Advocacy

The AAWC is an active member of the Alliance of Wound Care Stakeholders. The Alliance of Wound Care Stakeholders is a 501(c)(6) nonprofit multidisciplinary trade association representing physician specialty societies, clinical and patient associations whose mission is to promote evidenced-based quality care and access to products and services for people with chronic wounds. Through advocacy and educational outreach in the regulatory, legislative, and public arenas, the Alliance unites leading wound care organizations and experts to advocate on public policy issues that may create barriers to patient access to treatments or care. Our key focus areas are coding, coverage and reimbursement; quality measures and wound care research.

Review news releases.

Alliance of Wound Care Stakeholders Summaries of CY 2025 CMS Final Rules: Physician Fee Schedule, Hospital Outpatient PPS, Home Health PPS

All of the CY 2025 final Medicare payment rules were issued late in the afternoon on November 1, 2024.
We have provided a brief summary of the some of the wound care provisions in these final rules. We will be sending out more information to our members in the weeks to come

Physician Fee Schedule

CMS finalized its CY 2025 physician fee schedule which includes a conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29. Here are provisions which may be of interest to Alliance members:

1. Autologous Blood Derived Products

• a. CMS finalized a national facility payment rate for G0465 of $770.83
• b. In the non-facility setting, CMS finalized a national non facility payment of $890.18.
• c. Recognized that the proposed payment of $678.57 was too low
• d. Debridement is included in the rate

2. CTPs

• a. Payment in physician offices is status quo. No changes.
• b. CTPs will not be counted for purposes of identifying refundable drugs for calendar quarters in 2025.
• c. CMS stated they still have the intention to move forward with a future proposal to achieve a consistent payment mechanism for all CTPs.

3. Caregiver Training

• a. CMS is moving ahead with the creation of new codes along with payment for caregiver training.
• b. CMS stated that when a product such as a surgical dressing is provided by a DME supplier, the supplier is responsible and will get paid for the caregiver training so as to not duplicate what is in the DMEPOS benefit requirements.
• c. CMS did not change the term “decubitus ulcer” as they stated it is in the code descriptor and encompasses pressure injury.
• d. With respect to certain wound care terminology used in the code descriptor, CMS decided to change the language. Now instead of the example of “wound dressing” changes they simply state “wound care”. Specifically, the new and finalized code descriptors for caregiver training services state the following:
• G0541 (Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; initial 30 minutes);
• G0542 (Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) (Use G0542 in conjunction with G0541)); and
•  G0543 (Group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications (including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control) (without the patient present), face-to-face with multiple sets of caregivers)).

4. Recell Autologous Cell Harvesting Device

• a. The product will continue to be contractor priced as CMS did not agree with the RUC valuation.
• b. CMS will review these codes again after reconsideration of the coding structure and re-survey is complete.

5. Physical Therapy Supervision

• a. CMS finalized their proposal to allow remote therapeutic monitoring (RTM) services to be furnished by occupational therapy assistants (OTAs) and physical therapy assistants (PTAs) under the general supervision of occupational therapists (OTs) and physical therapists (PTs) in private practice
• b. CMS is finalizing their proposal to provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation and will replace the term “plan of care” with “plan of treatment.”

6. Telehealth
Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services. These include geographic and location restrictions on where the services are provided, and limitations on the scope of practitioners who can provide Medicare telehealth services. However, the final rule reflects CMS’ goal to preserve some important, but limited, flexibilities in our authority, and expand the scope of and access to telehealth services where appropriate. For example, CMS finalized the following:

• a. For CY 2025, CMS will add several services to the Medicare Telehealth Services List, including caregiver training services on a provisional basis.
• b. Beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time, audio-only communication technology for any Medicare telehealth service furnished to a beneficiary in their home, if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.
• c. Through CY 2025, CMS will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home.
• d. A certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising practitioner, to permanently adopt a definition of direct supervision that allows the supervising physician or practitioner to provide such supervision via a virtual presence through real-time audio and visual interactive telecommunications. Specifically,
• i. Make permanent that the supervising physician or practitioner may provide such virtual direct supervision (1) for services furnished incident to a physician or other practitioner’s professional service, when provided by auxiliary personnel employed by the billing physician or supervising practitioner and working under his or her direct supervision, and for which the underlying HCPCS code has been assigned a PC/TC indicator of “5” and services described by CPT code 99211, and (2) for office or other outpatient visits for the evaluation and management of an established patient who may not require the presence of a physician or other qualified health care professional. For all other services furnished incident that require the direct supervision of the physician or other supervising practitioner, CMS finalizing to continue to permit direct supervision be provided through real-time audio and visual interactive telecommunications technology only through December 31, 2025.

Hospital Outpatient PPS

Here are provisions which may be of interest to Alliance members:
1. CTPs

• a. Payment methodology for CTPs is status quo in the hospital outpatient setting.
• b. CMS did not adopt any of the Hospital Advisory Panel (HAP) recommendations
• c. CMS will continue to assign any skin substitute product that is assigned a code in the HCPCS A2XXX series to the high-cost skin substitute group, including new products without pricing information.
• d. New skin substitutes without pricing information that are not assigned a code in the HCPCS A2XXX series would be assigned to the low-cost category until pricing information is available to compare to the CY 2024 MUC and PDC thresholds.
• e. The final MUC threshold will be $50 per cm2 (rounded to the nearest $1)
• f. The final PDC threshold will be $833 (rounded to the nearest $1)

2. Total Contact Cast (TCC)

• a. CMS acknowledged the HAP recommendation regarding the separate payment for a TCC when performed on the same date of services as a debridement or application of a CTP. They did not make any changes in this rulemaking but stated, “we will take commenters’ suggestions into consideration for future rulemaking”.

3. Blood Derived Products

• a. CMS finalized its payment methodology to make separate payments for blood and blood products through APCs rather than packaging payment for them into payments for the procedures with which they are administered.

4. Prior Authorization

• a. CMS finalized its proposal to reduce the review timeframe for standard prior authorization requests for certain covered outpatient department services paid under the OPPS from 10 business days to 7 calendar days.

5. Omeza

• a. Applied for a new device category for transitional pass- through payment status. CMS did not approve their application because it stated that while OMEZA did meet some of the necessary requirements, it did not meet the substantial clinical improvement criterion.

Home Health PPS

1. Disposable Negative Pressure Wound Therapy (dNPWT)

• a. CMS finalized the payment rate for dNPWT. The rate for CY 2025 will be $276.57. The CY 2024 rate was $270.09.