On October 30, 2015, the first Medicare Physician Fee Schedule (MPFS) final rule since the repeal of the Sustainable Growth Rate formula by the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 was released. It was officially published in the Federal Register on November 16, 2015. The 2016 MPFS updated the payment policies that apply to services furnished by qualified healthcare professionals (QHPs) in all sites of service. Because of the updated policies, QHPs who specialize in wound care will experience some ups and downs in their 2016 Medicare allowable rates. Let's take a look at how some of these 2016 national average Medicare allowable rates, for common wound care services that QHPs perform in their offices and in facilities, compare with the 2015 allowable rates. As you read the following MPFS allowable rate comparison tables, please note that the 2016 allowable rates that increased are identified with bold font.

Office/Outpatient Evaluation and Management: New and Established Patients

The national average Medicare allowable MPFS rates increased slightly for 3 of the 10 office/outpatient evaluation and management (E/M) codes, whereas the other 7 codes decreased slightly (Table 1). As always, the allowable rates for E/M services performed in the QHPs' offices are higher than the allowable rates when QHPs perform E/M services in facilities. Qualified healthcare professionals should carefully document their E/M services and follow the E/M guidelines provided by the American Medical Association.

Table 1. EVALUATION AND MANAGEMENT NATIONAL AVERAGE RATES

Surgical and Medical Debridement

The national average Medicare allowable MPFS rates decreased slightly for all of the surgical and medical debridement codes, except for the surgical debridement of bone, which increased slightly (Table 2). As always, the Medicare allowable rates are higher for surgical debridement than for medical debridement. Qualified healthcare professionals should fully document their debridement work and select the appropriate procedure code based on the level of the tissue debrided and the size of the debrided surface area.

Table 2. SURGICAL AND MEDICAL DEBRIDEMENT NATIONAL AVERAGE RATES

Autografts

The national average Medicare allowable MPFS rates increased for split-thickness autografts performed in both offices and facilities (Table 3). The story is different for epidermal autografts: most of that work performed in the office will be paid at slightly higher rates, whereas most of the work performed in facilities will be paid at slightly lower rates. Qualified healthcare professionals should select the appropriate code based on type of autograft and location and size of the defect.

Table 3. AUTOGRAFT NATIONAL AVERAGE RATES

Cellular and/or Tissue-Based Products for Wounds [outdated term "skin substitute grafts"]

All of the national average Medicare allowable MPFS rates for the base codes to apply cellular and/or tissue-based products (CTPs) decreased slightly, and rates for only 2 add-on codes increased (Table 4). When QHPs apply CTPs in facilities, they will be paid by Medicare for the application of the CTPs covered by their Medicare Administrative Contractor (MAC). When QHPs apply CTPs in their offices, they will be paid by Medicare both for the covered CTPs and for their application.

Table 4. CELLULAR AND/OR TISSUE-BASED PRODUCTS FOR WOUNDS NATIONAL AVERAGE RATES

Some of the CTPs' average sales prices are listed on the quarterly updated Medicare Part B Drug Average Sales Price file. Some of the CTPs are not included on that file. In that case, the payment allowable is based on the published Wholesale Acquisition Cost (WAC) or invoice pricing. In determining the payment limit based on WAC, the MACs follow the methodology specified in Publication 100-04, Chapter 17, Drugs and Biologicals, for calculating the average wholesale price, but substitute WAC for average wholesale price. The payment limit is 106% of the lesser of the lowest-priced brand or median generic WAC. When submitting claims for CTPs, without published rates on the Average Sales Price file, applied in QHPs' office, include the following information in field 19 of a paper claim or in the narrative field of an electronic claim:

* product name

* product size

* product number

* invoice price per piece

This information will educate your MAC about the cost of specific covered CTP that was applied.

Compression

The application of an Unna boot was the only compression system that received a slight increase to the national average Medicare allowable MPFS rates (Table 5). The application of total contact casts and multilayer compression systems to all anatomic locations received slight allowable rate decreases. Qualified healthcare professionals should select the appropriate compression code based on the type of compression applied.

Table 5. COMPRESSION NATIONAL AVERAGE RATES

Negative-Pressure Wound Therapy: Durable Medical Equipment and Disposable

The national average Medicare allowable MPFS rates decreased for negative-pressure wound therapy (NPWT) (durable medical equipment) performed in both offices and facilities (Table 6). The national average Medicare allowable MPFS rates for NPWT (disposable) remain contractor priced under the Physician Fee Schedule. Please contact your local Medicare Administrative Contractor for payment amounts. When submitting claims for NPWT (disposable), QHPs should include the following information in field 19 of a paper claim or in the narrative field of an electronic claim:

Table 6. NEGATIVE PRESSURE WOUND THERAPY NATIONAL AVERAGE RATES

* product name

* product size

* product number

* invoice price, each

This information will educate your Medicare Administrative Contractor about the costs of the new disposable NPWT.

Low Frequency, Noncontact, Nonthermal Ultrasound

The national average Medicare allowable MPFS rates decreased slightly for the use of low frequency, noncontact, nonthermal ultrasound (Table 7). Qualified healthcare professionals should use this code only for technologies that meet the definition of the code.

Table 7. LOW-FREQUENCY, NONCONTACT, NONTHERMAL ULTRASOUND NATIONAL AVERAGE RATES

Hyperbaric Oxygen Therapy

The national average Medicare allowable MPFS rate decreased slightly for the supervision of hyperbaric oxygen therapy in both facilities and QHP offices Table 8. The allowable rate also decreased slightly for each 30-minute increment of hyperbaric oxygen therapy when performed in QHP offices. Qualified healthcare professionals should report G0277 only when they provide hyperbaric oxygen in an office setting.

Table 8. HYPERBARIC OXYGEN THERAPY NATIONAL AVERAGE RATES

Summary

Qualified healthcare professionals may find additional 2016 MPFS allowable rates, as well as their state-specific allowable rates, by using the MPFS Look-Up Tool: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.ht.