How CMS 2025 Proposed Payment Updates Could Impact Wound Care

Insights and Advocacy from the Alliance of Wound Care Stakeholders

The Centers for Medicare and Medicaid Services (CMS) releases each summer a series of proposed Medicare payment rate policy updates for the coming year ahead—such as the Home Health Prospective Payment System (PPS)¹, Hospital Outpatient PPS (OPPS)² and Medicare Physician Fee Schedule³—and provides a 60-day window for stakeholder comments. These annually evolving regulations set Medicare payments, with far-reaching impact across medical care and—depending on included provisions—on wound care.

The proposed policies for calendar year 2025 impact payment for autologous blood-derived products used in wound healing and reimbursement for cellular- and tissue-based products for wounds (CTPs, or skin substitutes), as well as caretaker training services, prior authorization, and more. Policy experts at the Alliance of Wound Care Stakeholders summarize provisions most relevant to wound care, and report on recommendations that the Alliance, its members, and aligned stakeholders forwarded to CMS to protect and defend wound care.

2025 Medicare Physician Fee Schedule

Warned CMS about the impact of ongoing payment rate cuts. The fee schedule has, for years, prompted comments from hundreds of physician specialty groups due to the cuts it continues to make that fail to support clinicians and the business realities of healthcare practices in local communities today. With the proposed 2.8% conversion factor reduction included in the policy for 2025, the Alliance again flagged this as a concern that wound care providers share and encouraged CMS to work with Congress to ensure that payments to clinicians are adjusted each year with an inflationary update.³ Without congressional action, CMS will not only implement the pay cuts, but also continue to make payment cuts that negatively impact clinicians.

Fought inadequate payment for autologous blood-derived products. The proposed 2025 physician fee schedule included for the first time provisions establishing national pricing for autologous platelet rich plasma or other blood-derived product for diabetic chronic wounds/ulcers (HCPCS code G0465)—a unique category of wound care product that physicians prepare from a patient’s own blood.⁴ However, CMS’ proposed valuation failed to adequately reimburse for physician time and effort and the cost of the product, as the policymakers “cross walked” CPT codes associated with skin substitutes to set the pricing, tying reimbursement for blood-derived products to products that a physician can apply to a wound straight out of the packaging. The Alliance and other clinical organizations representing wound care—as well as a number of individual wound care providers—emphasized to CMS in submitted comments why that valuation was inappropriate and inadequate: off the shelf skin substitute/CTP products don’t require the time intensive collection, preparation, and application processes of autologous blood derived products.⁵

The potential impact: By not reflecting the physician work, resources, and supplies involved in furnishing these products, the proposed reimbursement for G0465 will not cover the cost to providers, thereby hindering Medicare beneficiary access.

To address this issue, the Alliance and other stakeholders has urged CMS to:

• Change the proposed skin substitute-aligned CPT crosswalk codes to more clinically aligned and appropriate epidermal and dermal autograft codes;
• Include appropriate RVUs for debridement in the total RVU calculation for G0465 (or clarify that debridement can be billed separately if it is not included); and
• Remove provisions restricting a provider from billing for more than one unit of G0465 per day so that patients with multiple foot wounds can to be treated.

Recommended improved payment methodology for CTPs/skin substitutes. In past rulemaking cycles, CMS has proposed bundling CTPs in the physician office setting by classifying CTPs as “incident to supplies”—then retracted the proposed policies following an outpouring of stakeholder concerns and comments.⁶ While no specific reimbursement process changes were proposed for 2025, the Agency stated its continued interest in bundling and realigning CTP payment moving forward. To that end, the Alliance used the comment opportunity to again urge CMS to adopt a universal average sales price (ASP) reimbursement methodology for all CTPs—an approach that ultimately could mitigate the concerns that are driving CMS to consider disruptive payment approaches that could limit patient access to needed care.^4,5 Education and recommendations forwarded in this rule making cycle can hopefully have influence if/when CPT payment methodologies are reconsidered in future Fee Schedule updates.

Sought clarity surrounding new reimbursement provisions for caregiver training services in wound care. CMS proposed new codes (GCTD1, GCTD2, and GCTD3) for caregiver training services—allowed with or without the patient present—to provide support for patients with an ongoing condition or illness.⁴ Of particular interest to wound care clinicians, the provisions specifically referenced the training examples of “techniques to prevent decubitus ulcer formation, wound dressing changes, and infection control.” The Alliance supports clinicians being reimbursed for time training caregivers but does not believe that caregiver training should be provided without the patient present in many circumstances. In comments to CMS, the Alliance sought additional detail about how this benefit would be implemented and urged CMS to work with the wound care stakeholder community to ensure that caregiver training services are implemented in an appropriate way that does not negatively impact patient care or wound healing outcomes.⁵

Encouraged CMS to develop quality measures for meaningful to wound care. The Alliance sought CMS feedback and collaboration on the potential creation of a Chronic Wound Management Merit-based Incentive Payment System (MIPS) Value Pathway (MVP) to properly associate/identify quality and the cost of wound care under the Agency’s Quality Payment Program (QPP).5 CMS has indicated that it is moving toward solely using MVPs in 2029.⁴ Therefore, establishing a Chronic Wound Management MVP is important as it would enable physicians practicing wound management (which is not a recognized medical specialty) to use participation in the Chronic Wound Management MVP as a surrogate for specialty designation. CMS is otherwise unable to identify wound care-focused practitioners because they have many different board certifications.

2025 Medicare Hospital Outpatient Prospective Payment System (OPPS)

The OPPS sets reimbursement for hospital outpatient services. Provisions in the proposed 2025 OPPS rule of particular relevance to wound care—and where updates could reduce barriers to patient care—include payment policies for CTPs/skin substitutes.² On behalf of the wound care community, the Alliance submitted comments and policy update recommendations to remove access challenges.

Recommended policy adjustments to remove access barriers to CTPs. Currently, the OPPS packages CTPs/skin substitutes into a base application code that does not enable provider-based departments to purchase the sizes of CTPs necessary to apply to larger sized wounds, forcing outpatient departments to absorb the cost of additional CTP product themselves to treat larger wound.² As a result, many cannot offer CTPs for larger wounds (between 26–99 sq cm and >100 sq cm), creating an access barrier. Medicare patients with large wounds are often now being treated in either the operating room or are referred to physicians’ offices for treatment with a CTP. In a similar challenge, CMS currently 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, unequal reimbursement is provided for wounds of the same size across different parts of the body—even though the identical amount of CTP product must be purchased regardless of the anatomic location of the wound.

The current impact: Together, these reimbursement challenges negatively impact access to CTPs in outpatient departments.
To address outpatient department access challenges to CTPs, the Alliance has again urged CMS to update to OPPS provisions to (1) equalize payment for the application of CTPs on wounds/ulcers of the same size regardless of anatomical location; and (2) allow “add on codes” to enable outpatient departments to be reimbursed for an adequate amount of CTP products for larger wounds.⁷ Both policy recommendations above have been repeatedly endorsed by CMS’ Advisory Panel on Hospital Outpatient Payment, yet not incorporated into OPPS annual policy updates by the Agency. The Alliance continues to elevate these access issues and policy solutions.

Worked to protect access to total contact casting (TCC). Due to current inconsistencies in CMS policies and an inappropriate NCCI edit, hospital outpatient departments are not getting paid separately for TCC when provided on the same date of service as a debridement or CTP application. This discourages facilities from performing both services on the same day, despite the fact they are separate services that are appropriate to be performed and reported on the same day. While TCC was not specifically included in the CY 2025 OPPS updates, the Alliance opted to use the comment opportunity to elevate this issue and forwarded a recommendation for CMS to establish and pay a separate APC for the TCC when a debridement or CTP application is performed on the same date of service so that facilities can be paid, and patients can receive TCC care.⁷ This approach has the endorsement of CMS’ OPPS Advisory Panel and could be implemented as part of updates to the OPPs to remove barriers and improve access.

Urged reduction of prior authorization review timelines. In the draft OPPS rule, CMS proposes to harmonize the timeline for review for non-urgent services/procedures by changing the current prior authorization (PA) review timeframe from 10 business days to 7 calendar days to align with the Medicare Advantage regulations.² While the Alliance supports a reduction in the PA timeframes, its comments to CMS questioned why the Agency did not also align the timeframe for PA requests for urgent reviews and encouraged a shortening of the mandated timeframes for PA requests of all types.⁷

2025 Home Health Prospective Payment System

Sought fair payment for measuring/fitting of lymphedema compression treatment items. The Alliance has been a persistent advocate urging that coding and payment provisions be put in place to ensure that qualified health professionals (QHPs) can get reimbursed for the measuring, fitting, and training services they provide when furnishing patients with lymphedema compression treatment item mandated under the Lymphedema Treatment Act passed in late 2022. As the lymphedema/compression garment issues were not addressed in the CY 2025 proposed rule, the Alliance reminded CMS of the importance of their attention to this issue.⁸ “request[ed] that CMS ensure payment is provided to the individuals that render these critical services, and to provide patients with meaningful options in seeking measuring and fitting services from the QHP of their choosing ... Suppliers are being compensated for all of these despite not performing any of the services. This was not the intent of Congress and is impacting patient access and patient care. Compensating DME suppliers, but not QHPs, for work that QHPs are performing is an inefficient and inequitable use of Medicare dollars, disincentivizes the use of lymphedema clinician/therapists’ expertise in garment selection and diminishes patient choice in the provision of their care."

The proposed rules also addressed a range of aligned issues relevant to wound care such as telehealth, the Medicare Diabetes Prevention Program, the Global surgery package and more. The comment deadline was Sept. 9, and CMS is now reviewing the thousands of comments and recommendations submitted by organizations like the Alliance, medical professional societies, individual clinicians, manufacturers, business entities and more.¹ The Agency will make the changes it feels is appropriate and issue its final rules on the 2025 payment updates in mid- to late November for implementation on Jan. 1, 2025.

Stay tuned and look to the Alliance of Wound Care Stakeholders to get updates then on what is—and isn’t—included in the final rules and the impact the finalized regulations will have on wound care.

Marcia Nusgart, RPh, is founder and CEO of the Alliance of Wound Care Stakeholders, and Karen Ravitz, JD, is the Alliance’s health care policy advisor. Learn more here.

References
 
1. Centers for Medicare and Medicaid Services. CMS-1803-P. Accessed Oct. 7, 2024.
2. Centers for Medicare and Medicaid Services. CMS-1809-P. Accessed Oct. 7, 2024.
3. Centers for Medicare and Medicaid Services. Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule. Published July 8, 2024. Accessed Oct. 7, 2024.  
4. Centers for Medicare and Medicaid Services. Fact Sheet: Calendar Year (CY) 2025 Medicare Physician Fee Schedule Proposed Rule (CMS-1807-P)-Medicare Shared Savings Program Proposals. Published July 8, 2024. Accessed Oct. 7, 2024.
5. Alliance of Wound Care Stakeholders. Comments to proposed 2025 Medicare Physician Fee Schedule. Published Sept. 7, 2024. Accessed Oct. 7, 2024.
6. Nusgart M. CMS withdraws local coverage policy that dramatically restricted access to CTPs (skin substitutes). Today’s Wound Clinic. 2023; 17(9). Published Sept. 29, 2023. Accessed Oct. 7, 2024.
7. Alliance of Wound Care Stakeholders. Comments to proposed 2025 Medicare Hospital Outpatient Prospective Payment System (OPPS). Published Sept. 9, 2024. Accessed Oct. 7, 2024.
8. Alliance of Wound Care Stakeholders. Comments to Proposed 2025 Home Health Prospective Payment System Update. Published Aug. 27, 2024. Accessed Oct. 7, 2024.