Overview
This episode covers Medicare’s forthcoming WISER program—prior authorization requirements for certain urologic procedures in select states—and discusses documentation and reimbursement for steerable suction catheters. The panel outlines regulatory, reimbursement, and workflow impacts, alongside practical advice for urology practitioners.
Thriving Urology Practice Facebook Group
- This is a free group for US-based urology teams to share information and support practice growth.
- Vendors are excluded to maintain a practitioner-focused, safe discussion space.
Medicare WISER Program (Wasteful and Inappropriate Service Reduction)
- WISER is a CMS demonstration project launching January 1, 2026, for six years in NJ, OK, OH, TX, AZ, and WA.
- It introduces prior authorization requirements for incontinence devices, sacral neuromodulation, and impotence devices under traditional Medicare.
- About 18.5% of US Medicare beneficiaries in these states will be affected, but not those with Medicare Advantage.
- Providers must obtain pre-service authorization from “model participants” or risk payment delays and post-service denials.
- Model participants (authorization entities) are incentivized financially to issue appropriate denials, potentially leading to care delays.
- AI and limited human review will be used for authorizations, and contractors have not yet been chosen.
- Prior authorization is voluntary, but non-participation means records must be reviewed before payment, thus delaying reimbursement.
- The program targets high-cost, high-volume procedures previously scrutinized by Recovery Audit Contractors (RACs).
- National and local coverage determinations (NCDs/LCDs) guide which services are included, but some (e.g., impotence treatments) have vague criteria.
Anticipated Impact and Concerns
- Documentation will become more burdensome; clear, thorough notes will be vital for both approval and appeals.
- There is concern about mismatch between specialty society guidelines and Medicare’s coverage policies.
- Potential exists for model participants and RACs to benefit financially at the expense of providers and patients.
- Uncertainty remains regarding payers’ interpretations and enforcement, especially around ambiguous coverage or new technology.
Catheters That Suck: Steerable Suction Catheter Coding
- C9761 is used for facilities performing procedures with steerable ureteral catheters, originally defined for devices like Kalixo.
- Documentation must state use of a steerable suction-assisted device and justify medical necessity.
- Definition of "steerable" is debated—newer catheters rely on the ureteroscope for steering, raising coding interpretation issues.
- Facilities should report device usage upfront; reimbursement risk lies mainly on the facility side.
- Ambiguity in definitions creates hesitancy and may limit patient access to effective stone removal technology.
Decisions
- Monitor for release of affected CPT codes and model participant lists.
- Increase documentation efforts for procedures requiring prior authorization under WISER.
Action Items
- Fall 2024 – All Providers in Targeted States: Review and prepare for new prior authorization processes by identifying relevant codes and model participants.
- Fall 2024 – Practices: Expand billing/prior auth teams as needed for affected services.
- Ongoing – Practitioners: Stay informed on LCDs, NCDs, and evolving documentation requirements.
- Ongoing – Urologists: Engage with specialty societies and advocacy organizations to influence policy and stay updated.
Recommendations / Advice
- Clearly document use and necessity of steerable suction devices in operative notes when using C9761.
- Prepare for possible increased denials; appeal inappropriate denials thoroughly.
- Understand NCDs/LCDs/LCAs relevant to your practice and monitor for updates.
- Participate actively in professional and advocacy groups to collectively address regulatory challenges.
- Consider personal and practice sustainability—focus on procedures and patient populations that bring professional fulfillment.