90% reduction in skin sub reimbursement, 2026

[heybrother]

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The 2026 CMS Final Rule Fee schedule is out.

1. Skin subs are apparently getting "slaughtered". $127.28 per square centimeter starting in 2026. Apparently they could previously go as high as $2000 sq cm.
2. We are supposedly getting a fee schedule increase per APMA, Big Beatiful bill etc ie the conversion factor is going up
3. However, if you read online commentary, the pain forum etc - there are procedural reimbursement cuts coming because of the belief that we've all become more "efficient" to the tune of -2.5% for procedural codes.
4. Fee schedules posted elsewhere suggested the possibily of increasing professional fees for services performed in non-facility rather than facility.

I guess we'll see what the future holds come January 1st.

I think the big thing to keep in mind when we get an "increase" is that we got a hard cut last year.

 

[Adam Smasher]

OG apligraf is 44 sq cm. At $127/sq cm, that's $5588

lobsters always survive

 

[heybrother]

OG apligraf is 44 sq cm. At $127/sq cm, that's $5588

lobsters always survive

Yeah, as I wrote this I thought about how small a sq cm is and how big most grafts I've seen are. Added the quotations on slaughtered for a reason.

Yesterday I saw a woman who was sent to a WHC for an ingrown toenail. The general surgeon was was loading her up with alginate and collagen, but hadn't decided yet whether the nail was actually ingrown. There are many forms of food on the bottom of the ocean.

 

[Homo sapien]

Yeah, as I wrote this I thought about how small a sq cm is and how big most grafts I've seen are. Added the quotations on slaughtered for a reason.

Yesterday I saw a woman who was sent to a WHC for an ingrown toenail. The general surgeon was was loading her up with alginate and collagen, but hadn't decided yet whether the nail was actually ingrown. There are many forms of food on the bottom of the ocean.

What the hell for? Did she have a wound affiliated there or something

 

[Adam Smasher]

What the hell for? Did she have a wound affiliated there or something

There's big money in collagen powder. You can milk an extra $100-200/visit by ordering collagen powder for your patients.

We had a "lunch and learn" several weeks back with a company that would deliver collagen + related supplies to our pt's homes if we ordered it. We were to buy the collagen and then bill their insurance. All I could think about however was the time I would need to spend chasing down invoices, billing codes, and fielding inane phone calls from patients ("do I wash my wound in a clockwise direction or counterclockwise direction?"). But the money is there to be made if you want to put in the work.

 

[heybrother]

What the hell for? Did she have a wound affiliated there or something

She had some granulation tissue in the corner. Paronychia. A 3rd year pod student could solve it. This is the second patient I've seen in about 6 weeks with an ingrown toenail that was sent to a WHC and then botched. I got a 17 year old college girl a little while back who had a botched matrixectomy that needed more nail removed. She spent 6 months at a WHC being debrided. Should have seen my face when I saw "non-healing wound" listed on the referral paperwork. She'll never trust the medical system again. They billed the hell out of her.

 

[Weirdy]

Pain medicine is also getting hammered with prior authorizations for procedures they didn't have to get PAs for in the past.

 

[air bud]

There's big money in collagen powder. You can milk an extra $100-200/visit by ordering collagen powder for your patients.

We had a "lunch and learn" several weeks back with a company that would deliver collagen + related supplies to our pt's homes if we ordered it. We were to buy the collagen and then bill their insurance. All I could think about however was the time I would need to spend chasing down invoices, billing codes, and fielding inane phone calls from patients ("do I wash my wound in a clockwise direction or counterclockwise direction?"). But the money is there to be made if you want to put in the work.

We are in the northern hemisphere so They would wash it in a clockwise direction. Reverse if they travel to Australia.

 

[Boba Foot]

There's big money in collagen powder. You can milk an extra $100-200/visit by ordering collagen powder for your patients.

So I guess this is why I had a patient with a closed TMA that dehisced after some home care nurse slathered collagen all over it and it macerated.

 

[Weirdy]

So I guess this is why I had a patient with a closed TMA that dehisced after some home care nurse slathered collagen all over it and it macerated.

Is that before or after you told the nurse you didn't want her soaking the dehiscence site because it "looked flaky" and she did that for a week before patient got in to see you again?

 

[Homo sapien]

Is that before or after you told the nurse you didn't want her soaking the dehiscence site because it "looked flaky" and she did that for a week before patient got in to see you again?

I'm sick of these ****ers soaking everything

 

[Flip-flop-flerpity]

We are in the northern hemisphere so They would wash it in a clockwise direction. Reverse if they travel to Australia.

You would also need a billable dressing to keep the collagen powder from falling off into outer space

 

[eyeeye_captain]

I'm sick of these ****ers soaking everything

I tried to warn you about those Utah pods

 

[Adam Smasher]

So the mustache/TFP insight for the day is that soaking actually dries the skin out, because it rinses away the essential oils that promote proper skin turgor and neutralizes the skin pH which should be slightly acidic. For this reason, older adults are actually encouraged not to bathe daily but rather every other day to prevent excessive drying of the skin.

 

[SubungualDebris]

Yeah, as I wrote this I thought about how small a sq cm is and how big most grafts I've seen are. Added the quotations on slaughtered for a reason.

Yesterday I saw a woman who was sent to a WHC for an ingrown toenail. The general surgeon was was loading her up with alginate and collagen, but hadn't decided yet whether the nail was actually ingrown. There are many forms of food on the bottom of the ocean.

I never quite got the grasp of these grafts. Admittedly, I don't do much wound care in general so naturally it makes sense.

Don't suppliers price these grafts per square centimeter? Are there actually grafts available on the market that are priced significantly less than what medicare would reimburse per square centimeter?

If there are grafts that are priced substantially cheaper than $127 per square centimeter, I don't see how people won't continue to abuse this system. Even if a provider was only making $50 per square centimeter after you factor in cost of the graft, for a 20 square centimeter wound that's 1k profit. Per visit. And you can slap on 4+ of these?? I have to be missing something here, surely there aren't any grafts available for $127 dollars per centimeter, right?

 

[Adam Smasher]

surely there aren't any grafts available for $127 dollars per centimeter, right?

In addition to apligraf, a 10-pack of oasis 2x3 cm sells for $1250, so I guess you could say...

...it brings home the bacon

 

[SubungualDebris]

In addition to apligraf, a 10-pack of oasis 2x3 cm sells for $1250, so I guess you could say...

...it brings home the bacon

That's unbelievable, the reimbursement per square centimeter is still $100+

Which begs the question, prior to this upcoming reform how much were these grafts reimbursing per square centimeter? I'm willing to bet that number is nauseating

 

[air bud]

That's unbelievable, the reimbursement per square centimeter is still $100+

Which begs the question, prior to this upcoming reform how much were these grafts reimbursing per square centimeter? I'm willing to bet that number is nauseating

Ding ding ding

 

[dtrack22]

I never quite got the grasp of these grafts. Admittedly, I don't do much wound care in general so naturally it makes sense.

Don't suppliers price these grafts per square centimeter? Are there actually grafts available on the market that are priced significantly less than what medicare would reimburse per square centimeter?

If there are grafts that are priced substantially cheaper than $127 per square centimeter, I don't see how people won't continue to abuse this system. Even if a provider was only making $50 per square centimeter after you factor in cost of the graft, for a 20 square centimeter wound that's 1k profit. Per visit. And you can slap on 4+ of these?? I have to be missing something here, surely there aren't any grafts available for $127 dollars per centimeter, right?

The manufacturer has a negotiated reimbursement rate (per square cm generally speaking though there are some odd ones like Apligraf) with CMS. They will make that the “invoice” price of the graft. You pay the manufacturer for the graft, you submit the claim to Medicare with the appropriate HCPCS code/units used/invoice price and then Medicare reimburses you. The manufacturer then give you a “rebate” (aka a kickback) that is 10-40% of the “invoice” price. If you put on a few grand worth of skin subs, the company whose product you used will write you a check for $500-1000. It’s actually wild that we got away with it for so long when you think about it.

 

[Adam Smasher]

Which begs the question, prior to this upcoming reform how much were these grafts reimbursing per square centimeter? I'm willing to bet that number is nauseating

For me nauseating is getting $460 for a mpj fusion. In a sane universe, podiatry gets reimbursed fairly and difficult/skillful things get reimbursed better. However, here on Earth where we all work, bizarre topsy turvy incentives exist to do silly things to keep your business in the black. If Medicare never wanted us to use these expensive grafts, they never would have offered us $$$$$ to do it.

 

[eyeeye_captain]

For me nauseating is getting $460 for a mpj fusion. In a sane universe, podiatry gets reimbursed fairly and difficult/skillful things get reimbursed better. However, here on Earth where we all work, bizarre topsy turvy incentives exist to do silly things to keep your business in the black. If Medicare never wanted us to use these expensive grafts, they never would have offered us $$$$$ to do it.

That’s what our cataracts are about to pay and our lens folks are losing their minds. I’m getting a 9% cut on my already unprofitable surgeries. I might just start printing out directions to the nearest academic ED.

Every surgical/procedural field is getting creamed, especially if your population is on the older side. Like Weirdy said, pain is a good example with auths, and it looks like a lot of their peripheral blocks won’t be covered.

The graft money game gets played in various forms across medicine. I think there was some investigation into buy and bill in the last couple years, but nothing came of it. Maybe it’s too close to a retail model. I make some money with it, but it’s nowhere near what you’re quoting on the skin stuff.

 

[Stormblest]

A couple of guys the last place I lived went from making ~400k a year to around 1 million a year due to the graft business. All of the sudden every wound needs a graft every 2 weeks.

Rarely are grafts needed for foot wounds imo. You can’t convince me there is no financial incentive. Glad they have cracked down some but sounds like the graft grift will continue.

 

[Weirdy]

A couple of guys the last place I lived went from making ~400k a year to around 1 million a year due to the graft business. All of the sudden every wound needs a graft every 2 weeks.

Rarely are grafts needed for foot wounds imo. You can’t convince me there is no financial incentive. Glad they have cracked down some but sounds like the graft grift will continue.

Will 2nd this.
Most wounds will heal by themselves given everything else is in place.
Some wounds don't heal by themselves- those usually need some kind of surgical offloading.
Some wounds don't heal because the patients are train wrecks with 6 different comorbidities and the wound is the least of their worries.

I've been on the hunt for wounds that genuinely need grafts to try to bill for one and see how it works.
So far havn't had any because they either healed and stayed healed with normal offloading/vascular/DM control, need surgical offloading, or need an amp.

 

[Adam Smasher]

From my rep:

 

[Sybly]

The 2026 CMS Final Rule Fee schedule is out.

1. Skin subs are apparently getting "slaughtered". $127.28 per square centimeter starting in 2026. Apparently they could previously go as high as $2000 sq cm.
2. We are supposedly getting a fee schedule increase per APMA, Big Beatiful bill etc ie the conversion factor is going up
3. However, if you read online commentary, the pain forum etc - there are procedural reimbursement cuts coming because of the belief that we've all become more "efficient" to the tune of -2.5% for procedural codes.
4. Fee schedules posted elsewhere suggested the possibily of increasing professional fees for services performed in non-facility rather than facility.

I guess we'll see what the future holds come January 1st.

I think the big thing to keep in mind when we get an "increase" is that we got a hard cut last year.

Good , end abuse!

 

[DYK343]

Chronic stuck stasis ulcers grafts can benefit.

Im a Kerecis fanboy for covering bone/tendon under a vac. I love it.

Keep in mind Im wRVU based and I get paid very little to put these things on. I have no incentive other than I find them useful in certain situations for my patients.

 

[heybrother]

Chronic stuck stasis ulcers grafts can benefit.

Im a Kerecis fanboy for covering bone/tendon under a vac. I love it.

Keep in mind Im wRVU based and I get paid very little to put these things on. I have no incentive other than I find them useful in certain situations for my patients.

You'll still get to put them on people. I just won't have reps coming by promising me a 40% rebate...probably.

 

[Feli]

This will hopefully put a lot of WC centers out of biz.

They should target HBO with rate cuts next.

 

[heybrother]

I saw this on my facebook feed and thought ... what is this. And then sure enough.

 

[Boba Foot]

Love that they throw that 5 year mortality rate out there as if their $2000 Listerine strip is going to overcome the fact that they’re likely ESRD, PVD, well-progressed diabetic with a host of other comorbidities.

That mortality rate isn’t so high because of the amputation, but because of how they got there.

 

[Hybrocure]

Chronic stuck stasis ulcers grafts can benefit.

Im a Kerecis fanboy for covering bone/tendon under a vac. I love it.

Keep in mind Im wRVU based and I get paid very little to put these things on. I have no incentive other than I find them useful in certain situations for my patients.

I don’t think PP makes much from the more popular grafts like kerecis or epifix, etc.

It’s the niche up and comers that from my experience they tell you to code weird to get paid big bucks

 

[diabeticfootdr]

This will hopefully put a lot of WC centers out of biz.

They should target HBO with rate cuts next.

No, the new fee schedule is actually financially better for HOPDs than the current system of bundled payments, and potentially worse for physician office/home place of service. For HOPDs they can now treat larger wounds and receive a separate facility fee.

HOPDs
A. Old Reimbursement
Bundled rate (facility fee and supply) of ~$1800 regardless of the type of graft or size of wound
+ physician fee

B. 2026
Facility fee ~$600
$127/cm2 (if a graft costs $70/cm2, that about $50/cm2 net profit, so for 10 cm2 = $500)
+ Physician fee

Physician Office
A. Old Reimbursement
Physician fee + invoice cost of graft

B. 2026Physician fee + 127/cm2

This is a response to the very small number of providers engaged in massive amounts of fraud, waste, and abuse. Some providers were collecting $300,000/application and then receiving a "rebate" on the graft, which is really a kickback. I co-authored an article recently analyzing the 2024 CMS dataset, which found 100 individual NPI numbers were responsible for 57% of the total spend on skin substitutes nationwide. The national spend was just over $10B. The hundred NPIs received approximately $5.7B.

 

[Hybrocure]

No, the new fee schedule is actually financially better for HOPDs than the current system of bundled payments, and potentially worse for physician office/home place of service. For HOPDs they can now treat larger wounds and receive a separate facility fee.

HOPDs
A. Old Reimbursement
Bundled rate (facility fee and supply) of ~$1800 regardless of the type of graft or size of wound
+ physician fee

B. 2026
Facility fee ~$600
$127/cm2 (if a graft costs $70/cm2, that about $50/cm2 net profit, so for 10 cm2 = $500)
+ Physician fee

Physician Office
A. Old Reimbursement
Physician fee + invoice cost of graft

B. 2026Physician fee + 127/cm2

This is a response to the very small number of providers engaged in massive amounts of fraud, waste, and abuse. Some providers were collecting $300,000/application and then receiving a "rebate" on the graft, which is really a kickback. I co-authored an article recently analyzing the 2024 CMS dataset, which found 100 individual NPI numbers were responsible for 57% of the total spend on skin substitutes nationwide. The national spend was just over $10B. The hundred NPIs received approximately $5.7B.

Gonna guess mostly those home wound care MDs who can hire a NP and multiple mobile nurses yet only see 4 patients a day, pay for those salaries and still make bank?

 

[air bud]

Shouldn't it really be that easy then? Everything is hooked up to an NPI number.

 

[heybrother]

HOPDs always win, but their physicians don't usually have an "incentive" to place biologic grafts. Am I wrong?

Small sample size, but my town has more "office" WHCs than facility.

 

[DYK343]

HOPDs always win, but their physicians don't usually have an "incentive" to place biologic grafts. Am I wrong?

Small sample size, but my town has more "office" WHCs than facility.

1.83 wRVU to place a graft. About $90-100 reombursement to the provider.

 

[diabeticfootdr]

HOPDs always win, but their physicians don't usually have an "incentive" to place biologic grafts. Am I wrong?

Small sample size, but my town has more "office" WHCs than facility.

The fee schedule change was done to remove the incentive for using high cost (mostly amniotic) products from companies playing the "ASP game", which keeps the costs high. Then providers get reimbursed for the amount of their paid invoice for the product. Afterwards, companies give the provider a "rebate" (aka kickback). That incentive didn't exist in the HOPD since there was a bundled payment.

 

[NRAI2001]

Bump

 

[air bud]

Bump

Bump

 

[NRAI2001]

Bump

I like your style