Reimbursement Readiness

Wound Care Today USA
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Business Tip for all types of wound practices. Hosted by Kathleen D. Schaum and Friends.

  1. FEB 12

    Ep, 19 Autologous Platelet Rich Plasma (PRP) or Other Blood-Derived Products for Diabetic Chronic Wounds/Ulcers

    Episode 19 of Reimbursement Readiness: Business Tips for Wound Practice tackles the surge of reimbursement questions surrounding autologous platelet-rich plasma (PRP) and other blood-derived products for diabetic chronic wounds. After the 2026 OPPS and Physician Fee Schedule changes, many outpatient departments and physician practices are evaluating whether and how to add PRP/blood-derived technologies into their treatment pathways—and Kathleen Schaum breaks down what Medicare actually allows. Kathleen answers the top five PRP reimbursement FAQs, starting with what the NCD 270.3 (effective April 13, 2021) covers—and what it does not—plus the key coding distinction between G0460 vs G0465 and what must be built into your systems (EHR/CDM/coding/billing) to bill correctly. She also clarifies the covered places of service, how multiple-procedure payment reductions can apply when more than one unit is needed, and what to know about the MUE limit of 2 for G0465. Finally, she addresses whether WISER prior authorization applies (it does not for G0465), while emphasizing that advanced therapies still require tight documentation—including medical necessity, plan of care, and a complete procedure note.

    16 min

  2. JAN 29

    Ep.18 Physicians' FAQs about CTP Purchase & Application in 2026

    Send us your feedback: Audience Survey ------ In Episode 18 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum welcomes reimbursement expert Donna Cartwright to tackle the flood of physician questions surrounding the 2026 CTP payment changes. With misinformation circulating widely, this episode focuses on what CMS has actually finalized—and what physicians need to operationalize now. Donna walks through the most common FAQs about purchasing and applying CTPs under the 2026 Medicare Physician Fee Schedule, including the shift to a uniform per–square centimeter product payment, how geographic adjustment affects rates, and what practices must update in their charge description masters and internal systems. She also clarifies a major compliance pitfall: wastage is no longer payable for non-BLA skin substitutes, and JW/JZ modifiers are not appropriate for CTPs under incident-to supply payment—meaning only the administered portion is billable. The episode closes with practical reminders around system updates, documentation discipline, and when to escalate unresolved contradictions to your MAC. Downloads: MFPS_Rates_2026.pdfGPCI_Rates_by_locality.pdf

    19 min

  3. JAN 22

    Ep.17 2026 OPPS Payment Changes for CTPs Will Not Happen “By Magic”

    As 2026 begins, Kathleen Schaum opens Episode 17 of Reimbursement Readiness: Business Tips for Wound Practice with a candid assessment of the turbulence wound care teams endured in 2025—particularly around cellular and tissue-based products (CTPs). While the 2026 Medicare Outpatient Prospective Payment System (OPPS) Final Rule brought meaningful improvements for hospital-owned outpatient provider-based departments (PBDs), Kathleen is still fielding urgent calls from departments that have not yet aligned their systems to capture those payments correctly. In this episode, Kathleen walks PBD leaders step-by-step through the critical operational refinements required to receive appropriate CTP reimbursement in 2026. She explains how unpackaged payment affects application codes, why charges must be adjusted, which legacy codes must be removed, and how flat-rate CTP product payment changes purchasing strategy. Kathleen also highlights the importance of updating formularies, charge description masters, EHR workflows, coding tools, and billing systems—emphasizing that improved reimbursement will not “happen by magic” without deliberate action. This episode serves as a practical readiness checklist for PBDs using CTPs today. If physicians or qualified healthcare professionals are applying CTPs in your department, this conversation helps you confirm what’s complete, identify what’s missing, and act quickly to avoid lost revenue in 2026. Download the Quick Guide

    15 min

  4. JAN 15

    Ep.16 Incident-to-Billing

    In Episode 16 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum addresses one of the most frequently misunderstood topics in Medicare reimbursement: Incident-to billing. Drawing from common questions submitted by Wound Care Today USA subscribers—and recurring errors seen in real-world consulting—this episode is designed to clarify what Incident-to billing truly is, when it applies, and when it does not. Kathleen is joined by reimbursement expert Amiee Coriano, who provides a clear, practical breakdown of the CMS rules governing Incident-to services. Together, they walk listeners through who may provide Incident-to services, the strict supervision and documentation requirements, eligible places of service, and the critical distinction between new versus established patients. The episode also explains how Incident-to billing impacts Medicare payment rates, including when practices may bill at 100% of the Physician Fee Schedule versus 85%. This episode is essential listening for wound care practices that rely on physicians, nurse practitioners, and physician associates working together in office-based settings. Whether your goal is compliance, revenue optimization, or audit readiness, this conversation helps ensure your team applies Incident-to billing correctly—and avoids costly missteps.

    8 min

  5. 12/18/2025

    Ep.15 WISeR Model 2026

    In Episode 15, Kathleen Schaum and Amiee Coriano walk Wound Care Today USA subscribers through CMS’s new WISeR Model, a national initiative designed to reduce fraud, waste, and abuse by applying prior authorization and enhanced medical review to select services in traditional Medicare. While the 2026 payment rules for CTPs are now known, this episode underscores a critical point for every revenue cycle: coverage and payment require meeting Medicare’s policy expectations—not simply billing a payable code. Amiee details where the WISeR Model will apply first—beginning with six states and four key places of service—and clarifies the wound care category included in the model: skin substitute grafts / CTPs for treatment of diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs). She also explains how WISeR participation works based on MAC jurisdiction, including the third-party participants responsible for administering the model in each state. Finally, the episode breaks down WISeR’s operational impact starting January 1, 2026, including timelines, two pathways for compliance (prior authorization versus prepayment medical review), and how decisions, resubmissions, and peer-to-peer options function within the process. Kathleen and Amiee also highlight key submission methods and point listeners to an accompanying handout with links and resources to help teams prepare workflows and avoid preventable denials.

    7 min

  6. 12/11/2025

    Ep.14 2026 Home Health Payment Updates

    Kathleen welcomes Yesenia Banks to break down Medicare’s 2026 Final Rule for Home Health Agencies and DME suppliers, rounding out the series on year-ahead payment policy. Yesenia explains the Patient-Driven Groupings Model (PDGM)—how 30-day periods, admission source/timing, clinical groupings (including wounds), functional status, and comorbidity adjustments combine into case-mix weights and payment. She also clarifies LUPA thresholds, outlier scenarios, and why accurate, specific diagnosis coding remains essential to payment integrity. Turning to 2026 updates, Yesenia notes an overall 1.3% home health payment decrease—smaller than the larger cut originally proposed—and underscores that wound clinical groupings remain among the highest-paid. She details key exclusions from the 30-day PDGM bundle: DME NPWT devices and supplies are billed directly by the DME supplier, while disposable NPWT can be billed separately by the HHA on the same claim under the Better Wound Care at Home Act. Practical guidance helps teams hit visit thresholds, manage labor and supply costs, and protect margins despite recent year-over-year pressure on rates. Finally, Yesenia previews CMS’s move to restart the DMEPOS Competitive Bidding Program, including calculating winning bids at the 75th percentile, streamlined financial documentation, new product categories (CGM and insulin pumps; urological, ostomy, and tracheotomy supplies), and more frequent surveys/re-accreditations (at least every 12 months). The episode closes with links to CMS resources and learning materials so leaders can brief their teams, align documentation, and prepare workflows for January 2026.

    15 min

  7. 11/26/2025

    Ep.13 Payment: OPPS Final Ruling (2026)

    Kathleen walks hospital-owned outpatient wound and ulcer management teams through the OPPS Final Rule for 2026, clarifying how CMS turns policy into payment via APC groupings and where to locate the official national rates in Addendum A (by APC) and Addendum B (by HCPCS). She details the headline changes for CTPs: unpackaging products from the application procedures, eliminating high/low cost tiers, establishing a single OPPS product rate of $127.14 per cm² (not geographically adjusted), and standardizing application reporting with 15271–15278. The episode also flags what does not change—non-sheet products won’t be separately paid under OPPS in 2026—and underscores that published rates don’t guarantee coverage; LCDs, MAC policies, and airtight medical necessity documentation still rule. Looking ahead, Kathleen notes that after 2026, CTPs will be grouped by FDA regulatory status (e.g., PMA, 510(k), 361 HCT/P) with payment details to follow, and she highlights a key win for large foot ulcers, which will now be paid at parity with large leg ulcers—opening the door for better access to care.

    19 min

  8. 11/13/2025

    Ep.12 Payment: MPFS Final Ruling (2026)

    In Episode 12 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum unpacks the 2026 Medicare Physician Fee Schedule (MPFS) Final Rule—a document that determines how physicians and qualified healthcare professionals (QHPs) will be paid in the coming year. She explains how this 2,000-page rule shapes the final payment policies for services, procedures, and products, and highlights key changes across telehealth, surgical services, chronic care, and, most importantly, cellular and/or tissue-based products (CTPs) for skin wounds. Kathleen also clarifies the distinction between the MPFS and the final rule itself, showing how conversion factors and relative value units translate to real-world reimbursement rates. Listeners will gain a clear understanding of how 2026 payment updates affect both the application and product sides of CTP reimbursement. Kathleen explains why non-facility rates are increasing while facility rates are decreasing, and how CMS is introducing a single national allowable rate of $127.28 per square centimeter for most CTPs—with exceptions for BLA-approved and non-sheet products. She also emphasizes the importance of reviewing payer-specific coverage policies, reminding providers that a listed code or rate does not guarantee payment. The episode concludes with guidance on where to access the official Medicare links and an invitation to join Kathleen and Dr. Alton Johnson for a Wound Care Today USA Learning Live event covering CTP strategies for 2026.

    18 min
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Business Tip for all types of wound practices. Hosted by Kathleen D. Schaum and Friends.

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