A claim routed to WISeR for an out-of-scope wound is a payment-delay problem. The claim is being sent to a reviewer that should not be deciding its medical necessity, and it remains suspended until the review is dismissed and returned to the MAC for ordinary Medicare processing.
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Get the editable WISeR ADR Prepayment Response template.
Request the letter Arclight prepared for claims that may be outside the model's diagnosis-limited scope.
How to spot an out-of-scope ADR
A WISeR ADR may identify a Medicare claim, name a WISeR contractor, request the familiar wound-care record, and give the practice 45 calendar days to respond. Yet the claim may concern a pressure ulcer of the buttock, sacrum, or another non-lower-extremity wound. The procedure code 15271 may apply to the trunk, arms, or legs, while the diagnosis pointers confirm that the product was not applied to a diabetic foot ulcer or venous leg ulcer.
While that routing error is sorted out, payment is delayed.
What WISeR is supposed to review
CMS explains that certain skin-substitute procedure codes are narrowed by an ICD-10 list in the WISeR operational guide. When a claim does not carry a diagnosis from that list, CMS says it is out of scope and will not be included in WISeR. The operational guide describes dismissal as the expected disposition. A dismissed request is not reviewed for medical necessity.
How to respond
- Start with the claim line. Confirm the procedure and HCPCS codes, diagnosis pointers, ICD-10 descriptions, and wound site documented in the encounter and procedure notes.
- Match the record to the claim. Identify the wound actually treated and explain whether any other wound in the chart is unrelated to the billed application.
- Submit a timely, focused packet. Include the ADR, relevant claim detail, encounter or procedure note, and a signed addendum if needed to clarify site or treatment.
- Ask for the actual disposition. Request an out-of-scope dismissal, notice to the MAC, and written confirmation that the claim will return to ordinary Medicare processing.
- Require a specific answer if the reviewer disagrees. Ask for the ICD-10 code and CMS policy provision claimed to place the service within WISeR.
The next practical step
Arclight has prepared an editable cover-letter template for practices that receive a WISeR ADR on a skin-substitute claim that may be outside the model's diagnosis-limited scope.