Looking Ahead in 2026: How CTP Regulatory Changes Are Making Waves

As CTP oversight intensifies heading into 2026, practices are discovering that the most significant changes aren’t just about reimbursement—they’re about proof. This Q&A explores how data-driven medical necessity, tighter operational controls, and smarter clinical decision-making are redefining compliance, sustainability, and success in advanced wound care.

Key Takeaways

1. CTP use has shifted from volume-driven reimbursement to data-driven medical necessity. 
Recent regulatory changes are less about headline reimbursement cuts and more about enforcing long-standing expectations: rigorous documentation of standard-of-care (SOC) execution, clear demonstration of failure, and tight alignment with LCD pre-application criteria. Programs like WISeR will accelerate this shift through increased ADRs and front-end scrutiny, making defensible documentation the primary determinant of payment and compliance. 

2. Practice sustainability now depends on tighter operational controls and true margin awareness. 
CTPs are now treated as incident-to supplies under the MPFS, with geographic rate variation, NP payment reductions, and no reimbursement for wastage. Practices that historically relied on CTP revenue to subsidize operations must pivot—tracking margins by case, refining service areas, adjusting staffing models, and proactively managing revenue cycle risk rather than reacting to denials or audits after the fact. 

3. The greatest optimization opportunity lies in smarter clinical decision-making supported by technology and human expertise. 
Aligning the timing of advanced therapies with SOC progression improves both outcomes and defensibility. AI and digital tools can meaningfully reduce administrative burden—flagging missing documentation, automating verification, and tracking denial patterns—but they cannot replace clinical judgment. The winning model blends automation with human oversight, ensuring practices “treat the patient, not the numbers,” while staying audit-ready and financially sustainable. 

To truly understand “what’s changed,” it’s important to first acknowledge that there is a tremendous amount of misinformation regarding these changes that needs clarification. The industry has been reacting to headlines (specifically, to the recent reimbursement rate changes for CTPs) while potentially missing the operational and compliance changes that will from now on drive real-world, patient-focused outcomes. The industry has essentially moved to a data-driven utilization model where practices will succeed (and stay out of trouble) based on how well they can prove medical necessity. By the way, this is not a “new reality,” in fact, this was always the intended design of our healthcare system. The focus of advanced wound care has been to demonstrate that relevant and meaningful standard of care (SOC) was properly executed and failed on a non-healing wound (or, in the example of a post-surgical acute wound - to justify why SOC was not attempted) prior to moving to an advanced modality such as a skin substitute. Practices must consistently meet standards of conservative care and monitor/control influencing comorbidities. This is the required pre-application criteria for any CTP treatment. Unfortunately, many have not adequately met the required standards, simply because there was an intention to use a CTP from admission. 

We feel that programs like WISeR (in the states where it's applicable) will accelerate this shift to focus on medical necessity and evidence of properly executed SOC, because they are designed to pay special attention to the exact LCD requirements – specifically the detailed pre-application criteria (not just the application event itself). In practical terms, we will see more ADRs (requests for additional documentation) prior to claim payments, which will be tied directly to the documentation of quality execution of care. 

The biggest changes to coding, billing, and reimbursement of CTPs for providers is that now providers need to understand that CTPs are now considered a supply/incident-to the procedure: 

• Payment for CTPs is now aligned with the MPFS (Medicare Physician Fee Schedule) payment model. Rates vary geographically¹; it is not “one flat rate of 127 everywhere.” It will be important to check local rates to understand full allowable payments. 

• Under the MPFS schedule, nurse practitioner payments are subject to 85% of allowable. They must consider this in their business plans. 

• Since the codes are now considered “incident-to” supplies, wastage expectations have changed. Medicare no longer pays for wastage² and practices must align billing behavior accordingly. 

Practices that previously leaned heavily on CTP-driven income, or that used CTP income to subsidize the rest of the business, will need to pivot toward broader wound-care service lines, have tighter internal control, and focus on metrics that connect care delivery. This is the moment where practices should stop guessing and start utilizing a proactive protection model, with specific systems developed to monitor Key Performance Indicator metrics, curtailing coverage verification, documentation readiness, payer policy (not just Medicare LCD alignment), and denial pattern recognition. In other words, expert reimbursement and business tracking support is very much needed and should be sought to prevent audit exposure and protect revenue proactively, rather than trying to “appeal” after the fact. 

At a local level, providers will feel immediate impact in their practice relative to revenue cycle, and clinical workflow areas. Once providers start tracking true margins by patient/case, many will realize some patients are financially draining the operation, forcing tough decisions, especially for many practices in the mobile wound care space that were relying on CTP reimbursement for subsidizing their business model. Practices will need to reprioritize by tightening service areas, adjusting staffing, and being more selective with high-complexity patients, and those patients with deep histories of not adhering to clinical recommendations. In the past, regardless of these recent policy changes, once practices have developed more sophisticated measurement standards and methods (usually with the help of a revenue management professional), they have identified these same detriments whose impact will only now be exponentially amplified.

Relating to policy, the WISeR model introduces prior authorization administrative pressure in the limited states where it is applied to CTPs. The need for prior authorization will increase front-end revenue cycle management (RCM) workload (verification, requirements check, documentation readiness). The highest-leverage response will be to prioritize proactive controls prior to claim submission: for example, a documentation QA/scrubbing process, staff training for policy interpretation. I would encourage leveraging expert support so that potential denials are prevented and, should they occur, recovery is much cleaner and streamlined. 

I believe that the clinical area would carry the greatest opportunity: better alignment between standard-of-care progression and the timing of advanced modality utilization. Instead of volume chasing, optimization would shift the focus on the best clinical and financial outcome per case, and not just "maximum CTP use." This requires strong policy interpretation, documentation QA/scrubbing, and advanced payer intelligence such as understanding denial patterns. This would thereby enable practices to confidently say: we utilized this therapy appropriately. Questioning as to whether an advanced therapy is truly needed now, and why, supports clinical appropriateness and makes defending payment easier. 

It is well worth mentioning that workflow improvement is also very important at this time. Efficiency in time management will be critical for practices, particularly mobile wound care providers. Decisions should be guided by properly developed metrics, and practices could standardize documentation and implement QA checks to tighten feedback loops between clinical, billing, and compliance. The initial focus of many mobile practices might be on increasing the number of daily visits and reducing drive time. However, these types of reductions in service areas or even likely foregoing more sparsely populated areas all together, can potentially create de facto care delivery deserts in rural communities. Instead, there is a real opportunity to focus on providing better care and spending more time per patient and getting paid appropriately for that time and care. Providers can either see a higher volume of patients at a lower reimbursement per patient, or lower volume at a higher per-patient return. Finally, from the financial (payer) perspective, there is also an important opportunity to negotiate managed care contracts and improve payment rates, aligned to the patient population being treated.

There is a huge emergence of tools today, some embedded in EMR systems, and some peripheral add-ons, that can, for example, flag missing medical necessity elements before submission. This is a big win in our industry and makes things more efficient, having less re-work and saving very important and precious time. It is imperative that we recognize AI’s limits and understand that our reliable friend “Dr. ChatGPT” does not truly have critical thinking skills. These AI tools would have a hard time, for example, justifying why SOC is being bypassed in an acute wound that is eligible for a CTP. Artificial intelligence (AI) has utility, but overreliance can be very problematic. Specifically, the use of AI cannot preclude proper execution of care in compliance with policy. 

Use of AI in our space is critical, important, and quite arguably even medically necessary. Use of AI is excellent for things like insurance verification automation, gathering and analyzing payer and billing intelligence data, and denial and approval pattern tracking. Understanding this, it is of utmost importance to remember that the human brain must stay engaged when caring for the patient, such that we continue to treat the patient and not the numbers. 

If we were to narrow recommendations down to one piece of advice, it would be to make audit preparedness your true priority and use products that are supported by evidence. It is clear today that a large recoupment from an expansive audit can trigger financial damage that is potentially unrepairable. Specifically, this recommendation would be to pressure-test your practice as if an audit is already underway. If a provider is not fully confident that they could defend their cases under rigorous scrutiny, it behooves the provider to bring in expert reimbursement/compliance support to validate, stress-test, and harden processes well beyond what a generic checklist from a colleague or vendor can offer. 

• For example, one wise action would be reviewing a sample of recent and typical CTP cases and grading them against payer policies/LCD requirements and the WISeR model. It is especially important to determine how well they demonstrate pre- application candidacy criteria. This will help to identify which cases are high-risk and why. 

• Another recommendation is confirming that records clearly show that standard of care was fully and appropriately attempted with demonstrated failure (not implied). Outlining the details of SOC and demonstrating why advanced therapy is explicitly supported creates defensibility. 

• Documentation QA before submission: Practices can implement a pre-bill QA/scrubbing workflow that flags missing medical-necessity elements before claims go out, reducing denials and ADR vulnerability. 

• AI + human oversight: Use automation where it excels (verification, payer data, pattern tracking), while keeping human expertise focused on clinical rationale and nuance—so you continue to, previously mentioned, treat the patient, not the numbers. 

This approach materially reduces the chance that an audit becomes an event that jeopardizes the entire practice and more importantly, improves patient outcomes. 

John Garrettson currently holds the position of Partner with GR Strategic Advisors and Health Policy Advisor with RMBB. Mr. Garrettson serves clinical practices, manufacturers and distributers as a contracted industry consultant. Whereby, his expertise is utilized to devise revenue cycle improvements, reimbursement/market access strategies, financial value propositions, and product commercialization platforms. He also contributes in conceptualizing, developing and improving product designs for the medical device industry.

1. Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule Federal Regulation Notice: CMS-1832-F. CMS; published November 5, 2025. Accessed January 26, 2026. https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1832-f

2. Centers for Medicare & Medicaid Services. Discarded drugs and biologicals—JW modifier and JZ modifier policy: frequently asked questions. Updated December 22, 2025. Centers for Medicare & Medicaid Services. Accessed January 26, 2026.