Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and the Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2026. The focus is on outpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the OIG or RAC compliance concern, the month and year published and added to the plan, and related coding and documentation requirements is included below. More importantly, for each outpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts.

The information below includes an analysis of the following active outpatient topics:

• Medicare Payments for Chronic Care Management Services (OIG)
• Spinal Cord Neurostimulation: Medical Necessity and Documentation Requirements (RAC)
• Annual Wellness Visit: Incrrect Coding (RAC)
• External Counterpulsation (ECP) Therapy for Severe Angina: Coverage Determination and Documentation Requirements (RAC)
• Wireless Capsule Endoscopy: Medical Necessity and Documentation Review (RAC)

Medicare Payments for Chronic Care Management Services

Announced March 2026

Chronic care management (CCM) is managing multiple (2 or more) chronic conditions that:

• Are expected to last at least 12 months or until death
• Place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline

Chronic care management codes are based on time per calendar month.

CCM services may be non-complex (at least 30 minutes per month) or complex (at least 60 minutes per month.

Example of chronic conditions include:

• Alzheimer’s
• COPD
• Hypertension
• Diabetes

Chronic Care Management Billing Guidelines:

• Prior to CCM services starting an initial face-to-face visit must be performed.
• An initiating face-to-face visit can be separately billed.
• You can’t report non-complex CCM and complex CCM for the same patient in a calendar month.
• You can’t report complex CCM and prolonged E/M services in the same calendar month.
• You can’t count time toward the CCM service code for any other billed code.
• You can report CCM codes for services provided during the 30-day transitional care management (TCM) service period.
• You can bill either remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM), but not both, concurrently with any CCM.
• Complex CCM services require and include moderate-to high-complexity medical decision-making.

Additional information on Chronic Care Management coding and billing requirements can be found in the Medicare Learning Network article: MLN909188 June 2025. Available at: https://www.cms.gov/files/document/chroniccaremanagement.pdf

Spinal Cord Neurostimulation: Medical Necessity and Documentation Requirements

Approved August, 2025

Dorsal Column (Spinal cord) stimulation involves surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space.

The implantation consists of two stages:

• The first stage contains an implantation of neurostimulator electrode(s) and a connection of an external neurostimulator.
• In some cases, temporary electrodes are used. It is a short trial to assess the patient’s suitability for ongoing treatment with a permanent surgically implanted nerve stimulator. If pain relief is achieved, the temporary system may be transitioned to a permanent system.
• The second stage involves subcutaneous insertion of a permanent neurostimulator with connection of the implanted electrode(s).

Documentation should include:

• Condition requiring procedure
• Physical evaluation
• Treatments tried and failed including but are not limited to:
• Spine surgery
• Physical therapy
• Medications
• Injections

Annual Wellness Visit: Incorrect Coding

Approved August, 2025

When practices perform initial preventative physical examinations (IPPEs) or annual wellness visits (AWVs), it’s essential to select the right code.

Medicare also has extremely specific timelines for these codes. For instance, both G0402 and G0439 are “once in a lifetime” codes, while G0439 can be reported every 12 months.

CMS has launched RAC audits to confirm that practices are reporting these services accurately and within the frequency guidelines

Initial Preventative Physical Examination (IPPE)

• HCPCS code G0402
• Within 12 months of Part B enrollment
• Covered once in a lifetime
• Review of medical and social health history
• Preventive services education

Annual Wellness Visit (AWV) Initial:

• HCPCS code G0438
• Personalized prevention plan (PPPS)
• May not be billed more than once in a lifetime
• Includes health risk assessment

Annual Wellness Visit (AWV) Subsequent:

• HCPCS code G0439
• Includes a personalized prevention plan (PPPS)
• Is covered once every 12 months
• Includes review and update of health risk assessment

Medicare Part B covers an AWV if performed by a:

• Physician (a doctor of medicine or osteopathy)
• Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)
• Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of medical professionals directly supervised by a physician (doctor of medicine or osteopathy)

Medicare waives both coinsurace or copayment and the Medicare Part B deductible for AWV.

Additional information on Annual Wellness Visit coding and billing requirements can be found on the Medicare Learning Network webpage. Available at: https://www.cms.gov/medicare/coverage/preventive-services/medicarewellness-visits/annual-wellness-visit

External Counterpulsation (ECP) Therapy for Severe Angina: Coverage Determination and Documentation Requirements

Approved March 2026

External counterpulsation (ECP) is a noninvasive treatment for coronary artery disease refractory to medical and/or surgical therapy. The Food and Drug Administration (FDA) has cleared ECP devices for use in unstable and stable angina pectoris, acute myocardial infarction, congestive heart failure and cardiogenic shock.

External counterpulsation involves the sequential compression (inflation/deflation) of cuffs wrapped around the patient’s calves, thighs, and buttocks. By timing the inflation/deflation sequence to the patient’s cardiac cycle, the intention of ECP is to increase diastolic aortic pressure, thereby increasing coronary perfusion pressure possibly by enhancing the development of coronary collateral circulation and reducing the workload of the heart.

Nationally Covered Indications:

Coverage is provided for the use of ECP for patients who have been diagnosed with disabling angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, because:

1. Their condition is inoperable, or at high risk of operative complications or postoperative failure;
2. Their coronary anatomy is not readily amenable to such procedures; or
3. They have co-morbid states which create excessive risk.

A full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, usually 5 days per week. The patient is placed on a treatment table where their lower trunk and lower extremities are wrapped in a series of three compressive air cuffs which inflate and deflate in synchronization with the patient’s cardiac cycle.

Nationally Non-Covered Indications:

All other cardiac conditions not otherwise specified as nationally covered for the use of ECP remain nationally non-covered

Wireless Capsule Endoscopy: Medical Necessity and Documentation Review

Approved March, 2026

Wireless capsule endoscopic (WCE) imaging is intended as an adjunctive tool in the detection of certain gastrointestinal (GI) conditions. This procedure requires that a patient ingest a small capsule containing a disposable light source, miniature color video camera, battery, antenna, and a data transmitter. The self-contained capsule is made of specially sealed biocompatible material that is resistant to the digestive fluids throughout the GI tract.

Following ingestion of the capsule, natural contraction and relaxation of the GI tract propels the camera forward. The camera contained in the capsule records images of the intestinal mucosa as it travels the length of the digestive system. wears a data recorder around the waist, which captures and stores the images transmitted by the capsule’s camera. After completion of the procedure, the patient data recorder is connected to a computer workstation where the images are downloaded, reviewed, and interpreted by the physician. The capsule is designed to be disposable and is excreted naturally from the body.

Indications for wireless capsule endoscopy:

• For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive fecal occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source;

• For evaluation of regional non-metastatic carcinoid tumors of the small bowel in persons with carcinoid syndrome;

• For evaluation of persons with celiac disease with a positive serology and negative biopsy;

• For re-evaluation of persons with celiac disease who remain symptomatic despite treatment and there is no suspected or confirmed GI obstruction, stricture, or fistulae;

• For initial diagnosis in persons with suspected Crohn’s disease (abdominal pain or diarrhea plus 1 or more signs of inflammation (e.g., fever, elevated white blood cell (WBC) count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel follow-through or abdominal computed tomography (CT) scan/CT enterography and upper and lower endoscopy (EGD and colonoscopy);

• For re-evaluation of persons with Crohn’s disease who remain symptomatic despite treatment and there is no suspected or confirmed GI obstruction, stricture, or fistulae;

• For surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel; or

• For screening or surveillance of esophageal varices.

Category III Codes

Category III codes are a set of temporary codes for emerging technology, services, procedures, and service paradigms. Category III codes allow data collection for these services/procedures. Use of unlisted codes does not offer the opportunity for the collection of specific data. If a Category III code is available, this code must be reported instead of a Category I unlisted code. The use of the codes in this section allows physicians and other qualified health care professionals, insurers, health services researchers, and health policy experts to identify emerging technology, services, procedures, and service paradigms for clinical efficacy, utilization and outcomes. Additional information on the use of Category III codes can be found in CPT Assistant, July 2011, Volume 21, Issue 7, page 14.

Cardiac Contractility Modulation (CCM) for Heart Failure (HF)

Cardiac Contractility Modulation (CCM) is an advanced therapy used to treat certain patients with Heart Failure (HF)—especially those who still have symptoms despite optimal medications but are not candidates for traditional device therapies like cardiac resynchronization.

CCM is a device-based treatment that improves the strength of heart muscle contractions without increasing oxygen demand significantly.

• It delivers non-excitatory electrical signals to the heart muscle during the absolute refractory period (when the heart cannot be re-stimulated to beat).
• These signals enhance calcium handling and gene expression in heart cells, improving contractility over time.

CCM is typically recommended for patients with:

• Moderate-to-severe HF symptoms (NYHA Class III or ambulatory Class IV)
• Left ventricular ejection fraction (LVEF) ~25–45%
• Normal or slightly prolonged QRS duration (not ideal for CRT)

Patient Eligibility Criteria (per NCD)

To qualify for coverage, patients must:

• Meet FDA-approved indications for CCM
• Have persistent symptoms despite ≥3 months of guideline-directed medical therapy (GDMT)
• Be evaluated by a heart team before implantation

Medicare will not cover CCM if the patient:

• Has contraindications per FDA labeling
• Has had a heart transplant
• Is under age 18

Suggested Compliance Activities for All Initiatives

1. Run reports, as applicable, to determine the frequency of these diagnoses and/or procedures.
2. Findings related to this data should be audited for documentation and coding accuracy.
3. Request and review any denials received for these diagnoses and/or procedures.
4. Conduct an audit to determine the accuracy of specific code assignments.
5. Assess and categorize the risk.
6. Calculate the error rate from the audit
7. If the error rate is greater than 5%, determine the type of error or if specific to a particular group or individual. Determine if additional case audit is needed.
8. Develop an action plan to address a high error rate, that may include one or more of the following:
9. Correct erroneous claims
10. Provide physician education on documentation requirements
11. Implement EHR revisions and reminders
12. Establish a timeframe for a follow up audit to assess effectiveness of corrective action(s)

Works Cited

Office of Inspector General (OIG). Work Plan. Available at: https://oig.hhs.gov/reports/work-plan/

Centers for Medicare & Medicaid Services (CMS). Approved RAC Topics. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD): Electrical Nerve Stimulators (160.7). Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=240&ncdver=1

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD): External Counterpulsation (ECP) Therapy for Severe Angina. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=97&ncdver=2

Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L33774). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33774&ver=15