Correct Inadequacies in CTP Payments and Remove Barriers to Access

Coverage and payment regulations from the Centers for Medicare and Medicaid Services (CMS) dictate which products and services wound clinics and wound care clinicians can provide to their patients, and at what reimbursement rate. This week, important progress was made in advocacy efforts to correct inadequacies in payments for cellular and tissue-based products (CTPs, formerly known as skin substitutes) in CMS’ Hospital Outpatient Prospective Payment System (HOPPS) and remove barriers to access.

The Alliance of Wound Care Stakeholders, an association representing 20+ clinical and patient associations and physician specialty societies involved in wound care, is providing the following update together with instructions on how the wound care provider community can support these policy changes via submitting comments to CMS.

Support the CMS Advisory Panel on Hospital Outpatient Payment Recommendations to Correct Inadequacies in CTP Payments and Remove Barriers to Access

At its public meeting on August 23, the Advisory Panel on Hospital Outpatient Payment unanimously approved two recommendations made by the Alliance of Wound Care Stakeholders that, if accepted and implemented by CMS, can correct flaws in the payment policy that have negatively impacted reimbursement for CTPs. As these policy changes can remove barriers to access for these important products, now is a unique time for the wound care community to voice its support of these recommendations to CMS.

Recommendation 1: CMS assigns the existing CPT add-on codes (15272 and 15276; 15274 and 15278) to an appropriate Ambulatory Payment Classification (APC) group, allowing for payment, and issues an exception for the payment of CTP add-on codes.

o    Current payment challenge: As the Outpatient Prospective Payment System currently does not pay for most add-on codes and because the payment for the CTP is packaged into the base application code, OPPS does not provide adequate payment for Provider Based Departments (PBDs) to purchase an adequate amount of CTP products for wounds between 26 and 99 sq. cm., and over 100 sq. cm.

o    Positive impact of policy change: If CMS adopts this recommended policy change, add-on codes would be paid and include adequate payment for Provider Based Departments (PBDs) to purchase the additional sq. cm. of CTPs for the various wound sizes.

•    Recommendation 2: CMS assigns APCs for the same size wound regardless of anatomical location on the body.

o    Current payment challenge: CMS has assigned the application of CTPs applied to 100 sq. cm. or greater wounds on the feet to a lower paying APC Group than the same size wounds/ulcers on the legs. As a result, the OPPS currently does not provide equal payment for wounds that are 100 sq. cm. or more on the feet.

o    Positive impact of policy change: If CMS adopts this recommendation, the OPPS would be adjusted so that all anatomic locations of the same size wound be paid the same because they require the same amount of product to be purchased

Call to Action: Submit Comments to CMS Supporting These Recommendations by Sept. 17

The recommendations were submitted to the Panel in advance of the meeting by the Alliance of Wound Care Stakeholders. The Panel’s unanimous decision to elevate these recommendations to CMS was made after Alliance Executive Director Marcia Nusgart, RPh, presented them at the meeting, highlighted current payment challenges and emphasized impact. It is important to note, however, that while the Advisory Panel submits a broad range of detailed recommendations to CMS for consideration, the Agency is not obligated to move its recommendations forward. That is why now is a unique time for the wound care community to make its voice heard to CMS so that the two wound-specific recommendations are not overlooked as the proposed 2022 OPPS policy is revised and finalized.

Help ensure that CMS adopts and implements these recommendations by showing the Agency that our diverse multi-specialty wound care community supports them. Here’s how:

1.    For context, if you are interested, see CMS’ proposed CY 2022 OPPS policy (CMS-1753-P). (Note, it’s 800+ pages. This CMS fact sheet might help. Provisions specific to wound care are few and far between, which is why it is key to give visibility to the importance of this issue by submitting comments.)
2.    Review the Alliance’s submitted recommendations in its letter to the HOPPS panel. (You can borrow/repurpose language from this letter for your own statement of support.)
3.    Articulate your support of the recommendations and your role in wound care in a brief letter/comment statement. Statements of support can come from individual clinicians, practice groups, clinics, hospitals, organizations, manufacturers, businesses, etc. (Be sure to reference “file code CMS-1753-P” in your letter.)  
4.    Submit your letter directly to the OPPS docket on Regulations.gov here.
5.    Comments are due by Sept. 17, 2021. The final rule is expected to issue in November.

Click here to learn more about the Alliance advocacy and its impact on CMS policies.

Click here to download a PDF of this article.

Marcia Nusgart, R.Ph., is the Executive Director of the Alliance of Wound Care Stakeholders