s condition. Instead, the focus shifts to keeping the patient comfortable and preserving dignity during their final days.
That’s why wound staging plays a different role in hospice compared to home health. In home health, providers work to heal and improve the patient’s condition. But when a patient enters hospice, they legally acknowledge they are no longer seeking curative treatment, only comfort.
Now that you understand why we won’t be talking about hospice, let’s dive deeper into why proper pressure wound staging is essential for home health.
Why Does Pressure Wound Staging Matter in Home Health Care?
Pressure injuries, also called pressure ulcers or decubitus ulcers, are some of the most common wounds you’ll encounter in home health. They usually develop when patients remain in one position too long without being turned or offloaded.
As Dr. Goldberg explains: “When patients lay on a regular mattress, the skin gets compressed, squeezing out all the blood flow. Eventually the skin dies, and that’s how they get pressure wounds.”
These wounds aren’t just painful and debilitating, they’re notoriously hard to heal. They can last for years, often extend to the bone, and carry a high risk of infection. That can mean:
- higher hospitalization rates
- higher costs
- lower quality of life for patients
Correct staging from the start helps ensure proper treatment plans, prevent patient care errors, and supports accurate billing.
What Tissue Layers Do Clinicians Need to Understand Before Staging Pressure Wounds?
The National Pressure Injury Advisory Panel (NPIAP) provides the framework agencies follow for wound staging. They describe four main layers of soft tissue:
- Skin: made up of the epidermis (outer layer) and dermis (layer with blood vessels, nerve endings, hair follicles).
- Fat (Subcutaneous Tissue): cushions and insulates the body.
- Muscle: surrounded by fascia, a connective tissue sheath.
- Bone: deepest level where pressure injuries can progress.
What Are the Four Stages of Pressure Injuries?
If you take anything away from this article, let it be this: the four layers of soft tissue and the four stages of pressure injuries are not the same. Noting the differences is absolutely essential. Confusing the two is one of the most common reasons for wound care errors in home based care.
Here are the four stages of pressure injuries:
- Stage 1: Non-Blanching Erythema
- What It Looks Like: The skin is intact but red. Normally, when you press on redness it turns white for a moment (blanching). Here, it doesn’t, showing the skin is damaged.
- What It Looks Like: The skin is intact but red. Normally, when you press on redness it turns white for a moment (blanching). Here, it doesn’t, showing the skin is damaged.
*Image courtesy of National Pressure Injury Advisory Panel (NPIAP).
- Stage 2: Partial-Thickness Skin Loss
- What It Looks Like: This is the first stage where skin actually breaks. It may appear as a fluid-filled blister or shallow open wound exposing the dermis.
- What It Looks Like: This is the first stage where skin actually breaks. It may appear as a fluid-filled blister or shallow open wound exposing the dermis.
*Image courtesy of National Pressure Injury Advisory Panel (NPIAP).
- Stage 3: Full-Thickness Skin Loss into Fat
- What It Looks Like: The wound extends into subcutaneous fat. The depth varies depending on the patient’s body type. Some may have very little fat, while others have a thicker layer.
- What It Looks Like: The wound extends into subcutaneous fat. The depth varies depending on the patient’s body type. Some may have very little fat, while others have a thicker layer.
*Image courtesy of National Pressure Injury Advisory Panel (NPIAP).
- Stage 4: Full-Thickness Skin Loss into Muscle, Fascia, or Bone
- What It Looks Like: At this point, the wound has advanced into deeper structures. Infection risk skyrockets, and complications are far more severe. As Dr. Goldberg noted: “The complications starting with stage four are far worse than stage three.”
*Image courtesy of National Pressure Injury Advisory Panel (NPIAP).
*Here’s where things get tricky: a lot of clinicians assume Stage 1 = skin, Stage 2 = fat, Stage 3 = muscle, Stage 4 = bone. That’s wrong, and it can lead to dangerous under-staging.
Dr. Goldberg offers a simple anchor to prevent mistakes:
“Always remind yourself—muscle is stage four. Then go from there.”
Why does he say that when NPIAP classifies Stage 4 as muscle or bone involvement? Because when we look to the stages of pressure wounds, as soon as a wound extends beyond the fat layer into muscle or deeper, you’re already in Stage 4 territory. Whether it stops at fascia, involves muscle, or exposes bone, it’s all Stage 4.
This matters because many clinicians mistakenly label a wound that extends into muscle as Stage 3, thinking bone must be visible for it to “count” as Stage 4. This error underestimates the severity, delays interventions, and can even lead to ADR denials.
Even experienced clinicians struggle with this. Dr. Goldberg recalled:
“I had a professor of podiatry try to convince me stage three was muscle and stage four was bone. We spent 30 minutes on the phone until he finally looked it up.”
By remembering Muscle = Stage 4, your clinicians will consistently stage correctly, even if the wound hasn’t yet reached bone.
How Do the Four Stages of Pressure Wounds Affect Home Health Billing?
For billing, fat, muscle, and bone each have their own code. The way the codes are structured make it look like it would match the stages, but it doesn’t. The coding is actually flipped compared to the stages.
This mismatch is one reason wound staging also remains a common pitfall in home health billing. Again, make your team aware, and always double check to ensure accuracy.
What Are the Key Takeaways for Home Health Agencies?
- Proper pressure wound staging is essential for compliance, reimbursement, and, most importantly, patient safety.
- Pressure injuries progress quickly and carry long-term risks if not managed early and correctly.
- Staging confusion is common, even among experienced professionals. But it can be avoided with consistent education.
- Use simple anchors like “Muscle = Stage 4” to build staff confidence and accuracy.
- There is no continuity between skin layers, staging, and coding/billing.
How Can Agencies Work with Dr. Goldberg for Wound Care Support?
For agencies in the Los Angeles area, Dr. Goldberg provides mobile wound care services through his practice, Goldbro MD Professional Medical Corporation.
Agencies can request to work with him by visiting goldbro.md to find his office contact information, or by sending referrals directly through phone or email. While his current practice area is limited to Los Angeles, Dr. Goldberg has plans to expand his services in the future.
If you’re looking for more patient-care related guidance, check out our article on The Structure of Episodes and Benefit Periods below to strengthen your agency’s clinical and billing accuracy across the board.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
