September 11, 2023
In comments to CMS' proposed 2024 Hospital Outpatient Prospective Payment System (HOPPS) rate update, the Alliance submitted five specific policy recommendations to help correct payment methodology flaws and inappropriate APC assignments that have impacted access to CTPs ("skin substitutes") and created barriers to care in hospital outpatient departments. The Alliance reminded CMS that the Agency's own Advisory Panel on Hospital Outpatient Payment has recommended that CMS adopt these policy updates:
  1. enable HOPDs be reimbursed for an adequate amount of CTP products for larger wounds so that they do not need to absorb the cost or refer patients out by assigning the existing CPT® add-on codes (15272, 15274, 15276, and 15278) and HCPCS codes (C5272, C5274, C5276, and C5278) to appropriate APC groups allowing for separate payment and issue an exception to separately pay for these add-on codes.
  2. equalize the payment for CTP application for wounds/ulcers of the same size no matter the location by assigning the CPT and HCPCS codes for the same size wound, regardless of anatomical location on the body, to the same APC groups.
  3. assign all CTPs with either HCPCS codes of Q or A to the low-cost APC groups until a manufacturer provides cost information to CMS.
  4. realign both the high-cost and low-cost application procedure codes to higher paying APC groups that reflect the current average sales prices of all CTPs. Manufacturers are required to submit average sales prices, and this pricing should be used to map to an appropriate APC for all CTPs, whether they are issued a HCPCS A code or Q code.
  5. do not assign CTPs that are not in sheet form to any APC group, because these products are not allowed to use the current application codes of HCPCS codes 15271-15278; C5271- C5278; which drive the APC group assignment.

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