If anyone will be at HCCA’s regional conference next week in Alaska, I will be there speaking about e/m changes. Please come say hey if you are there.
My presentation is: “Code Breakers: Navigating Key Changes in CMS Evaluation & Management Services and Coding”
Speaker: Knicole C. Emanuel
Healthcare Compliance: Intermediate
I plan to: 1. Present common legal arguments to defend against alleged overpayments; 2. Clarify significant CMS E/M coding and documentation changes from 2021 through the upcoming 2025 updates, including new telemedicine codes; and Offer guidance and practical strategies to ensure compliance with these changes, optimize reimbursement, and reduce risk of overpayments.
Back to today’s blog… In CMS’ constant attempt to conquer fraud, waste, and abuse, CMS launched the WISeR (Wasteful and Inappropriate Service Reduction) Model and it began Jan. 1, 2026, using technology-enabled prior authorization for a set of items/services that CMS believes are vulnerable to fraud/waste. It’s currently limited to six states, Texas, Arizona, Washington, New Jersey, Ohio, and Oklahoma. Implementation details/operational steps are spelled out in CMS model materials. This matters for providers because it changes front-end billing workflows (documentation, ordering, timing, and appeals posture) for impacted services and sites of care.
The WISeR model reportedly is aimed to combat fraud and will employ private companies to test if AI can handle the prior authorization process used to determine if a recipient of Original Medicare is eligible for funding for a health service. The model will specifically look at services that CMS considers to be “particularly vulnerable to fraud, waste, and abuse.” If you operate in WISeR states, treat it like a new “mini-utilization management” layer for Original Medicare—build a same-day documentation/PA packet process and track denial reasons from day one.
What services are included in the new initial phase of the Wiser program? My list here is not comprehensive.
1) Nerve stimulator implants and neuromodulation. These are high-cost implantable or invasive neurostimulation procedures:
For example, Electrical nerve stimulators (NCD 160.7)
Sacral nerve stimulation for urinary incontinence (NCD 230.18)
Phrenic nerve stimulator (NCD 160.19)
Deep brain stimulation (Parkinson’s disease, essential tremor) (NCD 160.24)
Vagus nerve stimulation (NCD 160.18)
These alone hit neurology, neurosurgery, urology, and pain management heavily.
2) Pain management procedures (major audit risk area)
These are some of the most targeted pain interventions nationwide:
Epidural steroid injections, Induced lesions of nerve tracts, Percutaneous image-guided lumbar decompression, Arthroscopic lavage and debridement for osteoarthritic knee.
These services are heavily utilized and frequently audited by UPIC, RAC, and MAC contractors already.
3) Spine and orthopedic surgery procedures
Major spine and orthopedic procedures now subject to WISeR prior authorization: Cervical fusion procedures (excluding certain OPD-covered codes), Lumbar decompression procedures, and Vertebral augmentation procedures.
This is significant because these are high-value, high-volume services with large reimbursement exposure.
4) Sleep apnea implant procedures
Specifically targeted: Hypoglossal nerve stimulation for obstructive sleep apnea.
This is a rapidly growing implant procedure with aggressive utilization growth.
5) Urology and genitourinary procedures/devices
Includes: Incontinence control devices (NCD 230.10) and Diagnosis and treatment of impotence (NCD 230.4).
These involve implantable devices and surgical interventions.
6) Wound care: skin substitutes and tissue products (VERY important)
This is one of the most heavily targeted areas—and one that I frequently litigate:
Bioengineered skin substitutes for chronic wounds, Cellular and tissue-based products (CTPs) and Skin and tissue substitute applications to lower extremity wounds
These products have been the subject of massive UPIC and DOJ enforcement actions already.
Why CMS chose these services (and why providers should be concerned)
CMS explicitly states the model targets services that are: “known source of potential waste… vulnerable to fraud, waste, and abuse… costly, elective services.”
The services are High-cost, Elective or non-emergent, Vulnerable to fraud or overuse, Already subject to coverage criteria (NCDs/LCDs), and Frequently audited or denied historically.
Critical legal implication most providers miss, if providers do NOT submit prior authorization:
Their claim will automatically be flagged, Subject to pre-payment medical review, Potentially denied before payment, Or delayed significantly.
This effectively creates de facto mandatory prior authorization, even though CMS calls it “voluntary.”
Based on CMS selection criteria and historical audit targets, future WISeR additions will likely include:
- Genetic testing
- DMEPOS (orthotics, braces, power wheelchairs)
- Advanced imaging
- Interventional pain procedures
- Behavioral health services
- Additional wound care products
CMS confirmed it will expand services over time.
WISeR currently applies to:
- Physician groups
- Hospitals
- Ambulatory surgery centers
- Pain management clinics
- Wound care providers
- Spine surgeons
- Device-implanting specialists
I would love to hear from providers located in the six states in which WISeR has been implemented. Is WISeR really wiser?