Description of Calculation of CY 2026 Payment Rates for Skin Substitutes
"1. Use the list of HCPCS codes in the spreadsheet containing skin substitute products by FDA regulatory category, using the regulatory categories identified in the proposed rule[1]."
2. Define a 4th quarter 2024 payment rate for each HCPCS code from a hierarchy of these data sources:
a.  Identify the quarterly 2024 Average Sales Price (ASP) payment limits from CMS ASP Pricing Files.[2]  Calculate HCPCS code-specific payment amounts as the ASP payment limits divided by 1.06.
"b. For HCPCS codes without a quarterly 2024 payment amount in the ASP Pricing File, use the 2026 OPPS MUC (geometric mean cost) data (based on 2024 claims) for the HCPCS code[3]"
"3. Extract unit counts from Medicare Part B OPPS-paid fee-for-service claims for the 4th quarter 2024. Utilize OPPS outpatient facility claims with a claim type 40 and bill type 12, 13, or 14.  Exclude denied claims and claim-level allowed amount ? 0."
"4. Calculate the weighted average rate for the 4th quarter of 2024, separately for 361 HCT/P, 510(k), and PMA, using the 4th quarter payment rates derived at the HCPCS level from Step 2, weighted by the unit volume at the HCPCS level derived in Step 3. The maximum of these three average rates will be used."



[1] Available at https://www.cms.gov/files/zip/cy-2026-pfs-final-rule-skin-substitute-products.zip 
[2] Available at https://www.cms.gov/medicare/payment/part-b-drugs/asp-pricing-files
"[3] Just as the NPRM file ""2026 NPRM Drug Blood and Brachy Cost Statistics File.07.15.2025.xlsx"" was available at https://www.cms.gov/files/zip/2026-nprm-opps-cost-statistics-files.zip, the final rule OPPS file will be available at https://www.cms.gov/files/zip/2026-nfrm-opps-cost-statistics-files.zip  after the publication of the CY 2026 OPPS final rule."
