On July 13, 2023, CMS issued proposed rules for the 2024 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). Comments for both are due on September 11, 2023, by 5 pm Eastern.
You should read the documents yourself, but here are a few observations about the 2024 PFS pertaining to Cellular and/or Tissue-Based Products in the doctor’s office setting:
Regarding Cellular and/or Tissue-Based Products (CTPs) otherwise known as Skin Substitutes
While CMS is still considering alternative payment models for CTPs in the outpatient setting, CMS did not move forward with any of the methodologies that it has proposed in the past. Instead, CMS is continuing to pay for CTPs the same – using the high and low cost categories. The following are being proposed:
- The CY 2024 MUC is $47 per sq cm (same as CY 2023)
- CY 2024 product per day cost (PDC) is $817 per sq cm (a decrease of $30 from CY 2023)
- Any CTP that was assigned to the high-cost group in CY 2023 would similarly be assigned to the high-cost group in CY 2024
- Pass through products will be assigned to the high-cost category
- If ASP is not available, CMS proposes to use WAC plus 3%
- CMS proposes to use 95% of AWP to assign a CTP to either the high or low-cost category.
- Any CTP that is assigned a code in the HCPCS A2XXX series would be assigned to the high-cost category including new products without pricing information.
- New CTPS without pricing information that are not assigned a code in the HCPCS.
- A2XXX series would be assigned to the low-cost category until pricing information is available to compare to the CY 2024 MUC and PDC thresholds.