Inpatient Facility Coding & Compliance Alert

Question: Our Medicare contractor is denying payment for 89321, whether we’re billing for inpatient or outpatient, and whether or not we use modifier QW. Why aren’t our claims paid?

Illinois Subscriber

Answer: The place of service (inpatient or outpatient) shouldn’t impact billing for 89321 (Semen analysis; sperm presence and motility of sperm, if performed). The question doesn’t provide enough information to know for sure why your Medicare contractor is denying the claim. However, the denials are probably due to coverage issues.

You should use modifier QW (CLIA waived test) with 89321 only if your lab operates under a CLIA certificate of waiver and you’re performing a test on the CLIA waived list, such as SpermCheck Vasectomy by Princeton BioMeditech Corp or Fertell Male Fertility Test by Genosis, Ltd.

Also, the test is indicated as a post–vasectomy semen test, usually performed 12 to 14 weeks after the procedure to confirm a successful surgery. Perhaps you are not reporting the appropriate diagnosis code to show medical necessity for the test, such as V25.8 (Other specified contraceptive management, postvasectomy sperm count). You shouldn’t use this diagnosis code for sperm count following sterilization reversal or sperm count for fertility testing.

Also, be sure to check for any local coverage decisions (LCDs) from your Medicare administrative contractor.