CMS targets two new enforcement areas. Is your practice ready?

In early May 2026, a federal oversight report landed quietly in the health care community. No names were named. No charges were filed. But its findings carried unmistakable weight: Roughly one-fifth of Medicare Part B spending on peripheral vascular procedures performed in office-based laboratories (OBLs) in 2023 — approximately $105 million — may have been medically unnecessary. The agency that produced the report, the U.S. Department of Health and Human Services Office of Inspector General (OIG), handed its findings directly to the U.S. Centers for Medicare & Medicaid Services (CMS) and asked for active follow-up. CMS agreed.

Within weeks, recovery audit contractors (RACs) expanded their audit targets to include selective catheter placement procedures across the same specialty. Two enforcement streams, converging simultaneously on the same set of practitioners. For vascular surgeons, interventional cardiologists and interventional radiologists operating in the OBL setting, this is not a background compliance concern. It is a present-tense enforcement environment.

What the OIG found

The OIG report analyzed Medicare Part B payments for peripheral vascular procedures — angioplasty, stenting and atherectomy — performed to treat peripheral artery disease. Over the five-year study period ending in 2023, total procedure volume and Part B payments declined. But the site of care shifted substantially toward OBLs, physician-owned outpatient procedural facilities where vascular interventions are performed outside the hospital setting. Physician reimbursement in OBLs is meaningfully higher than in hospital outpatient departments.

In 2023, Medicare paid approximately $548 million for peripheral vascular procedures performed in OBLs. Of that, the OIG identified $105 million as potentially unnecessary — concentrated in 139 physicians who accounted for 7% of the total OBL-based vascular billing pool. There were 26 physicians responsible for 61% of the flagged payments, averaging around $3 million each in Medicare reimbursement. They treated more than four times the average number of Medicare patients and performed double the average number of procedures per patient.

Two procedure categories drew particular concern. OBL physicians performed 75% of all atherectomies and 47% of all tibial artery procedures in 2023 — both clinically controversial procedure types with documented complication risks. The OIG's conclusion is not subtle: A financial incentive structure has, in a meaningful subset of cases, overridden clinical judgment about when intervention is warranted.

The OIG was careful in its language, noting that determining whether specific physicians engaged in fraudulent or abusive practice was outside the report's scope. But its finding that certain billing patterns "warrant further scrutiny" is as close to a warning shot as federal oversight language gets without a formal referral to the U.S. Department of Justice.

Why this is bigger than 139 physicians

It would be tempting to read this report as narrowly targeting a small cluster of outliers. That reading is probably wrong.

The OIG's methodology was statistical, not clinical. The 139 flagged physicians were identified through outlier analysis — high procedure volume, high per-patient procedure rates and heavy use of clinically controversial procedures. No chart review was conducted. The 139 are the statistical tail of a distribution that, by definition, has a body. They are the starting point for targeted enforcement, not the outer boundary of the problem.

The structural incentive that produced these patterns has not been changed. The payment differential between OBL settings and hospital outpatient departments is large and well documented, and has been the subject of policy concern for years. The OIG report recommends monitoring, not payment redesign — leaving the underlying incentive architecture intact. Practices whose billing patterns fall within the statistical range that generated the 139 flagged physicians are, by definition, within the scope of the monitoring now under way.

This report also did not emerge in isolation. A 2023 ProPublica investigation documented how high Medicare reimbursements for office-based vascular procedures had fueled a surge of interventions that put patients at risk of amputation or death. The OIG began its analysis in April 2024, cited that reporting, and broadly corroborated its findings. The lag between journalism and federal response is itself instructive: Enforcement has not kept pace with the problem's scope. That gap is now being closed.

It’s not just a specialist problem

Primary care physicians should also pay attention to these developments. Many patients with peripheral artery disease, diabetes-related vascular complications, and lower-extremity symptoms first present in primary care settings. Because federal scrutiny is increasingly focused on whether conservative treatment was appropriately attempted before intervention, documentation generated in the primary care setting may play an important role in supporting medical necessity when patients are referred for vascular procedures.

RAC auditors have expanded the target zone

Concurrent with the OIG report's release, RACs added selective catheter placement to their active audit priorities — specifically Current Procedural Terminology (CPT) 36247 (selective catheter placement, arterial system, third order or more selective) and CPT 37229 (endovascular revascularization, tibial/peroneal artery, with transluminal angioplasty). These codes are frequently billed alongside OIG-flagged peripheral vascular procedure codes. A practice that performs office-based vascular interventions now faces scrutiny from two separate enforcement directions simultaneously.

As Medical Economics has previously reported, audit risks from cardiology and vascular codes carry unique exposure because CMS contractors often apply local coverage determination criteria inconsistently, making documentation precision more critical — not less — than in other specialties.

RAC reviewers examining these claims will focus on medical necessity documentation, catheter selectivity verification (for CPT 36247, does the operative and imaging record confirm third-order or higher selectivity?), bundling compliance and clinical indication for diagnostic angiograms and embolizations co-billed with interventional codes.

The enforcement consequences have already moved beyond the theoretical. Shortly after the OIG report's release, a vascular practice agreed to pay more than $6.73 million to settle False Claims Act allegations related to unnecessary vascular interventional procedures.

What physicians should do now

The statistical triggers that produced the 139 flagged physicians are known. Physicians whose practice patterns approach any of these thresholds should act before auditors do.

Medical necessity documentation is the highest-priority vulnerability. For every peripheral vascular procedure billed under Medicare, the record must establish that conservative management — medication optimization, supervised exercise therapy, lifestyle modification — was attempted and documented before intervention. Documentation that skips or underrepresents conservative treatment history is the single most significant exposure point in an OBL vascular practice.

For CPT 36247, operative reports and imaging must clearly confirm third-order or higher catheter selectivity. Upcoding catheter placement levels is a documented audit trigger. A systematic review of co-billed code combinations — particularly CPT 36247 and 37229 alongside interventional procedure codes — should be conducted to verify bundling compliance.

Procedure volume, per-patient procedure rates and procedure mix should be benchmarked against CMS utilization data for comparable specialty and geography. If a practice's ratios fall significantly above peer norms — particularly for atherectomy and tibial interventions — that indicates heightened audit risk regardless of clinical intent.

For practice leaders and health systems employing OBL-based vascular specialists, the exposure is shared. As Medical Economics has noted, building a culture of compliance — including internal audits, staff training and documented policies — is not only best practice but also a material mitigating factor if a government auditor does arrive.

The takeaway

The federal government has documented a significant program integrity problem in office-based vascular care, handed CMS a specific list of physicians for follow-up and expanded RAC audit targets into adjacent procedure codes — all in a political environment where health care waste reduction is an explicit administration priority. The specialty societies, for their part, have publicly aligned with OIG's goals rather than defending high-volume OBL billing as a protected clinical prerogative. That signal matters.

The question for every vascular physician and OBL operator billing under Medicare Part B is not whether enhanced scrutiny is coming. The question is whether your documentation, billing patterns and compliance posture are ready for it.

Elina Sabilova, CPC, CFPC, CPMA, is a billing and compliance specialist in the Billing Department at WCH Service Bureau, a nationwide medical billing, credentialing and compliance firm. As supervisor of revenue cycle management at WCH Service Bureau, she oversees complex billing operations for high-volume specialty practices, ensuring accurate reimbursement while maintaining strict compliance with federal, state, payer, American Medical Association and Society of Interventional Radiology guidelines.