Q&A: What changes are coming for skin substitute payments in 2019?

Q: CMS considered changing its skin substitute payment model in the 2019 OPPS proposed rule. What changes did it finalize?

A: CMS will continue to categorize skin substitute products into high- and low-cost groups and will assign the items based on either a product’s geometric mean unit cost (MUC) exceeding the geometric MUC threshold or the product’s per-day cost (PDC)—the total units of a skin substitute multiplied by the MUC and divided by the total number of days—exceeding the PDC threshold.

Due to several skin substitute manufacturers raising concerns about significant fluctuations in both the MUC and PDC thresholds from year to year, CMS asked commenters for feedback on several alternate models.

Those models include:

• Allowing for the payment of current add-on codes or creating additional procedure codes to pay for skin graft services between 26 sq. cm and 99 sq. cm and substantially over 100 sq. cm.
• Eliminating the high- and low-cost categories and only have one payment category and set of procedure codes for all skin substitute products
• Establishing a lump-sum “episode-based” payment for a wound care episode
• Keeping the high- and low-cost skin substitute categories, but changing the threshold used to assign skin substitutes in the groups

CMS said each policy had commenter support and opposition and will continue to take the feedback into consideration when looking ahead to 2020 rulemaking.

Editor's note: For more information on the 2019 OPPS final rule, listen to this webinar with expert speakers Jugna Shah, MPH, and Valerie A. Rinkle, MPA. This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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