Wiki CLIA Denials (QW)

Create Wiki Sort by votes
N

nneecole44

Guru
Messages
105
Best answers
0
Starting 10-1-25 anything that will bill Medicare Part B for with a QW gets a CO-87 denial (Contractual Obligations- This provider was not certified/eligable to be paid for this procedure/service on this date of service.) OutrCLIA certificate of waiver is current. We called Medicare and of course they are very vague. The lady laughed when I asked about this. She said a lot of people are calling about this. Yet, she can't tell me why. The only thing she could say was each denial has to be appealed and our CLIA certificate uploaded for each one. We have 40 so far. Frustrating. I have left messages with my local CLIA branch. Waiting for that call back. I appreciate any help. Denials on the following:
85610
87880
83036
87804
87811

Thank you!!
 
0
Neecole44
What are the dx codes linking to each lab CPT code? If it is the first dx starting with Z dx ..that s wrong. I can tell you what I use according to what provider searching or dx code given for when pt treated that day using these lab codes linked dx. It is not inclusive dx code list probably more disease.
CPT 85610 use possible dx R79.1 or cardiac dx code.
CPT 83036 use possible dx R73.9 or R73.03 or E11.9
CPT 87811 use COVID dx or Resp dx J98.8, Z11.52 but if lab test positive for Covid use U07 dx
I hope this helps you somewhat
Lady T
 
0
Thank you for your response. I finally got an answer today. I called WPS back and asked to speak to a supervisor. I was told Medicare is doing a nationwide audit of clia wavied lab tests. Basically anything with the modifier QW. She said it could last 6 months or a year. They only just started. We have to appeal each one and upload our CLIA certificate for documentation. Eeeek.
 
0
And then I get this Medicare email this morning with different CLIA information. It just gets deeper. LOL.


2: Denied Laboratory Services and Clinical Laboratory Improvement Amendments (CLIA)



We have been receiving calls from providers regarding denials for laboratory services. Upon research we’ve found these denials are due to issues with the laboratory CLIA certificate.



Your CLIA certificate specifies your laboratory specialties and subspecialties, outlining the tests you are authorized to perform and bill for. These specialties align with the testing scope approved under your CLIA certification and do not require annual renewal.



If Medicare indicates a specialty is terminated, it may be due to a retired specialty code or a discrepancy between your CLIA and Provider Enrollment, Chain and Ownership System (PECOS) record. To resolve this, confirm your current specialties with your state CLIA office and update your CLIA and Medicare enrollment records.

  • Contact your CLIA agency for assistance. You may need to submit a revised CMS Form 116.
  • Once your CLIA certificate is updated, submit an enrollment update through PECOS using form CMS-855B or CMS-855I to ensure Medicare reflects your current CLIA information.
 
0
We are having the same issue with 80307, G0480, G0481, G0482 and G0483.
Have you made any progress on the CMS Form 116? If so, what? Did you have to resubmit your 116?
 
0
No progress yet. Our office manager called CLIA again and got a different answer. She told him they were told today it was a error on the Medicare side. She said to resubmit claims in a week or two. I will keep this updated.
 
You must log in or register to reply here.
Top