MLN Matters Article 12093 Outlines Use of CLIA Waiver Modifier for Two Codes

On December 23, 2020, CMS issued MLN Matters Article MM12093, Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 87811 and 87428 (PDF, 179 KB). Providers are reminded that while the MLN Matters article has an effective date of October 6, 2020, each of these codes has separate effective dates for use of the modifier QW as noted below. Additionally, the MLN Matters Article lists an implementation date of April 5, 2021. This means that the CMS claim processing system used by all Medicare Administrative Contractors (MACs), the Multi-Carrier System (MCS), will not be able to accept the modifier QW on these two codes until April 5, 2021.

MACs will not search files to either retract payment for claims already paid or to retroactively pay claims. However, MACs will adjust claims that are brought to their attention through the claim reopening process.  Reopening requests may not be requested until April 5. 2021. Providers may choose to hold new claims for these two services until April 5, 2021, or after. Please note the effective date of service for each code, indicating the date modifier QW may be used with each code.

CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare and Medicaid only pay for laboratory tests in a facility with a valid, current CLIA certificate, laboratory claims are currently edited at the CLIA certificate level.

• The use of code 87811 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver is permitted with dates of service on or after October 6, 2020
• The use of code 87428 QW for claims submitted by facilities with a valid, current CLIA certificate of waiver is permitted with dates of service on or after November 10, 2020