Opportunities for Wound Care Providers in 2025 Medicare Final Payment Rules

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Update, January 2, 2025: CMS has changed the APC group, status indicator, and allowable rates for 2 codes. Codes 15013 and C8002 each now have a status indicator of S, an APC Group of 1532, and a National Average Allowable Rate of $7,250.50. The tables in the article reflect the updated information.

The Medicare Final Payment Rules provide many opportunities for wound/ulcer management physicians and other qualified health-care professionals (QHPs), as well as hospital-owned outpatient wound/ulcer management provider-based departments (PBDs). The following are some of the opportunities that these stakeholders may choose to enhance their businesses.

2025 Outpatient Prospective Payment System (OPPS) Final Rule¹ Opportunities

Cellular and/or tissue-based products (CTPs) for skin wounds. Contrary to widespread rumors, the OPPS payment methodology for the application of CTPs will not change in 2025.¹ The payment for the CTP products is still packaged into the payment for their application. The products are still assigned to the high-cost or low-cost ambulatory payment classification (APC) group based on either their geometric mean unit cost (MUC), which increased from $47 to $50 per sq cm (rounded to the nearest $1), or their per day cost (PDC), which increased from $807 to $833 per day (rounded to the nearest $1).

The OPPS Final Rule lists all the new CTPs, which have been assigned HCPCS codes throughout 2024, and their assignment to the high-cost or low-cost APC group.¹ It also lists the CTPs that have been reassigned from the low-cost to the high-cost APC group. Table 135 in the OPPS Final Rule displays all the CTPs and the 2024 vs 2025 high-cost or low-cost APC group assignments.¹

The 2025 OPPS national average allowable rate for the packaged application of CTPs increased for the 4 payable base Current Procedural Terminology (CPT^®) codes:^1,2
15271                    $1829.23 from $1,737.53
15273                    $3,660.97 from $3,418.26
15275                    $1829.23 from $1,737.53
15277                    $1829.23 from $1,737.53

Reminders:

All PBDs should verify that their charges adequately reflect their costs for the purchase and application of CTPs

• The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) continue to instruct PBDs, physicians, and QHPs not to report the CTP application codes when they apply products other than sheets, such as gel, powder, ointment, foam, liquid or injected products.
• The fact that a CTP has an assigned HCPCS code and is assigned to the high-cost or low-cost APC group does not mean that the CTP is covered by Medicare. In fact, the future effective Local Coverage Determinations (LCDs) and Local Coverage Articles LCAs), which were released by all the Part A and Part B Medicare Administrative Contractors (MACs), list the CTPs that will be covered based on published clinical evidence and the CTPs that will not be covered due to a lack of published clinical evidence. These LCDs and LCAs will become effective on February 12, 2025.

Autologous platelet-rich plasma (PRP) or other blood-derived products. Unlike with CTPs, CMS has created a National Coverage Determination (NCD) for PRP or other blood-derived products, which provides positive coverage for use of these products when applied on chronic nonhealing diabetic wounds.³ 2025 OPPS national average allowable rate, for this work when reporting G0465, is $1,829.23 (an increase from $1,737.53).

Reminders:

• HCPCS code G0465 is assigned a “T” status indicator, which means the Medicare OPPS payment rate will be reduced when the procedure is performed at the same encounter as another procedure, which is also assigned a “T” status indicator.
• When PRP or another blood-derived product is applied to ulcers other than diabetic ulcers, that work should be reported with G0460. That code has the same 2025 OPPS allowable rate as G0465.³ However, the assignment of a code and an OPPS payment rate does not guarantee that the application to ulcers other than diabetic ulcers will be covered by the MAC that processes the PBD’s claims.

Skin cell suspension autograft (SCSA). CMS created 1) a new set of codes for the SCSA manual process and 2) a new code for PBDs to report the SCSA automated process.¹ The codes, status indicators, APC Group assignments, and 2025 national average OPPS allowable rates for the manual process to harvest, prepare, and apply SCSA are:¹

The code, status indicator, APC Group assignment, and 2025 national average allowable rate for the entire SCSA automated process are:¹

Reminders:

• Verify that your MAC covers the manual and automated SCSA process.
• The base codes for the manual process and the one code for the automated process are assigned status indicator “T,” and the add-on codes for the manual process are assigned status indicator “N,” which means the payment for the add-on codes is packaged into the payment for the base codes.

 
Increased OPPS payment for procedures commonly performed in PBDs. Most of the OPPS national average allowable rates increased for 2025.¹ Following is a sample of pertinent OPPS increases:¹

0598T                     $311.40 from $299.37
0640T                     $39.25 from $38.26
11042                    $399.53 from $380.32
11043                    $612.13 from $599.02
29445                    $265.58 from $256.15
29580                    $157.79 from $150.29
29581                    $157.79 from $150.29
97597                    $198.70 from $190.94
97607                    $399.53 from $380.32
97610                    $198.70 from $190.94
G0277                   $137.90 from $132.21
G0463                   $128.87 from $126.08

Reminders:

• PBDs should review their actual 2025 Medicare allowable rates and make appropriate adjustments to the charges in their Charge Description Masters.
• PBDs can view a complete list of all 2025 OPPS national average allowable rates in Addendum A or B here:⁴

2025 Medicare Physician Fee Schedule (MPFS) Final Rule Opportunities³

CTPs. Also contrary to widespread rumors, in 2025, CMS will continue to pay physicians/QHPs separately for medically necessary covered CTPs and their application.¹ Like most services and procedures, the CTP application 2025 national average allowable rates are slightly reduced from 2024. Physicians/QHPs should locate their own 2025 facility and non-facility allowable rates on their MAC’s websites.⁵

Reminders:

• Report the HCPCS code assigned to the product purchased for the patient. Do not report the HCPCS code for another product because it has a higher payment rate.
• Report the CTP application code based on the wound surface area to which the CTP was applied, not based on the size of the CTP that was purchased.
• Only report the application codes for CTPs that are purchased and applied in full sheets and anchored with the physician’s/QHP’s choice of fixation.

PRP or other blood-derived products. Because CMS released an NCD for PRP or other blood-derived products in April 2021, all MACs are required to cover the medically necessary procedure for chronic diabetic ulcers. As described above, CMS assigned G0465 to an APC group, which provides payment for PBDs.¹ However, CMS did not assign relative value units to G0465, which required each MAC to determine the payment rate for physicians and QHPs in their jurisdiction. Throughout the country, the payment rates for G0465 were disparate, inadequate, and sometimes non-existent.

After 3 years of lobbying the MACs and CMS, a national average allowable rate was announced in the 2025 MPFS Final Rule.³ Based on claims submitted by physicians/QHPs and cost information submitted by stakeholders, CMS set the non-facility allowable rate at $890.18 (includes $770.83 for the supply code), and the facility allowable rate at $87.34.

Reminders:

• Ensure that your product costs are reflected in your charges. If your product costs more than $770.83, share your invoice costs on your Medicare claim form and adjust your charges accordingly. Remember that CMS will use information reported on claims to adjust allowable rates 2 years from now. Therefore, the future allowable rates for G0465 are dependent on your current reported charges.
• Verify that your coding, billing, and charging systems contain G0465. When the NCD was first released, G0460 was the only code available for this procedure. Because the NCD only provides coverage for chronic diabetic ulcers, CMS realized it needed 2 codes: one for chronic diabetic ulcers (G0465) and one for chronic non-diabetic ulcers (G0460), Therefore, if your systems only list G0460, your claims for chronic diabetic ulcers will be denied because you incorrectly reported the code for chronic non-diabetic ulcers.      

SCSA. CMS does not agree with the RUC-recommended work relative-value units (RVUs) for the 8 new codes assigned to the manual SCSA process.³ CMS wants the AMA to reconsider the coding structure. Until then the 8 codes will be contractor priced for physicians/QHPs.

CMS has not yet assigned a code for physicians/QHPs to report the automated SCSA process.

Reminders:

• Because 8 new codes have been created for the manual SCSA process, they must be reported rather than the unlisted code that was previously reported. Physicians and QHPs should verify their MAC’s allowable rates for the new codes.
• Because CMS has not yet assigned a code for physicians/QHPs to report the SCSA automated process, they should report the procedure with code 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue, which will be contractor priced, if the MAC covers the automated process. 

Postoperative care during the 90-day global surgery package. Following a surgical procedure that is assigned to a 90-day global surgery package, patients with postoperative wound complications frequently seek care from physicians/QHPs who are wound/ulcer management specialists. Of course, the specialists are glad to manage the wounds, but the physicians who performed the surgery rarely formally transfer the postoperative care to the wound/ulcer management specialists. In addition, the surgeons rarely proactively send the patient’s medical record and operative report to the wound/ulcer management specialists.

Therefore, during the patient’s first visit, the wound/ulcer management specialists usually must perform thorough evaluation and management services, must obtain and review the patient’s surgical medical records, must conduct the required diagnostic tests, and must create a plan of care for managing the wound complications. In the past, the global surgery package regulations often prevented the specialists from coding and receiving payment for this extensive evaluation and management during the patient’s first postoperative encounter.

CMS recognized that comparatively more resource time and costs are incurred when a practitioner who did not furnish the surgical procedure in a 90-day global package provides postoperative care to the patient. Therefore, effective January 1, 2025, CMS created a new postoperative care services add-on code to account for resources involved in postoperative care, during the global period, provided by a practitioner who did not furnish the surgical procedure and did not have the benefit of a formal transfer of care.³ The new add-on code and its description are:³

G0559                   Post-operative follow-up visit complexity inherent to evaluation and management services addressing surgical procedure(s), provided by a physician or qualified health care professional who is not the practitioner who performed the procedure (or in the same group practice) and is of the same or of a different specialty than the practitioner who performed the procedure, within the 90-day global period of the procedure(s), once per 90-day global period, when there has not been a formal transfer of care and requires the following required elements, when possible and applicable:

• Reading the available surgical note to understand the relative success of the procedure, the anatomy that was affected, and potential complications that could have arisen due to the unique circumstances of the patient’s operation.
• Research the procedure to determine the expected postoperative course and potential complications (in the case of doing a post-op for a procedure outside the specialty).
• Evaluate and physically examine the patient to determine whether the post-operative course is progressing appropriately.
• Communicate with the practitioner who performed the procedure if any questions or concerns arise. (List separately in addition to office/outpatient evaluation and management visit, new or established).

 
CMS stated that “It is often difficult for the practitioner, who did not perform the surgical procedure, to know how the wound looked after the procedure, and so it is more challenging to recognize possible changes that may have occurred since the time of the procedure (when this is something the operating surgeon would have been able to know).”³

During the 90-day global period, to more appropriately reflect the time and resources involved in the first postoperative visit, the new add-on code G0559 should be billed with the appropriate level of new or established patient office/outpatient evaluation and management visit. The add-on code should only be billed once during the 90-day global period. The national average allowable facility and non-facility rate for G0559 is $8.73, which will be paid in addition to the payment for the evaluation and management service.
 
Reminders:

• To justify the postoperative evaluation and management service and add-on code, the medical record documentation must specify that the visit was provided during a 90-day postoperative period of the specific surgical procedure that was performed.
• The documentation may include, but is not limited to, review of the surgical notes and the surgical history obtained from the surgeon, signs and symptoms of infection, considerations from the surgical procedure that may affect the wound/ulcer management, and postoperative complications that may arise.
• The add-on code should not be billed by another practitioner in the same group practice as the practitioner who performed the surgical procedure.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.

References
1. Centers for Medicare and Medicaid Services. CMS-1809-FC. Hospital Outpatient Prospective Payment- Notice of Final Rulemaking (NFRM). Accessed Dec. 5, 2024.
2. CPT is a registered trademark of the American Medical Association.
3. Centers for Medicare and Medicaid Services. Blood-Derived Products for Chronic Non-Healing Wounds. Published Nov. 1, 2024. Accessed Dec. 6, 2024. 
4. Centers for Medicare and Medicaid Services. License for Use of Current Procedural Terminology, Fourth Edition ("CPT®"). Accessed Dec. 6, 2024.
5. Centers for Medicare and Medicaid Services. Who are the MACs? Accessed Dec. 6, 2024.