QW modifier - CLIA waived Test

All clinical laboratory improvement amendments (CLIA) of 1988 require all testing sites to have one of the following certificates to perform clinical laboratory testing:

1. Certificate of Waiver
2. Certificate of Accreditation
3. Certificate of Registration
4. Certificate of Physician-Performed Microscopy

Each CLIA certificate allows the lab to perform certain tests. Two CLIA certificates prevent holders to certain test proedures: Certificate of Waiver (1) and Certificate of Physician-Performed Microscopy (4).

If a service that is a performed by the Lab is not covered under your CLIA certificate you can not bill the patient for this service and these codes will be billed with Modifier QW. The claim must also have the correct CLIA number on the claim to be billed.

Current Waived Tests under CLIA

• 83001QW Genosis Fertell Female Fertility Test
• 84443QW Jant Pharmacal Accutest TSH {Whole Blood}
• 86308QW Signify Mono Whole Blood
• 86308QW Clearview MONO Whole Blood
• 82465QW Cholestech LDX (Lipid Profile - ALT (GPT)){Whole Blood}
• 83718QW Cholestech LDX (Lipid Profile - ALT (GPT)){Whole Blood}
• 84460QW Cholestech LDX (Lipid Profile - ALT (GPT)){Whole Blood}
• 80061QW Cholestech LDX (Lipid Profile - ALT (GPT)){Whole Blood}
• 84478QW Cholestech LDX (Lipid Profile - ALT (GPT)){Whole Blood}
• 86318QW Immunostics Detector H. Pylori WB (H. pyloi Antibody Test) {Whole Blood}
• 86308QW Immuno Detector Mono {Whole Blood}
• 80101QW Innovacon Multi-Clin Drug Screen Test Device
• 80101QW Jant Pharmacal Accutest MultiDrug ER11 Drug Screen Test Device
• 87880QW Cardinal Health SP Brand Rapid Test Strep A Dipstick(K010582/A028)
• 86318QW Cardinal Health SP Brand Rapid Test H. pylori {Whole Blood}(K024350/A15
• 82042QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82310QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82565QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82947QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82950QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82951QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 82952QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 84520QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 1) {Whole Blood}
• 86308QW Cardinal Health SP Brand Rapid Test Mono {Whole Blood}
• 882247QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 2) {Whole Blood}
• 84075QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 2) {Whole Blood}
• 84157QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 2) {Whole Blood}
• 84450QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 2) {Whole Blood}
• 84460QW Arkay SPOTCHEM EZ Chemistry Analyer (Spotchem II Basicpanel 2) {Whole Blood}
• 86318QW Fisher Healthcare Sure-Vue H. pylori Test {Whole Blood}
• 89321QW Fertell Male Fertility Test

Medicare will identify this list of codes as waived tests and they do not require a QW modifier: 81002, 81025, 82270, 82272, G0394, 82962, 83026, 84830, 85013, and 85651

For a complete detailed list please copy this link and add it to the google toolbar:

wps.medicare.com/providers/pdfs/clia_tests.pdf

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CR Modifier in use with Hurricane Katrina Victims & future disasters

The CR Modifier code was initially created for Hurricane Katrina victims but will stay in use for Future Disasters. Using the CR modifier tells Medicare that you attempted to retain the patients existing health care records, current health status and/or verification of the patients Medicare or Medicaid Benefits.

If, by chance the patient did not have Medicare benefits Medicare states they will pay out to the provider on these claims unless they identify fraud or abuse by the medical practice.


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How quickly does NPPES update crosswalk

Scenario: Office is submitting claims and gets rejections M340, M379, M341, M380, M343, M381, M347, or M382 which are all NPI error messages from Medicare. These files are deleted by Medicare at the EDI department. (or if your state is not deleting them you will be told it's informational meaning you should fix this issue as soon as possible but Medicare will still process your claim)

The office will get Prepass reports from Medicare that state informational somewhere on the report along with the words file is deleted (these are not good things). This can mean several things:
1. The provider is not listed on the crosswalk
*Use this information to Validate a Providers NPI number

2. The provider is listed in NPPES however; the claims are not transmitting with the correct NPI#'s in the right areas of the electronic claims
* call your practice management software or reference documentation to identify the following fields in your software that corresponds with the correct Loop #.

Billing Provider level (2010AA)- M340 & M379
Pay To Provider level (2010AB) - M341 & M380
Rendering Provider level (2310B) - M343 & M381
Rendering Provider level (2420A) - M347 & M382

To contact NPPES:
The NPI Enumerator is responsible for assisting health care providers in applying for their NPIs and updating their information in NPPES.
1-800-465-3203 (NPI Toll-Free) 1-800-692-2326 (NPI TTY)
customerservice@npienumerator.com
NPI EnumeratorPO Box 6059Fargo, ND 58108-6059

Updates to the providers NPI #'s through NPPES can take from 8-10 days.


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Are you getting deleted claims from Medicare?

Most states are now starting to "delete" Medicare claims at the EDI level for invalid NPI crosswalks. It is extremely important to read your Carrier Forwarded Reports from Medicare to identify if your office is having these issues.

Medicare can delete your claims for the following reasons:

* Billing Provider level (2010AA) - M340 & M379
* Pay to Provider level (2010AB) - M341 & M380
* Rendering Provider level (2310B) - M343 & M381
* Rendering Provider level (2420A) - M347 & M382

Edits M340, M341, M343, and M347 occur when the NPI submitted with legacy number does not match the crosswalk; that is the NPI legacy is not on the crosswalk or is invalid.

Edits M379, M380, M381, and M382 will fail if you are sending NPI only and the NPI is not on the crosswalk or you are sending an EIN/SSN with the incorrect qualifier.

This is not a software vendor issue but if you need help with setting up your carrier correctly you may contact your practice management software support department for assistance. Mainly you will need to identify what fields in your practice management software relate to Loop(s) 2010AA, 2010AB, 2310B, and 2420A.


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How to bill for referring providers that do not have a NPI number?

If you find referring providers that are no longer accepting Medicare or are becoming Cash Pay only offices you can still bill with the referring provider information if you have that referring providers Legacy (UPIN) number.

Medicare is still accepting up to May 23 2008 the use of Legacy numbers on referring providers. It will become at some point mandatory for all physicians to register and maintain a NPI (national provider indicator) number.

Physician's who have decided that they do not want to become participating providers with Medicare will still be required to register for a NPI #. It's free and it will become mandatory so it's best to do it soon.

For additional Medicare documentation on this subject you can reference CR 5529.

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Can a provider register for a NPI number without having a license?

In order for a physician to apply for a National Provider Identifier # the physician will need to have a license to practice in one of the states. If the provider does not have a license they will not be able to apply for a NPI#.

To check for a provider or referring providers NPI# please visit:
https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind

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Medicare Secondary claims to be submitted electronically

Medicare Secondary Payor claims must be submitted electronically to Medicare unless your office fits the following exceptions:


*Small Provider with 9 or fewer full time employees
* Roster billing of mass immunizations covered by Medicare
* Claims for payment under Medicare demonstration projects when information is required that cannot be submitted electronically
* Claims where Medicare is the tertiary payer to two (or more) primary payers; e.g., Medicare is the third payer (not to be confused with claims where Medicare is the secondary payer)
* Dental claims to Medicare.


Remember when submitting claims electronically to Medicare or other insurance carriers your office will need to be well versed on Medicare claim adjustment Reason Codes.

I would suggest that you visit one of my other blogs that details these steps in full: Medicare Insurance Claim Adjustment Reason Codes


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If your office has any questions on MSP codes please post a log and I would be happy to assist.

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Remittance Advice Remark Codes crosswalk

If your office is receiving Medicare electronic explanations of benefits (EOB's) you may need to identify the meanings to specific Remittance Advice Remark Codes.

Copy the website and paste it in your toolbar on a new webpage: wpc-edi.com/codes/remittanceadvice
1. Down arrow and select Currently Valid Codes
2. Review the codes you are in need of a few samples are:

M1 - X-ray not taken within the past 12 months or near enough to the start of treatment.
M2 - Not paid separately when the patient is an inpatient.
M3 - Equipment is the same or similar to equipment already being used.
M4 - Alert: This is the last monthly installment payment for this durable medical equipment.Note: (Modified 4/1/07)
M5 - Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.
M6 - Alert: You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for every 6 month period after the end of the 15th paid rental month or the end of the warranty period.Note: (Modified 4/1/07)

These codes were valid as of last update on 8/1/07. Each quarter these codes are revised so please validate the most current valid codes through the above website.

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How to validate Referring Provider National Provider Indicator (NPI#)

The National Plan & Provider Enumeration System has recently released a website for medical practices to use to verify provider's NPI#. This website is extremely easy to use and will help medical offices identify providers NPI#'s without having to call the doctor directly.

1. Pull up this website: https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind
2. Enter in the providers or referring providers NPI#
*You can choose to enter in the following information
3. Provider First Name
4. Provider Last Name
5. Practice Address City
6. Practice Address State
7. Practice Address Zip Code

Click Search and you will receive the following information:
Organization Information
Authorized Official Information (office contact information)
NPI Information:
Provider Business Mailing Address including phone and fax #
Provider Business Practice Location Address including phone and fax #
Organization Taxonomy: What taxonomy #'s to use when billing claims
Other Provider Identifier: Unique ID#'s for Medicare, BCBS and possibly other state carriers

Click Back to results to begin search again.

*If NPI# is not known complete steps 3-7 and click search results.


To read more about Medicare updates including Billing Health Insurance Information check out Medicare Medical Coding and Billing Courses

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How to Validate your medical providers NPI numbers

Copy the following link and add it to the above Google Search to pull up this website in a new window: barrydebruin.com/php.npi/ to validate your medical providers National Provider Identifier (NPI) number. This is also helpful to validate Referring Provider NPI#'s.

If for any reason you do not have access to the internet and you need to validate the NPI# manually you can follow the following steps:

NPI #'s are generated using the Luhn formula so that the final digit can be derived by performing mathematical operations on the first 9.

NPI Check Digit Calculation:
The NPI # format consists of ten digits (9 numerics followed by 1 numeric check digit). The National Provider Identifier check digit is calculated using the Luhn formula. Example of Check Digit Calculation for NPI: Assume the 9-position identifier part of the NPI# is 123456789. Using the Luhn formula on the identifier portion, the check digit is calculated as shown below. NPI # without the check digit: 1 2 3 4 5 6 7 8 9
Step 1:
Double the value of alternate digits, beginning with the rightmost digit. Therefore, you would start with the first digit and double every other number.2 6 10 14 18
Step 2:
Add 24, plus the individual digits of products of doubling (shown in blue from step 1), plus unaffected digits from the original NPI.
24 + 2 + 2 + 6 + 4 + 1 + 0 + 6 + 1 + 4 + 8 + 1 + 8 = 67
Step 3:
Subtract the final product (from step 2) from the next higher number ending in zero.
70 – 67 = 3Check digit = 3NPI with check digit = 1234567893

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