Audit: A pre- or post-payment review process used by Medicare or other payers to determine whether documentation supports medical necessity and coverage requirements. 

Cellular and/or Tissue-Based Products (CTPs): Often called “skin substitutes,” these products are used as an advanced treatment to augment closure of chronic wounds. Beginning in 2026, Medicare pays for most of these as incident-to supplies at a standardized rate.

CMS (Centers for Medicare & Medicaid Services): Federal agency that defines Medicare coverage, payment rules, and medical necessity standards. 

Current Procedural Terminology (CPT®) Codes: Five-digit codes published by the American Medical Association describing medical services and procedures performed by physicians and QHPs. 

Documentation: The complete medical record of what was done, why, when, where, and to whom; the foundation for coding, billing, compliance, and audit defense. 

Evaluation and Management (E&M) Services: CPT codes reflecting cognitive services for assessing and managing patient conditions; may only be billed with procedures when distinctly separate and properly documented. 

Healthcare Common Procedure Coding System (HCPCS) Codes: Codes describing products, supplies, and services not included in CPT, including skin substitutes and other wound care items. 

International Classification of Diseases, 10th Revision-Clinical Modification (ICD-10-CM): Diagnosis coding system used to classify patient conditions with high specificity; must align with documented findings. 

Incident-to Supply: Under the 2026 Physician Fee Schedule, most CTPs are reimbursed as supplies incident to a covered procedure rather than as separately paid biologics. 

Local Coverage Determination (LCD): Coverage policy developed by Medicare Administrative Contractors (MACs) outlining medical necessity and documentation requirements. 

Medical Necessity: Defined by CMS as services that are reasonable and necessary for diagnosis or treatment, appropriate for the patient’s condition, consistent with accepted standards, and expected to produce meaningful outcomes. 

Medicare Physician Fee Schedule (PFS): Annual CMS rule establishing physician payment policies, including the 2026 standardized CTP payment change. 

National Coverage Determination (NCD): National Medicare coverage policy that must be followed by all MACs and providers. 

Site of Service: The physical location where care is delivered (eg, hospital, skilled nursing facility, office, home), which affects documentation and billing rules. 

Standard of Care (SOC): Foundational wound management interventions that must be documented before escalation to advanced therapies. 

WISeR Model: 2026 CMS Innovation Center initiative focused on reducing wasteful and inappropriate services; includes heightened scrutiny of skin and tissue substitutes. 

Wastage (CTPs): Unused portions of skin substitutes, which are no longer reimbursed by Medicare under 2026 payment rules. 

Current Procedural Terminology is a Registered Trademark of the American Medical Association. CPT codes, descriptions and other data only are copyright 2025 American Medical Association. All rights reserved.