Why the Same Square Centimeter Pays $109 in Arkansas
CMS announced one national skin substitute rate of $127.28 per square centimeter and then filed it as 3.81 practice expense RVUs. That makes it two rates before geography and 78 after it, running from $109.31 to $183.51 across the 109 Medicare localities. On a 100 square centimeter application the supply line is 98% of the allowed amount, and CMS has already written down the year that money starts moving everyone else's practice expense RVUs.
Every wound care practice in the country has the same number written on a whiteboard somewhere: $127.28 per square centimeter, the single national rate CMS finalized for skin substitutes in the CY 2026 physician fee schedule.
We went looking for that number in the fee schedule file. It isn't there.
"If CMS finalized one national rate, why does the relative value file carry a practice expense RVU instead of a price?"
The answer runs through the whole code family, and it decides what a graft is worth in your locality, what happens to it when the conversion factor moves, and which pool of money it comes out of starting in 2028.
A Rate That Isn't a Price
Here is the mechanic, straight from the final rule at 90 FR 49266: "For CY 2026, the PE and MP RVUs would result in an initial payment rate of approximately $127.28/cm2 (prior to the application of the geographic adjustments)."
CMS did not publish a fee. It published relative value units and let the standard formula produce the fee.
Pull the July 2026 relative value file and every sheet skin substitute code, A2001 through A2045 and the Q4101 series, carries the same line: status A, work RVU 0.00, non-facility practice expense RVU 3.81, malpractice RVU 0.00, global ZZZ. The rule says PE and MP. The file assigns all of it to practice expense.
So the payment for a square centimeter of graft is 3.81 x PE GPCI x conversion factor, and nothing else.
Run it at the non-qualifying conversion factor the file carries, $33.4009, and you get $127.26. Run it at the qualifying APM participant factor of $33.5675 and you get $127.89.
One announced rate, $0.63 apart before anyone applies a geographic index, because APM status splits the conversion factor and the conversion factor is half the formula.
The rounding costs something too. CMS finalized $127.28, which implies 3.81068 RVUs, and the file carries RVUs to two decimals.
So everyone bills against $127.26, two cents light. That is $2 on a 100 square centimeter wound and real money at the volumes this code family moves.
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