PRIA's Summary of the new WISeR Model Provider & Supplier Operational Guide from CMS

Our Summary of the Guide

1. CPT and ICD-10 Codes Identifying WISeR Services

• The WISeR model lists specific CPT, HCPCS, and ICD-10 codes (see Appendices A–C) that define the items and services subject to prior authorization or pre-payment medical review.
• These codes correspond to procedures like Vagus Nerve Stimulation (VNS), Cervical Fusion, Epidural Steroid Injections, and Percutaneous Vertebral Augmentation, among others.
• Appendix A identifies covered procedures and CPT/HCPCS codes; Appendix C lists related ICD-10 diagnostic indications. These collectively determine which services fall under WISeR oversight.

2. Refined focus for initial roll out of WISeR

• Deep Brain Stimulation (DBS) is explicitly excluded from WISeR’s initial phase, as its CPT codes (e.g., 61867, 61868) remain on Medicare’s inpatient-only list. CMS intends to re-evaluate DBS for possible future inclusion.
• NCD 160.1 will initially focus on nerolytic destruction of the trigeminal nerve
• NCD 160.7 will initially focus on spinal cord stimulators but will not overlap with CPT codes for spinal neurostimulators. Prior Authorization be being implemented for the permanent implantation procedure.
• NCD 230.10 will initially focus on mechanical/hydraulic incontinence control devices for the purposes of treating Stress Urinary Incontinence (SUI).
• NCD 230.18 Prior authorization is being implemented for the permanent, not trial, implantation procedure
• NCD 230.4 initially will implement prior authorization for the insertion of penile prostheses
• L39741, L39758, L39793 will initially focus on CPT codes 22554 and 22585

3. Model Participants and Submission Methods

• WISeR participants are six organizations contracted by CMS in six pilot states (AZ, NJ, OH, OK, TX, WA).
• Although participants are identified by state, their specific company names are not yet announced.
• These participants—and their associated Medicare Administrative Contractors (MACs)—will accept prior authorization requests and supporting documentation via fax, mail, esMD (Electronic Submission of Medical Documentation), or electronic portals.

4. CMS/CMMI Authority to Expand WISeR

• CMS, through the Center for Medicare & Medicaid Innovation (CMMI), has authority under Section 1115A of the Social Security Act to expand the WISeR model to additional services or therapeutic areas during the initial phase.
• This flexibility allows CMS to add or adjust covered procedures and codes to address new technologies or emerging areas of waste, fraud, and abuse without legislative action.

5. Settings of Care (POS Codes)

• WISeR applies only to specific settings of care, identified by Place of Service (POS) codes:
• 11 – Office
• 12 – Home
• 19 & 22 – Hospital Outpatient Department
• 24 – Ambulatory Surgery Center (ASC)
• These settings define where prior authorization and pre-payment review processes apply. Inpatient services are excluded.

Link to full document on CMS.gov

Notable future events:

AMA Webinar - Wed, Oct. 22   – Registration open to the public 

PRIA WISeR Operations Webinar – Week of Nov. 10^th