Reimbursement Readiness

Episode 21 of Reimbursement Readiness: Business Tips for Wound Practice addresses one of the most common—and costly—sources of claim denials in wound care: Medicare consolidated billing. Kathleen Schaum is joined by reimbursement expert Yesenia Banks, who explains why many wound care stakeholders only learn about consolidated billing after claims are denied or payments are recouped.

In this episode, Yesenia breaks down the fundamentals of home health and skilled nursing facility consolidated billing rules, including how payment responsibility is assigned during a defined episode of care and why verifying a patient’s status is critical before billing Medicare. She also walks through key distinctions that affect wound care services—such as what is bundled within the home health PDGM model, what remains separately payable under Medicare Part B, and how negative pressure wound therapy is handled differently depending on the care setting. The discussion also clarifies how consolidated billing functions within the SNF PDPM payment model, including the four CMS billing files used to determine which services are excluded, separately billable, or the responsibility of the facility. The episode closes with practical guidance and CMS resources to help providers avoid denials, compliance risk, and unexpected recoupments.

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Home Health Consolidated Billing list:
https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information

Skilled Nursing Facility Consolidated Billing List
https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/consolidated-billing

There are four Skilled Nursing Facility Consolidated billing list files:

• File #1 - Part A Stay (2026 Physician Services)(Physician Professional Services Other than Interpretation of Diagnostic Tests) These codes are not subject to SNFconsolidated billing.

• File #2 - Part A Stay (2026 Physician)(Professional Component of Services to be Submitted with a 26Modifier) These odes are not subject to SNF consolidated billing.
• File #3 Part A Stay (Ambulance) These codes are not subject to SNF consolidated billing.
• File #4 - Part B Stay Only (Therapy) These therapy codes are subject to SNF consolidated billing and must be billed through the SNF.

Episode 20 of Reimbursement Readiness: Business Tips for Wound Practice delivers a timely field report on the WISER Prior Authorization Program—based on real, early experiences from stakeholders submitting requests in New Jersey, Ohio, Oklahoma, and Texas. Even listeners outside the participating states asked for this update, because the “why” behind approvals and denials is helping teams everywhere tighten documentation for reasonable and medically necessary care.

Kathleen Schaum shares what she’s hearing from the first month of implementation—what surprised providers, how teams are adapting workflows, and why some are actually finding WISER beneficial (including faster clarity on coverage before purchasing a CTP). Then Kathleen interviews Kati Kauchel, DNP, FNP-C, CWS, founder of Kindling Consulting, who supports mobile wound care organizations and is actively working with groups submitting WISER requests in Texas and Oklahoma. Together, they unpack what “good” looks like under WISER: deliberate care plans, documentation that tells a clear longitudinal story, and escalation that’s clinically driven—not calendar-driven.

You’ll also hear the most common patterns behind non-affirmed decisions—often not the product itself, but gaps in the record (standard of care, readiness criteria, sequencing, missing elements like vascular assessment, A1C/compression compliance, etc.). Kati closes with practical guidance to “pressure test” documentation before submission, including a provider self-assessment tool listeners can download.

Episode 20 Handout

WISeR Professional Self-Assessment.pdf

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.

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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.pdf
• GPCI_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.

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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.

Ep.15 - WISeR Prior Authorization Model Resources

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.

Ep.14 - 2026 Home Health Payment Update

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.

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Ep.13. - Medicare OPPS Final Ruling Resources

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.

Download:

Ep.12 - MFPS Rates