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In Episode 29 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright continue the Wound and Ulcer Management Audit Readiness Series with Part 3, focusing on two of the most important components of the medical record: the plan of care and progress notes. Donna explains how a comprehensive plan of care supports medical necessity, communicates treatment goals, tracks changes over time, and helps auditors understand why specific services, procedures, and products were selected. She also reviews what should be documented for each wound or ulcer, including measurable goals, expected outcomes, barriers to healing, prior treatments, patient instructions, coordination with other clinicians, and changes made when treatment is not progressing as expected. The episode also takes a closer look at progress notes and how they should tell the ongoing story of each wound—from prior treatment results and clinical decision-making to measurements, wound appearance, signs of infection, overall assessment, and next steps. By keeping documentation consistent and showing how the patient is progressing from one encounter to the next, wound care teams can strengthen medical necessity and better prepare for payer audits. Downloads Plan of Care and Progress Notes Checklist Episode Survey Click Here

Episode Survey In Episode 28 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum turns the focus to a fundamental but often overlooked part of reimbursement: understanding the full descriptions behind CPT and HCPCS codes. As denials and audit failures continue to expose gaps between documentation and reported codes, Kathleen explains why knowing the code number alone is not enough. Using examples from debridement, CTP applications, autologous blood-derived products, negative pressure wound therapy, and wound care products, Kathleen breaks down the three key components of a code description: the service or product being identified, the clarifying information that defines its use, and the unit or measurement tied to reporting. She also highlights how seemingly similar codes can differ significantly based on anatomy, wound type, treatment method, or unit of measure. The episode reinforces one central principle: the documentation in the medical record must align with the code description reported on the claim. Kathleen also encourages clinicians, coders, and billers to review the codes they use most often, update their systems and workflows as needed, and use the provided checklist to strengthen coding accuracy and reduce denials, repayments, and compliance risk. Handout: Checklist for Selecting Wound and Ulcer Management Codes Based on Their Code Descriptions

In Episode 27 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright continue the Wound and Ulcer Management Audit Readiness Series with Part 2, focusing on wound and ulcer measurements and descriptions. Accurate documentation in these areas is essential not only for clinical continuity, but also for demonstrating medical necessity and supporting reimbursement during pre- and post-payment audits. Donna explains what auditors expect to see in the medical record, including consistent wound measurements, clear documentation of changes over time, complete descriptions of each wound’s origin and condition, and the results of previous treatments. She also reviews common documentation problems that can lead to denials or repayments, such as mismatched wound descriptions, missing post-procedure measurements, incomplete tissue percentages, unsupported treatment continuation, and incorrect CTP sizing or wastage reporting. The episode closes with practical guidance for conducting an internal self-audit and improving documentation workflows. Donna also provides a checklist that wound care teams can use to evaluate whether their wound measurements and descriptions clearly tell the story of each wound and support the medical necessity of the care provided. Episode 27 Evaluation Link: CLICK HERE DOWNLOADS: Checklist for Measurements and Wound Description

In Episode 26 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum addresses a common coding practice that can create serious repayment risk during audits: reporting an evaluation and management service with Modifier 25 when a minor wound or ulcer management procedure is performed during the same encounter. Kathleen reviews the 2026 NCCI Manual guidelines and explains why the decision to perform a minor procedure—and the related pre-, intra-, and post-procedure work—is generally included in the procedure payment. She clarifies that an E&M service may only be reported separately when the medical record supports a significant, separately identifiable service that goes beyond the work required to evaluate and perform the procedure, regardless of whether the patient is new or established. The episode also examines the proposed 2027 Medicare Physician Fee Schedule change that could reduce payment for one of the two services when a legitimate E&M visit and global procedure occur on the same day. Kathleen separates that proposal from misinformation circulating online and encourages practices that frequently use Modifier 25 to conduct a self-audit before unsupported billing leads to denials or recoupments. DOWNLOADS: Appropriate Use Of Modifer -25 with Minor Procedures 2026-ncci-medicare-policy-manual-all-chapters.pdf

In Episode 25 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright launch a new Wound and Ulcer Management Audit Readiness series focused on the documentation auditors expect to find in the medical record. This first installment examines the history and physical, showing how incomplete, inconsistent, or overly broad documentation can undermine medical necessity and place reimbursement at risk. Donna explains how to make each record self-contained, clearly identify the origin and location of every wound, document prior treatments and their effectiveness, and connect underlying conditions to the patient’s ability to heal. She also addresses common audit concerns such as inconsistent wound counts, contradictory physical-exam findings, missing results from previous therapies, and cloned or outdated information pulled forward by the electronic health record. Listeners will also receive a practical checklist they can use to self-audit their own history and physical documentation. The goal is simple: help the auditor understand the patient’s condition, the progression of each wound, and why the selected treatment was medically necessary. Download History & Physical Checklist

The 2027 OPPS and MPFS proposed rules are here. Sheet CTPs hold steady, non-sheet CTPs move to a size-based payment model, ABDP rates rise in OPPS only, and SCSA gets a whole new coding structure. Comments due August 31 (OPPS) and September 14 (MPFS). Watch for full update and view links below. 2027 Proposed Rule for Medicare Physician Fee Schedule (MPFS): https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1848-p2027 Medicare Proposed Rule for Outpatient Prospective Payment System (OPPS): https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1850-p

Coding correctly is about more than selecting the right CPT code. Understanding National Correct Coding Initiative (NCCI) edits is essential to avoiding denied claims, preventing compliance issues, and ensuring accurate reimbursement. In this episode of Reimbursement Readiness, Kathleen Schaum welcomes reimbursement expert Yesenia Banks to explain the fundamentals of NCCI edits in practical, easy-to-understand terms. Together, they discuss why NCCI edits exist, how they impact claims, the three major categories of edits, when modifiers may be appropriate, and where to find the official CMS resources your team should be using. Whether you're a clinician, coder, biller, or revenue cycle professional, this episode provides a practical foundation for understanding one of Medicare's most important coding safeguards—and how applying it correctly can improve reimbursement accuracy while reducing audit risk.

Documentation errors don't just create compliance headaches—they can lead to denied claims, recoupments, and unwanted audit scrutiny. In this episode of Reimbursement Readiness, Kathleen Schaum welcomes reimbursement consultant Donna Cartwright to discuss Medicare's rules for medical record documentation, late entries, addendums, and corrections. Together, they review what auditors look for, when documentation changes are appropriate, how to properly amend records, and why waiting too long to make corrections can create significant risk. Whether you're a clinician, coder, biller, revenue cycle leader, or compliance professional, this episode offers practical guidance to help ensure your documentation accurately reflects the care provided and stands up to audit review. Topics include: Medicare guidance on late entries, addendums, and correctionsDocumentation expectations during audits and ADRsCommon documentation mistakes that raise red flagsBest practices for paper and electronic medical recordsAudit risks associated with delayed documentation changesWhen—and when not—to amend the medical record This episode also addresses one of the most frequently asked audit questions: Can you go back and change a medical record before submitting it for review? Episode Evaluation link: Click Here

Episode 22 of Reimbursement Readiness: Business Tips for Wound Practice focuses on one of the most overlooked causes of denied claims and repayment demands in wound care: insurance benefit verification. Kathleen Schaum is joined by Amiee Coriano, who explains why verifying more than just “active insurance” is essential before every patient encounter—especially when advanced wound therapies are involved. In this episode, Amiee walks through the hidden billing risks tied to home health episodes, hospice enrollment, and skilled nursing facility stays, and explains how these care settings can dramatically affect who is financially responsible for wound-related services and supplies. The discussion covers common coordination pitfalls, Medicare consolidated billing concerns, and the critical questions providers and revenue cycle teams should ask before treatment begins. Listeners will also learn best practices for documenting episode dates, confirming payer responsibility, coordinating with outside providers, and building structured verification workflows that protect both patient care and reimbursement.

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 ------------------------------------------ Home Health Consolidated Billing list: https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/coding-and-billing-information Skilled Nursing Facility Consolidated Billing Listhttps://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.

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

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.

Send us your feedback: Audience Survey ------ 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.pdfGPCI_Rates_by_locality.pdf

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

In Episode 16 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum addresses one of the most frequently misunderstood topics in Medicare reimbursement: Incident-to billing. Drawing from common questions submitted by Wound Care Today USA subscribers—and recurring errors seen in real-world consulting—this episode is designed to clarify what Incident-to billing truly is, when it applies, and when it does not. Kathleen is joined by reimbursement expert Amiee Coriano, who provides a clear, practical breakdown of the CMS rules governing Incident-to services. Together, they walk listeners through who may provide Incident-to services, the strict supervision and documentation requirements, eligible places of service, and the critical distinction between new versus established patients. The episode also explains how Incident-to billing impacts Medicare payment rates, including when practices may bill at 100% of the Physician Fee Schedule versus 85%. This episode is essential listening for wound care practices that rely on physicians, nurse practitioners, and physician associates working together in office-based settings. Whether your goal is compliance, revenue optimization, or audit readiness, this conversation helps ensure your team applies Incident-to billing correctly—and avoids costly missteps.