Wiki Modifier QW Question

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andersona1229

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I posted this question previously and thought I had found my answer so I deleted it like a dummy. However, I didn't so I wanted to ask again.

I work at an independent laboratory that has a CoA CLIA and does urine tox, some molecular testing, and some blood testing. One of our Medicaid payers began partially denying claims for CPTs lacking modifier QW. I called them about it and they said that all CLIA waived tests require modifier QW and a phone rep who works at said payer and "recently obtained her CPC" (I use quotes because I can't confirm if she actually has or not) said that everyone needs to use modifier QW. My understanding for modifier QW is that the only CLIA levels who need to use modifier QW are labs with CoW or PPMP certificate. Furthermore, that it was only for specific test systems instead of a blanket QW for all test systems for the given CPT.

All of the research I've done has been very unclear about it. I have MLN Matters and payer policies stating that it's only for CoW and PMPP certificate level labs. I have others saying that all waived testing requires modifier QW but not giving specific information on if there is CLIA level involvement or not. We have no other payers that require modifier QW and we have never been asked to use modifier QW on these tests before.

Should we be using modifier QW on all of our waived tests even though we have a CoA and/or the test system isn't on the waived list? Is it possible that the payer has the wrong CLIA certificate level for us and we just need to update that? I'm confused and any help will be welcome. Thank you!

EDIT: Context & words
 
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I am a newly certified coder so don't quote me on this but I was under the impression that modifier QW was only required for CoW or PPMP certificates as well. Maybe this is a payer specific requirement. Appending modifier QW to any CLIA waived tests that requires it is not a bad coding practice however. The QW simply signifies to the the payer that your laboratory has met the clinical laboratory testing requirements to be certified by the Secretary of the Department of Health and Human Services (DHHS) to perform this level of testing. For a list of CLIA waived tests you could consult: https://www.cdc.gov/clia/docs/tests-granted-waived-status-under-clia.pdf or the FDA CLIA database, not sure if this helps. I'm not sure if this helps. :)
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p18cgoodridge said:
I am a newly certified coder so don't quote me on this but I was under the impression that modifier QW was only required for CoW or PPMP certificates as well. Maybe this is a payer specific requirement. Appending modifier QW to any CLIA waived tests that requires it is not a bad coding practice however. The QW simply signifies to the the payer that your laboratory has met the clinical laboratory testing requirements to be certified by the Secretary of the Department of Health and Human Services (DHHS) to perform this level of testing. For a list of CLIA waived tests you could consult: https://www.cdc.gov/clia/docs/tests-granted-waived-status-under-clia.pdf or the FDA CLIA database, not sure if this helps. I'm not sure if this helps. :)
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Okay, so I'm not going crazy. I got my CPB back in June and that's what I read too. You went to the same sources I did so it's nice to know I read them correctly. I'm leaning on the side that they have the wrong CLIA level in their system and need to update it to the correct. This payer updated their system back in March '23 and they had so many glitches was ridiculous. We had same claims reprocessed three times for various processing issues on their end including one where their system wasn't reading anybody's CLIA certificates and was denying them all.

The issue with the modifier QW is I would have to ask the lab which specific manufacturer and I probably wouldn't get an answer. Considering it's only one payer we'll probably take the L on this one and move on. Thank you so much for getting back to me and confirming that I'm not out of my mind.

ETA: Also, howdy fellow CT neighbor!
 
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