Implementation of Three Unexpected CTP 2026 Medicare Payment Changes: Part 2

• Physicians/QHPs (office setting), CTP sheets (2026): Base rate $127.14/cm² is GPCI-adjusted for product and application. QHPs paid 85% of the Medicare-adjusted rate if billing under their NPI, reducing both product and application payment.

• Non-sheet CTPs (physicians/QHPs): Coverage newly allowed at MAC discretion; payment not based on $127.14/cm² and set product-by-product by each MAC. Do not bill 15271–15278 for non-sheet products; report only other performed services (e.g., E/M, debridement).

• Hospital PBDs: Application payment adjusted by hospital cost-to-charge ratio; product paid at $127.14/cm² (not GPCI-adjusted). PBDs cannot receive payment for non-sheet CTPs.

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Welcome to the CTP News Desk. I'm going to be discussing with you three unexpected CTP 2026 Medicare payment changes. This is a three-part series. In the first part, we talked about the unexpected change of the same payment rate for all brands of CTP sheets. In this part, we're going to talk about the exceptions to the CTP Medicare payment of $127.14 per square centimeter. And in the third part, we will talk about no Medicare payment for CTP wastage. All of these things are very, very important because many people have prepared for these changes, but a lot of people did not because they were believing that nothing was going to change. And I spent the last couple of years telling everybody you really do need to prepare to change. So I'm going to share those tips with you in this series. 
 
My name is Kathleen Schaum and I'm the founder and president of Kathleen D. Schaum & Associates, and I am honored to be here with you today. And so let's begin with the second part of the unexpected payment changes. And that unexpected part was the exception to the CTP Medicare payment rate of $127.14 per square centimeter. Now, because of that, you're going to have to refine your business model and your revenue cycle processes to account for these exceptions. Now, these exceptions may generate more revenue for you, or they may generate less revenue for you. So it's very important to understand that. 
 
Now, I am going to talk to you about that in relationship to the various providers. So first, let's talk about the physicians and the qualified healthcare professionals. As you know, I call those QHPs. And a QHP is a nurse practitioner, physician assistant, et cetera. And we're going to talk about the physicians and QHPs who purchase CTPs. Understand that they will not all receive the same Medicare payment rate for the product. As you know, the payment for physicians in QHPs is adjusted. And I'm talking about payment for anything is adjusted based on the Geographic Practice Cost Indicator, better known as GPCI. And for some reason, the physicians and QHPs did not realize that they were going to have an adjustment not only for the application, but also for the product itself. 
 
So the physicians and QHPs, of course, first read, "Oh, it's $127.14." Yes, but it's going to be adjusted by the GPCI. And so therefore, you could have a lower or a higher cost per square centimeter. So it's very, very important for you to know what your exact payment rate is going to be for your geographic area. And then you need to refine your formulary based on that, not necessarily based on the $127.14.
 
The other surprise that everybody didn't think about was that we have a lot of QHPs who do this work. Now, QHPs typically get paid 85% of the Medicare physician fee schedule allowable rate, but if those QHPs are purchasing the product or the claim is going in under their NPI number, then not only are they going to have an 85% adjustment in the application rate, they're going to have an 85% adjustment to the CTP. So those people who are doing that, and that business model may have to look at that very carefully and be very selective on the types of products that they use, because they definitely are going to be paid less than $127.14 in most of the geographical areas for the QHPs. 
 
Now, we also know for physicians in QHPs that Medicare is allowing the Medicare Administrative Contractors to pay for non-sheet CTPs. That has never been the case prior to 2026. However, the non-sheet CTPs will not be paid based on the $127.14 per square centimeter. Medicare has said that each Medicare Administrative Contractor will determine if the documentation of the medical necessity justifies the coverage of the non-sheet CTP. So first, you have to have the medical necessity for it, probably need to show some clinical evidence, have that documented in the medical record. 
 
Then we also know that physicians and QHPs cannot report the CTP application codes when you are applying non-sheet CTPs. So the 15271 and 15278 cannot be on your claim form. You cannot bill for it if you are going to bill for a non-sheet product. All right? The only thing that could be on that claim form is for whatever work you may have done that day, such as you may have an evaluation and management, you may have debrided the wound, et cetera, then indeed you would be able to report that code, but do not report 15271 and 15278 because those codes do not reflect the work that is used for a non-sheet product. Also, the MACs will have to determine not only if they're going to cover it, but they will also determine a payment rate brand by brand, product by product, if they cover it. 
 
So be very careful with the non-sheet products. It's good news that the Medicare said they would allow payment, but it really is in the hands of the MAC. But most importantly, it's in the hands of the provider to select products that have published evidence to prove that published evidence to document it in the medical record. And then of course, to work with their MAC to get paid an amount of money that would be equal or allow them to even afford to do that. 
 
Now, many people say to me, "Well, do these payment exceptions apply to the provider-based departments of the hospital that is hospital owned?" Now, we know that the hospital's cost to charge ratio adjust each PBD's Medicare allowable payment rate for the application of CTPs.
 
So what does that mean? Every hospital has a cost to charge ratio. And when you see what the national average rate is, that's just the national average rate. Every hospital has their own adjusted application rates. And even, for example, if you were in Houston, Texas where all of those hospitals are all very close to one another, most likely none of those hospitals get paid the same amount of money for the same code because they use their hospital's cost to charge ratio to adjust those application rates. And that does apply to the application of CTPs, but it does not apply to the $127.14 for the product. So all of the outpatient departments, the PBDs in the country, their base rate is $127.14 per square centimeter for the CTP. So it's not adjusted like the physicians is for GPCI. 

Now, we also know though that if a QHP qualified healthcare professional works in a PPD, yes, they're still going to have an adjusted rate of 85% of their application rate. And one big important thing, I just got done talking about the non-sheet products for the physicians and the QHPs. That's if they purchase them. But if indeed a physician wanted to apply that in a PBD, the PBDs are not allowed to have payment for the non-sheet CTPs. 
 
So let's talk about a summary of what we talked about. Physicians and QHPs who purchase CTPs will receive the geographic practice cost index adjustment for the product and for its application. And of course, the QHPs will continue to have an 85% of the GPCI Medicare adjusted rate for the CTP and its application if they purchase it. And physicians and QHPs can receive payment for non-sheet CTPs if the MAC covers the product, but the payment for each non-sheet CTP will be determined by each MAC and PBDs cannot get paid to apply non-sheet products.
 
With that, I want to thank you for allowing me to share tips for refining your business model and your revenue cycle processes to account for these exceptions to the CTP Medicare payment rate of $127.14 per square centimeter. And I hope you will stay tuned for part three of this series when I will discuss how to implement not reporting wastage on your Medicare claim forms. Thank you very much.

Kathleen D. Schaum is a reimbursement strategy and education consultant to the wound/ulcer management industry. She has over 50 years of experience training professionals, executives, sales representatives, and investors how services, procedures, and products are reimbursed in various places of service.