Pain Management Coding Alert

Published on Mon Jul 04, 2016 PDF

Question: Our practice recently received its clinical laboratory improvement amendments (CLIA) waived certification. I’m a little mystified on how it will change things from a coding perspective. Can you help?

Montana Subscriber

Answer: For practices, the CLIA waiver will open up new revenue streams, as your providers will be able to perform some tests that are often the exclusive purview of laboratories. For coders, the CLIA waiver means that you will need to learn a new modifier in order to report these services correctly.

The basics: A CLIA waiver means that your office is permitted to perform certain tests, which require very little lab experience and pose low risk to the patient if performed incorrectly. Most of these tests involve one step, such as handling a urine dipstick.

For a list of all the CLIA-waived tests, go to: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf.

Modifier: You’ll use informational modifier QW (CLIA waived test) on lab service codes that are on the CLIA list of tests waived from regulatory oversight by Medicare. Any time your practice performs in-office lab services, you need to know whether you should add a modifier to your claim.

Example: Your physician orders a non-instrumented drug screening. If your practice is CLIA-waived certified, you will report G0477 (Drug test[s], presumptive, any number of drug classes; any number of devices or procedures, [e.g., immunoassay] capable of being read by direct optical observation only [e.g., dipsticks, cups, cards, cartridges], includes sample validation when performed, per date of service) with modifier QW appended. If your practice has a waiver and you neglect QW, you’re likely in for a denial dealing with your qualifications to perform the test.

Practices with a CLIA certificate of compliance or accreditation can perform non-waived tests and should not append modifier QW with those tests.

Also, you can’t code with modifier QW if the test or test kit are not waived. If the test and kit are waived, Medicare can still deny the lab test claims if you do not attach QW to the test code. Using modifier QW doesn’t change the actual amount you get reimbursed, but if you forget the modifier, you may not get paid at all.