Reimbursement Readiness

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.

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

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

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.

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.

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.

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.

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.

Reimbursement expert Kathleen D. Schaum, M.S. and Jeremy Bowden, President of WCT USA, break down the CY 2026 Medicare PFS Final Rule's bombshell changes to skin substitutes and CTPs!The Big Change: CMS is completely overhauling how skin substitutes are paid—moving from ASP-based methodology to incident-to supplies with product-category payment grouping.The Numbers That Matter: Part B spending exploded from $252M (2019) → $10B+ (2024) New payment rate: ~$127.28 (single rate for CY 2026)Effective: January 1, 2026Kathleen and Jeremy provide the reimbursement roadmap and what this means for your Q1 2026 planning.Read the CMS PFS Final Rule: https://lnkd.in/e6aHqJ73

In Episode 11 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum welcomes back Amiee Coriano, CEO of AMC Medical Consulting, for an in-depth discussion on contracting with commercial and private payers.Amiee explains the critical differences between credentialing and contracting, then walks through the essential elements every provider should understand before signing a payer agreement — from timely filing limits and fee schedules to plan types, coverage definitions, and provider obligations. She shares insights on when and how to renegotiate contracts, how to add new services or products, and common mistakes that can lead to claim denials or lost revenue.Whether you’re starting a wound care practice or refining your existing operations, this episode offers clear, actionable guidance for managing payer relationships and ensuring compliant reimbursement. Plus, subscribers can download Amiee’s companion contracting handout, which defines key contract terms and payer plan types referenced throughout the discussion.

Great News About the CMS Claims Hold!On October 15, 2025 Kathleen Schaum shared some bad news that was going to affect the cash flow of all professionals paid by the Medicare Physician Fee Schedule. Now on October 17, 2025 listen to Kathleen explain the breaking great news about the CMS Claims Hold. 

In Episode 10 of Reimbursement Readiness, Kathleen Schaum welcomes listeners back and reintroduces her guest, Amiee Coriano, CEO of AMC Medical Consultant. Kathleen highlights Amiee’s expertise in wound and ulcer management, coding, and billing, and sets the stage for another practical discussion on navigating reimbursement challenges in wound care. This episode continues the conversation with Amiee Coriano, who brings her deep experience in coding and compliance to address real-world reimbursement issues. She shares insights into common billing errors, strategies for optimizing documentation, and key considerations that providers should keep in mind to ensure accurate claims submission. Listeners will gain practical guidance to strengthen their wound care practice’s financial readiness while staying aligned with payer expectations.

If you are paid according to the Medicare Physician Fee Schedule, CMS has indefinitely extended the hold on your payment. Listen to host of Reimbursement Readiness Kathleen D. Schaum, M.S.explain this breaking news.

In Episode 9 of Reimbursement Readiness, Kathleen Schaum welcomes listeners back and reviews the progress made so far in understanding coverage policies, ICD-10-CM diagnosis codes, and ulcer classification. To continue the journey, she introduces a new guest expert who joins to share her insights on reimbursement and coding in wound care practice. This episode features special guest Amiee Coriano, who guides providers through the latest updates and practical strategies in wound care reimbursement. She explains how to approach new coding scenarios, highlights common pitfalls to avoid, and shares actionable tips for staying compliant while improving documentation. Listeners will walk away with a stronger grasp of real-world applications that support both patient care and accurate payment.

In this episode, Donna Cartwright walks providers through the newly released ICD-10-CM diagnosis codes for wound and ulcer management, effective October 1st. She explains what has changed, why these updates matter for clinical practice, and how to apply them correctly in documentation and reimbursement. Listeners will gain clarity on the latest code additions, adjustments, and practical strategies to stay compliant and ensure accurate claims submission.

In Episode 7 of Reimbursement Readiness: Business Tips for Wound Practice, Donna Cartwright joins Kathleen Schaum to tackle one of the most frequently asked questions in wound care coding: When should you report a wound or when should you report an ulcer?Donna breaks down the distinctions between acute wounds and chronic ulcers, covering examples from lacerations, burns, and surgical complications to diabetic and venous ulcers. She explains where to find these codes in the ICD-10-CM, when seventh characters are required, and why understanding the difference is essential for proper reimbursement. You’ll also hear best practices for coding multiple wounds, linking diagnoses to treatments, and navigating payer requirements for underlying causes versus manifestations.By the end of this episode, clinicians and coders alike will gain clarity on how to code accurately and confidently, ensuring compliance while telling the patient’s story correctly in the medical record.DOWNLOADSAcute Wound HandoutChronic Ulcer Handout

In this episode, Donna Cartwright explains why it’s critical to match ICD-10-CM diagnosis codes with the appropriate procedure codes outlined in Medicare’s Local Coverage Determinations (LCDs) and Local Coding and Billing Articles (LCAs). She breaks down six key reasons these code lists matter—from ensuring medical necessity and preventing improper payments to minimizing denials, reducing audit risk, and maintaining Medicare program integrity. Listeners will also learn about the risks of incorrect or unspecified coding, including overpayment recovery, sanctions, and reputational harm. This episode equips wound care professionals with practical strategies to code accurately, stay compliant, and protect their reimbursement.

Episode 05 – Specific Diagnosis Coding Instructions for Venous UlcersIn Episode 5 of Reimbursement Readiness: Business Tips for Wound Practice, expert Donna Cartwright returns to guide wound care professionals through ICD-10-CM coding for venous ulcers. This in-depth episode covers:Key coding terms in the Alphabetic Index: atherosclerosis, varicose veins, post-thrombotic syndrome, and chronic venous hypertensionNavigating ICD-10-CM code ranges (I70, I83, I87, L97) and using combination codesApplying “code first” and “use additional code” instructionsAvoiding unspecified codes by accurately identifying ulcer causes and locationsCoding for both underlying conditions and ulcer severityThis episode provides essential tools for selecting the most specific, audit-ready diagnosis codes—and reinforces that coverage policies follow these coding rules too.ICD-10-CM Guidelines (FY25 October 1, 2024)https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

Episode 04 – Specific Diagnosis Coding InstructionsIn Episode 4 of Reimbursement Readiness, Donna Cartwright dives deep into ICD-10-CM diagnosis coding for diabetic ulcers. She walks listeners through using the Alphabetic and Tabular Indexes, explains how to apply combination coding with ulcer severity, and highlights important coding notes such as “code first” and “use additional code.” You'll also learn the distinctions between Excludes 1 and Excludes 2 notes, and how causal relationships are presumed using terms like “with” and “and.” This episode equips wound care professionals to code diabetic ulcers accurately and compliantly—ensuring documentation supports medical necessity and meets audit expectations.ICD-10-CM Guidelines (FY25 October 1, 2024)https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

NEWS FLASH: Major Medicare Proposed Rule Changes Affecting CTPs7/23/2025 – CMS recently released proposed 2026 changes to the Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (HOPPS)—including a major shift in reimbursement for cellular and/or tissue-based products (CTPs).In this Reimbursement Readiness News Flash, expert Kathleen Schaum breaks down what providers need to know now and how to prepare for potential reimbursement changes for CTPs used in wound care.Let your voice be heard and submit a public comment on the proposed rule changes: Medicare Physician Fee Schedule (Submissions due 9/12/2025)https://www.federalregister.gov/documents/2025/07/16/2025-13271/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-schedule-and-other#open-commentHospital Outpatient Prospective Payment System (Submissions due 9/15/2025)https://www.federalregister.gov/documents/2025/07/17/2025-13360/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical#:~:text=Thank%20you%20for%20taking%20the,%2D2025%2D0306%2D0002