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Lab denials

  1. #1
    Default Lab denials
    Medical Coding Books
    We are getting denials for CPTs 84153, 84154, 84403, 88112, 81001 as provider not being certified. These are not CLIA waived tests. Any suggestions on this will be greatly appreciated.

  2. #2
    Seacoast- Dover New Hampshire
    I was told that codes that begin with 8 are suppose to have QW
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    I don't believe any of those codes would need the QW modifier but I would still make sure and submit the claim with your CLIA number on the claim
    Herbie W Lorona Jr., CPC, CPC-H

  4. Default Lab Denials
    Does your facility have a CLIA certificate? If they don't you can not bill for those services, the lab that performs the test must bill.

    If you do have a Waived CLIA certificate you can only bill for the test that are considered to be waived testing and is being performed at your facility. You can find a list of these tests in the CMS website, CLIA Waived Tests.

  5. #5
    Capital Coders, Columbia, SC
    You may want to check to see if these denials are coming from specific carriers. Some insurance companies (like Cigna) require some lab charges to be sent to their contracted lab. Therefore, if you attempt to bill them, they will be denied. You should be able to obtain the lab list from the carrier.

  6. #6
    You need to find out if you are recevieng denials for all insurances or just one in particular. Get in contact with the healthplan/s and find out excatly what the problem is. If someone in claims department is unabale to assist you get in contact with your provider rep.

    We had similar cases in our Arizona location were some providers were not allowed to bill specific codes becuase of their degrees. for examples NP's were not allowed to bill for ordered CT-Scans and PA's were restricted from billing some Lab codes.

    As far as the Modifier QW is concerned this modifier is only for CLIA waived test and you can find a list of codes that do require a QW modifier in the CMS website.

    I hope this helps.

    Marisela A. CPC

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