OIG Work Plan 2027: Wound Care Audit Priorities and Prep

OIG Work Plan 2027: What Wound Care Practices Are Facing This Fiscal Year

The OIG's fiscal year 2027 Work Plan takes effect October 1, 2026. For wound care practices, the shift from FY2026 to FY2027 is not a clean break — it is a continuation and escalation of audit scrutiny that has defined the past two years. OIG Work Plan 2027 priorities for wound care build on the skin substitute compliance crackdown, debridement coding complexity, and NPWT oversight that dominated FY2026. If you treated Medicare patients in 2026, your claims are within the audit lookback window, and the new fiscal year brings fresh OIG resources aimed at the same high-dollar categories.

The OIG does not publish its Work Plan as a single document dropped on October 1. Items are added throughout the fiscal year as audits and evaluations are initiated. But the pattern over recent years is clear: wound care billing — particularly skin substitutes, excisional debridement, and NPWT — generates outsized Medicare expenditures relative to patient volume, and that ratio draws disproportionate OIG attention.

Why Skin Substitute Billing Tops the FY2027 Audit List

CMS restructured skin substitute reimbursement in 2026, replacing individual Q-code product pricing with a single flat rate of $127.14 per square centimeter for products on the covered product list. That change was meant to reduce the financial incentive to apply the most expensive product rather than the most clinically appropriate one. It also created a new compliance landscape that the OIG is positioned to examine during FY2027.

Under the Q-code model, the primary audit risk was billing for high-cost products without adequate medical necessity documentation. Under the flat-rate model, the risk profile shifts. The OIG's focus can be expected to target:

Wound size accuracy — the billed square centimeter total must match the documented wound dimensions. The math must be in the note. Claims with no documented measurements, or where the documented dimensions do not support the billed area, create a straightforward discrepancy.
Wound type eligibility — the flat rate applies only to wounds that meet the applicable LCD criteria. Applying and billing a skin substitute on a wound that does not meet the coverage indications — regardless of how well documented the visit is — can result in recoupment.
Application frequency — most MAC LCDs cap the number of applications within a defined treatment period. Billing applications beyond the allowed frequency without documented exceptional clinical justification flags the claim.
Product list compliance — not every skin substitute qualifies for the flat-rate payment. Billing the flat rate for a product that has not been assigned to the covered product list results in noncovered charges.

The skin substitute billing guide provides the documentation framework tied specifically to the 2026 flat-rate model, including the measurement requirements and frequency rules by MAC jurisdiction.

Debridement Coding: The Perennial High-Risk Category

Debridement is the highest-volume wound care service billed to Medicare Part B, and it has appeared in OIG audit reports and RAC target lists every year for more than a decade. FY2027 continues that pattern. The coding hierarchy itself — from selective debridement (CPT 97597, 97598) through subcutaneous tissue excision (CPT 11042, add-on 11045) up to muscle/fascia (CPT 11043, add-on 11046) and bone (CPT 11044) — creates legitimate variation between coders, which also provides cover for upcoding.

The OIG's established pattern on debridement targets three specific failure modes:

Tissue type mismatch. The code billed must reflect the deepest tissue type debrided. A note that records removal of slough and eschar without specifying what anatomical layer was reached cannot support a subcutaneous tissue debridement code. If the note does not say it, the code cannot support it.

Missing wound dimensions. The add-on codes for excisional debridement (11045, 11046) apply for each additional 20 sq cm of wound area. That calculation must appear in the note. Claims billed for large areas without documented measurements that support the total are a direct audit trigger.

Unsupported code levels. Billing CPT 11043 (muscle/fascia debridement) or 11044 (bone debridement) requires documentation that muscle, fascia, or bone was actually encountered and debrided — not just that the wound was deep. Staging or depth estimates alone do not satisfy this requirement.

What the Debridement Note Must Establish

For every debridement claim to withstand audit review, the documentation should include: wound type and confirmed etiology; the specific tissue type debrided at its deepest layer; wound dimensions with the area calculation showing how the billed total was reached; the clinical rationale for debridement at this visit (not a template phrase); and the post-debridement wound bed status.

The wound care LCD compliance guide maps these documentation requirements to the specific MAC LCDs that govern debridement coverage in each jurisdiction.

NPWT Billing: The DME Split Remains a High-Risk Zone

Negative pressure wound therapy billing carries a persistent audit risk tied to the billing model split. When a DME company supplies an NPWT pump and bills Medicare for rental equipment, the wound care clinician cannot also bill CPT 97607 or 97608 for the same patient and wound on the same date. These codes are for clinician-applied disposable devices only. Billing them when a DME company is the equipment supplier constitutes double-billing regardless of intent.

The OIG targets this pattern because the data analysis is straightforward. Medicare claims data can identify cases where both a DME supplier and a physician/clinician billed for NPWT on the same beneficiary within the same period. When that overlap appears, it generates a referral — to the RAC, to a MAC's Targeted Probe and Educate program, or to the UPIC — without the OIG needing to review individual charts first.

Secondary NPWT audit targets in FY2027 include billing without a documented face-to-face evaluation establishing medical necessity, applying NPWT at a frequency exceeding what the applicable LCD allows, and billing the disposable device codes for reusable pump equipment.

Telehealth Wound Assessments: An Emerging FY2027 Review Category

Telehealth wound care services expanded rapidly during the COVID-19 public health emergency and have maintained a partial presence in wound care billing since. CMS has extended and in some cases permanently incorporated select telehealth flexibilities, but that expansion has also created a new audit exposure.

The OIG is examining whether telehealth wound assessments are billed at E/M levels appropriate to a telehealth encounter — where physical palpation, probing, and direct wound measurement are not possible — and whether the required telehealth modifier (modifier -95 for synchronous audio-video, or modifier -93 for audio-only where permitted) is correctly applied. Missing modifiers on telehealth claims generate automated claim edits and flag the practice for further review.

Telehealth wound assessments can support follow-up evaluation and treatment adjustment between in-person visits, but they should not be billed at the same E/M level as an encounter that includes hands-on wound assessment and procedure performance.

Key Takeaways

OIG Work Plan 2027 audit priorities for wound care continue the pattern set in FY2026: skin substitute billing, debridement coding, and NPWT model separation are the top three risk categories.
The 2026 CMS skin substitute flat-rate change shifts audit risk toward wound measurement accuracy, product list eligibility, and application frequency rather than product-level billing.
Every debridement claim at the excisional level requires documented tissue type, wound dimensions, and an area calculation that supports the billed code — missing any of these creates an unsupported claim.
NPWT billing risk concentrates in the DME vs. physician-applied split — confirm which billing model is active for each NPWT patient before submitting claims.
Telehealth wound assessments require the correct modifier and an E/M level appropriate to a remote encounter; billing them at the same level as in-person procedure visits is an emerging OIG concern.
Run a focused internal audit on 20–30 charts per clinician each quarter using the billing compliance audit process, updated for the FY2027 risk profile.
If you receive an audit request, the wound care audit appeal process guide covers the response framework from the initial ADR letter through ALJ appeal.