Pediatric Coding Alert

Question: Do I need to use modifier QW on all lab tests? Louisiana Subscriber  

Answer: You need HCPCS level-II modifier QW (CLIA waived test) on tests that qualify as both waived (simple) and nonwaived (moderately or highly complex). When a test is eligible for waived status only, you do not need a modifier to denote that you are performing a waived test. Pediatric-performed waived tests that do not require modifier QW, per CMS, include: 81002 -- Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81025 -- Urine pregnancy test, by visual color comparison methods 82270 and 82272 -- Blood, occult, by peroxidase activity (e.g., guaiac), qualitative ... 82962 -- Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 83026 -- Hemoglobin; by copper sulfate method, non-automated 85013 -- Blood count; spun microhematocrit. But when a test falls under both waived and nonwaived status, you may have to use modifier QW to indicate you are performing the test's waived version. Without the modifier, the "carrier says, 'This account isn't registered as a moderate-complexity lab under CLIA, but they're trying to bill us for a moderate-complexity test' and the claim is denied," says Sheila Dunn, MD, head of Quality American Inc., an Asheville, N.C.-based consulting firm, in "Check Your Knowledge of CLIA-Waived Tests" (Repertoire, March 2002). Two in-office pediatric examples of CLIA-waived tests that require QW include tests for influenza and strep. When reporting in-office waived versions of these tests to insurers that use QW, you should enter QW in the modifier field after the test code, for instance 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza) and 87880 (Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A). To check if you're using a test's waived version, look for the test name on the "List of Waived Tests" available from www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp#TopOfPage. If you do not find a test name, verify that your office is using a nonwaived test and has the required accreditation. In this case, you should not use QW on the corresponding CPT code.