WISeR Model 

October WISeR Updates: Coding, Documentation, and Review Tips—Plus Gold Card & Portal Updates

Leveraging precise procedure codes, diagnosis codes, modifiers, and units is essential for streamlining prior authorization reviews and minimizing delays under the WISeR initiative. Washington State physicians, providers, and suppliers can improve the efficiency and accuracy of their workflows by adhering to these guidelines:

• Specify Procedure Details: Clearly indicate the injection level(s), laterality (right, left, or bilateral), and number of levels treated for epidural steroid injections (ESIs) in orders and documentation. This ensures timely, accurate review and may reduce follow-up requests or delays.
• Ensure Accurate Coding: Use correct procedure codes, required modifiers, matching units, and submit primary and add-on codes together. Include all relevant diagnosis codes, including associated ones, for prior authorization requests.
• Follow Coding Best Practices: Always submit primary and add-on codes together for ESIs and kyphoplasty/vertebroplasty; never submit add-on codes alone. For hypoglossal nerve stimulation (HGNS), include qualifying sleep apnea and BMI codes. For malignant vertebral compression fractures, provide both fracture and malignancy diagnosis codes.
• Submit Complete Documentation: Include all records needed to show medical necessity and meet Medicare criteria, including National and Local Coverage Determinations, and related articles. Ensure submissions are complete, legible, and organized to help facilitate efficient review.

For additional information regarding coverage requirements, please refer to the selected NCDs and LCDs as part of Medicare coverage criteria, or reach out to our WISeR support team for additional guidance.

Program Announcements

The latest providers and suppliers who have achieved Gold Card status have been announced. Providers with an average affirmation rate of 80% or higher were notified of their exemption status on September 1, 2026. With Gold Card status, facilities can submit claims without a UTN or prior authorization by including the provider’s NPI in the appropriate claim field. For guidance, see section 5 (page 23) of the WISeR Provider and Supplier Operational Guide.

Effective January 1, 2027, the threshold will be increased to 90%. The original 80% threshold was established to allow providers sufficient time to become acclimated with Medicare requirements for these procedures. As providers now have a solid understanding of these requirements, we’ll align our threshold with the industry standard rate in 2027. For more information, review the Gold Card Fact Sheet. 

Technology Updates 

The WISeR Provider Portal now includes Google Places API integration, allowing for quicker and more accurate address entry in the beneficiary, facility, and provider information sections. As you type, the system now suggests verified addresses in real time, reducing manual entry errors, minimizing duplicate records, and streamlining your workflow from start to finish. Visit the WISeR Provider Portal to learn more.

Clinical Insights

The following definitions outline the key determinations used in the WISeR initiative. Understanding these terms is essential for physicians, providers, suppliers, and beneficiaries to navigate the requirements and outcomes associated with Medicare prior authorization requests, such as:

• Provisional Affirmation: A preliminary approval issued when a prior authorization request for a WISeR Select Item or Service includes all required information, pertains to eligible parties, and meets applicable Medicare coverage criteria.
• Non-Affirmation: A preliminary decision indicating that, despite complete and eligible submission, a prior authorization request does not meet Medicare coverage criteria or lacks adequate clinical documentation. It’s important to note: this is not a denial of care, and providers may resubmit within 120 days.
• Dismissal: The rejection of a prior authorization request due to missing, invalid, or out-of-scope information, preventing the request from being processed.