Reimbursement Readiness

Ep.21 Consolidated Billing

Episode 21 of Reimbursement Readiness: Business Tips for Wound Practice addresses one of the most common—and costly—sources of claim denials in wound care: Medicare consolidated billing. Kathleen Schaum is joined by reimbursement expert Yesenia Banks, who explains why many wound care stakeholders only learn about consolidated billing after claims are denied or payments are recouped. In this episode, Yesenia breaks down the fundamentals of home health and skilled nursing facility consolidated billing rules, including how payment responsibility is assigned during a defined episode of care and why verifying a patient’s status is critical before billing Medicare. She also walks through key distinctions that affect wound care services—such as what is bundled within the home health PDGM model, what remains separately payable under Medicare Part B, and how negative pressure wound therapy is handled differently depending on the care setting. The discussion also clarifies how consolidated billing functions within the SNF PDPM payment model, including the four CMS billing files used to determine which services are excluded, separately billable, or the responsibility of the facility. The episode closes with practical guidance and CMS resources to help providers avoid denials, compliance risk, and unexpected recoupments. Feedback Survey [https://forms.office.com/Pages/ResponsePage.aspx?id=hs-zYcbYwEabjd_GETWJ-J065C7wIRlHhgXb_vqW3VlUQVpJN1lRTTRSWFJNTUVNQ0RZOTJMNFhDNy4u&r56b7b01fe5534d5398344230a6e2effb=%2221%22] ------------------------------------------ Home Health Consolidated Billing list: https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information [https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information] Skilled Nursing Facility Consolidated Billing List https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/consolidated-billing [https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/consolidated-billing] There are four Skilled Nursing Facility Consolidated billing list files: * File #1 - Part A Stay (2026 Physician Services)(Physician Professional Services Other than Interpretation of Diagnostic Tests) These codes are not subject to SNFconsolidated billing. * File #2 - Part A Stay (2026 Physician)(Professional Component of Services to be Submitted with a 26Modifier) These odes are not subject to SNF consolidated billing. * File #3 Part A Stay (Ambulance) These codes are not subject to SNF consolidated billing. * File #4 - Part B Stay Only (Therapy) These therapy codes are subject to SNF consolidated billing and must be billed through the SNF.

Ep.20 WISeR Prior Authorization: First-Month Real Life Experience

Episode 20 of Reimbursement Readiness: Business Tips for Wound Practice delivers a timely field report on the WISER Prior Authorization Program—based on real, early experiences from stakeholders submitting requests in New Jersey, Ohio, Oklahoma, and Texas. Even listeners outside the participating states asked for this update, because the “why” behind approvals and denials is helping teams everywhere tighten documentation for reasonable and medically necessary care. Kathleen Schaum shares what she’s hearing from the first month of implementation—what surprised providers, how teams are adapting workflows, and why some are actually finding WISER beneficial (including faster clarity on coverage before purchasing a CTP). Then Kathleen interviews Kati Kauchel, DNP, FNP-C, CWS, founder of Kindling Consulting, who supports mobile wound care organizations and is actively working with groups submitting WISER requests in Texas and Oklahoma. Together, they unpack what “good” looks like under WISER: deliberate care plans, documentation that tells a clear longitudinal story, and escalation that’s clinically driven—not calendar-driven. You’ll also hear the most common patterns behind non-affirmed decisions—often not the product itself, but gaps in the record (standard of care, readiness criteria, sequencing, missing elements like vascular assessment, A1C/compression compliance, etc.). Kati closes with practical guidance to “pressure test” documentation before submission, including a provider self-assessment tool listeners can download. Episode 20 Handout WISeR Professional Self-Assessment.pdf [http://wct-us.com/wp-content/uploads/2026/02/Episode-20-Handout-WISeR-Professional-Self-Assessment.pdf]

Ep, 19 Autologous Platelet Rich Plasma (PRP) or Other Blood-Derived Products for Diabetic Chronic Wounds/Ulcers

Episode 19 of Reimbursement Readiness: Business Tips for Wound Practice tackles the surge of reimbursement questions surrounding autologous platelet-rich plasma (PRP) and other blood-derived products for diabetic chronic wounds. After the 2026 OPPS and Physician Fee Schedule changes, many outpatient departments and physician practices are evaluating whether and how to add PRP/blood-derived technologies into their treatment pathways—and Kathleen Schaum breaks down what Medicare actually allows. Kathleen answers the top five PRP reimbursement FAQs, starting with what the NCD 270.3 (effective April 13, 2021) covers—and what it does not—plus the key coding distinction between G0460 vs G0465 and what must be built into your systems (EHR/CDM/coding/billing) to bill correctly. She also clarifies the covered places of service, how multiple-procedure payment reductions can apply when more than one unit is needed, and what to know about the MUE limit of 2 for G0465. Finally, she addresses whether WISER prior authorization applies (it does not for G0465), while emphasizing that advanced therapies still require tight documentation—including medical necessity, plan of care, and a complete procedure note.

Ep.18 Physicians' FAQs about CTP Purchase & Application in 2026

Send us your feedback: Audience Survey [bit.ly/RR-Episode-18] ------ In Episode 18 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum welcomes reimbursement expert Donna Cartwright to tackle the flood of physician questions surrounding the 2026 CTP payment changes. With misinformation circulating widely, this episode focuses on what CMS has actually finalized—and what physicians need to operationalize now. Donna walks through the most common FAQs about purchasing and applying CTPs under the 2026 Medicare Physician Fee Schedule, including the shift to a uniform per–square centimeter product payment, how geographic adjustment affects rates, and what practices must update in their charge description masters and internal systems. She also clarifies a major compliance pitfall: wastage is no longer payable for non-BLA skin substitutes, and JW/JZ modifiers are not appropriate for CTPs under incident-to supply payment—meaning only the administered portion is billable. The episode closes with practical reminders around system updates, documentation discipline, and when to escalate unresolved contradictions to your MAC. Downloads: * MFPS_Rates_2026.pdf [https://s3.us-east-1.amazonaws.com/wctusa/General/MFPS_Rates_2026.pdf] * GPCI_Rates_by_locality.pdf [https://s3.us-east-1.amazonaws.com/wctusa/General/GPCI_Rates_by_locality.pdf]

Ep.17 2026 OPPS Payment Changes for CTPs Will Not Happen “By Magic”

As 2026 begins, Kathleen Schaum opens Episode 17 of Reimbursement Readiness: Business Tips for Wound Practice with a candid assessment of the turbulence wound care teams endured in 2025—particularly around cellular and tissue-based products (CTPs). While the 2026 Medicare Outpatient Prospective Payment System (OPPS) Final Rule brought meaningful improvements for hospital-owned outpatient provider-based departments (PBDs), Kathleen is still fielding urgent calls from departments that have not yet aligned their systems to capture those payments correctly. In this episode, Kathleen walks PBD leaders step-by-step through the critical operational refinements required to receive appropriate CTP reimbursement in 2026. She explains how unpackaged payment affects application codes, why charges must be adjusted, which legacy codes must be removed, and how flat-rate CTP product payment changes purchasing strategy. Kathleen also highlights the importance of updating formularies, charge description masters, EHR workflows, coding tools, and billing systems—emphasizing that improved reimbursement will not “happen by magic” without deliberate action. This episode serves as a practical readiness checklist for PBDs using CTPs today. If physicians or qualified healthcare professionals are applying CTPs in your department, this conversation helps you confirm what’s complete, identify what’s missing, and act quickly to avoid lost revenue in 2026. Download the Quick Guide [https://s3.us-east-1.amazonaws.com/wctusa/General/RR_Episode17_Quick_Guide_v2.pdf]