The 2024 Medicare Final Payment Rules Have Been Released: Part 1

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In the October Business Briefs column, we discussed the confusion about 1) the HCPCS codes assigned to cellular and/or tissue-based products (CTPs) for skin wounds, and 2) which CTPs are assigned to the high-cost and low-cost Outpatient Prospective Payment System (OPPS) payment groups. The October column also addressed physicians’ confusion about the published average sales prices (ASP) for CTPs applied in non-facility settings.

While wound/ulcer management stakeholders waited for the 2024 OPPS and Medicare Physician Fee Schedule (MPFS) Final Rules to be released, there were widespread rumors throughout the country that the Centers for Medicare and Medicaid Services (CMS) was going to change the 2024 OPPS and MPFS payment methodology for the application of CTPs.

Now that both the 2024 OPPS and MPFS Final Rules have been released, this Part 1 article will provide the correct payment information regarding CTPs and will provide a brief overview of the 2024 allowable rates for other common wound/ulcer management procedures and services.

2024 OPPS Final Rule Update

The October Business Briefs column provided a table that listed all the CTPs that were assigned “Q” and “A” HCPCS codes at the time the article was published. The 2024 OPPS Final Rule announced some new CTPs that have been assigned HCPCS codes. The new CTPs and their assignments to high-cost and low-cost OPPS packaged payment groups are listed in Table 1 below. If you wish to view the entire list of CTPs and their 2024 packaged payment group assignments, simply search for Table 95 in the OPPS Final Rule. Please note that assignment to a high-cost or low-cost package does not guarantee coverage by the Medicare Administrative Contractors (MACs). For example: If a CTP is not packaged in the form of a sheet, Medicare does not cover it.

Contrary to all the rumors that floated throughout the country, the packaged OPPS payment methodology for the application of CTPs remains the same in 2024. However, this author continues to be amazed by a few of CMS’ OPPS payment decisions for CTPs:

• CMS continues to assign all CTPs that are assigned codes in the A2XXX series to the high-cost group, regardless of their cost to the PBDs. This does not make sense because CMS ends up paying a much higher rate for some CTPs that may belong in the low-cost package.
• CMS continues to package the payment for the CTP application add-on codes into the payment for the base application code. This does not make sense, because the hospital owned outpatient wound/ulcer management provider-based department (PBD) must purchase additional product for the larger ulcers and the base code allowable rates do not include adequate payment to purchase product to cover the larger ulcers.
• CMS allows a higher allowable rate for application of CTPs to 100 sq cm ulcers on the legs than for application of CTPs to 25 sq cm ulcers. This makes perfect sense because the PBDs must purchase more product for the larger ulcers. However, what does not make sense is that CMS only allows the same allowable rate for ulcers on the legs that are 25 and 100 sq cm. That is why PBDs cannot afford to apply CTPs to larger diabetic foot ulcers.
• Even though CMS only covers CTPs that are in sheet form, CMS continues to incorrectly list some of the products that are not packaged in sheet form on their table of High-Cost and Low-Cost packaged CTPs and to incorrectly list some of them on the OPPS Addenda A and B. This misinformation causes PBDs to incorrectly believe that these products are covered by Medicare and leads to false claims.
• When the CTP OPPS packaged payment system began over a decade ago, ulcer management stakeholders provided CMS with a plethora of actual invoices to educate CMS that they had not incorporated adequate payment for the products into the application allowable rates. Unfortunately, CMS did not adjust the allowable rates, and has not adjusted them for more than a decade. Now that CMS requires the manufacturers to submit, on a quarterly basis, the average sales prices of their CTPs, one would expect that CMS should use that information to adjust the allowable rates for the application of both the high-cost (15271–15278) and low-cost (C5271–C5278) CTPs by assigning them to higher paying ambulatory payment classification (APC) groups.

Now let us discuss the 2024 OPPS allowable rates for other common services and procedures performed in PBDs. Most of the services and procedures that are performed in PBDs received OPPS payment increases, such as surgical/selective/non-selective debridement, application of total contact casts, application of paste boots, application of  multi-layer compression bandage systems, application of CTPs (both high-cost and low-cost products), autologous platelet rich plasma or blood derived products, negative pressure wound therapy (both durable medical equipment and disposable), non-contact near infrared spectroscopy, low-frequency non-contact non-thermal ultrasound, and non-contact real-time fluorescent wound imaging.

One surprise was the large 2024 OPPS payment decrease for hyperbaric oxygen therapy (from a national average allowable rate of $134.51 to $73.64). This author has no idea why CMS decreased this rate: the proposed rule never mentioned that CMS was proposing to decrease the rate. The Alliance of Wound Care Stakeholders and the Undersea and Hyperbaric Medical Society are reaching out to CMS to see if this was an error. Stay tuned—when CMS clarifies this issue, Business Briefs will keep readers informed.

2024 MPFS Final Rule Update

Even though the MPFS proposed rule for 2024 indicated that CMS was not going to change the payment methodology for CTPs applied in physician and other qualified healthcare professional (QHP) offices, widespread rumors continued to state otherwise. Now that the 2024 MPFS Final Rule is published, we know for sure that 1) CMS did not package the payment for the product into the payment for the application, and 2) CMS will continue to pay physician/QHP offices separately for CTPs and for their application if the CTPs applied are purchased in sheets and are covered by the MAC.

In the October Business Briefs column, this author provided a table with all the CTPs that have published ASPs. Effective January 1, 2024, CMS may list additional CTPs on the ASP file. However, that update is not yet available. When the ASP file is updated, it can be found here.

Because existing legislation forced CMS to reduce the 2024 allowable MPFS rates, all the services and procedures performed by wound/ulcer management physicians/QHPs were reduced. However, Congress might release legislation that adjusts that reduction before the January 1, 2024, implementation. Stay tuned—if Congress allows CMS to increase the allowable MPFS rates, Business Briefs will keep readers informed.

Now let us quickly discuss the large payment decrease for hyperbaric oxygen therapy (HBOT) that was in the proposed rule. That was due to a recommendation, from the American Medical Association Relative Value Unit Committee (RUC), to reduce the relative value units assigned to G0277. Luckily, CMS did not accept the entire recommendation. However, the portion of the reduction that was accepted pertains to the clinical labor times for room, equipment, and patient preparation. The 2 minutes of time allotted for this work is not adequate. Therefore, physicians who perform HBOT in their offices should educate CMS about the actual time required for this work.   

Watch for Part 2 of 2024 Medicare Final Payment Rules Have Been Released in the December Business Briefs column!
 
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.