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Three Hits in One Week: The 85% Rule Expands
This is the third major reimbursement change or clarification impacting wound care providers in a single week — and unfortunately, it’s another step in the wrong direction.
They say that events, good or bad, happen in 3s. Well, we have the third thing this week! Is it good or bad? This is the third major change or clarification to patients with wounds this week, and it is basically all bad. It relates to the 85% reduction for NP and PA providers delivering services covered by the physician fee schedule (PFS).
Unfortunately, although separately payable from the application code and involving no “services”, skin substitutes as “incident to” supplies are now also being reduced to 85% of the PFS rate. Yes, they are supplies that have the same cost in the hands of an NP/PA or physician, but it seems that the nearly unique construct that places skin substitutes as both separately payable and covered under the PFS delivers another unintended (or intended) consequence on top of zero wastage, the geographic indexing applied to the $127, and the removal of the LCD which would have at least made Med Advantage plans have to cover these products nationally for DFU and VLUs. An appropriate quote comes to many a mind at this moment:
“Everybody got a plan until they get punched in the face.” (sic)– Mike Tyson.
Except that this is three in one week. On the bright side, HR 6852 is beginning to get some traction among the US House on both sides of the aisle, and this legislation would cure all three problems plus make the application fee rise to $780 from roughly $175 in outpatient settings and raise the PFS rate to between $380-400/cm2. Maybe next we will get some good news for a change.
https://www.congress.gov/bill/119th-congress/house-bill/6852
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