The latest CMS reimbursement change affecting wound care is that, as of Jan. 1, 2028, each outpatient off-campus hospital department must use a National Provider Identifier (NPI) separate from the main hospital’s. This might not seem like such a big deal; however, this change will allow CMS to better track costs. In addition to the administrative burden of maintaining a separate NPI for each off-campus HOPD, this will make implementing site neutrality much easier.
The MEDPAC report in 2023 has 3 wound-related APCs (5052, 5023 and 5055) on the list of likely services that can be safely done in the office setting. These codes cover the 1104X debridement codes as well as 97597 debridement.
Looking at HOPD utilization numbers for 2024 and using the national average reimbursements for two commonly used codes, 11042 and 97597, site neutrality would have saved Medicare $294,367,703.00.
Hospitals must begin preparing for the possibility that the facility charges they currently enjoy could decrease substantially. Since one HOPD facility charge for 11042 is $415.32, and one 4-segment hyperbaric treatment is $560, the impact that site neutrality will have is not on the hyperbaric oxygen side, but on the wound care side. In a busy wound care center, a clinician can complete at least 4 11042s in the time it takes to complete one hyperbaric treatment.
The physician fee schedule calculates physician work, practice expense, and malpractice expense. For 11042, the maximum allowable payment for an office-based physician is $132.60. Of that $55.78 is physician work, and the difference is basically practice expense. In this instance, it would be $76.82. That includes staff, rent, and supplies. It is essentially the “facility charge”. If CMS implements 100% site neutrality, the HOPD facility charge would drop from $415.32 to $76.82.
HOPD-based wound care centers would struggle to survive under that scenario. The current model for wound care will be disrupted, and the impact on patients and their care is uncharted. Many office practices provide wound care, such as podiatry, but their scope is limited. It will be interesting to read the tea leaves as to which way this will go, but the MEDPAC has been recommending site neutrality for decades, and perhaps the powers that be at CMS are listening.
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