Internal Medicine Coding Alert
Remember Modifiers on CLIA-Waived Tests
Question: An established Medicare patient complain-ing of sore throat reported to the internist, who ordered a rapid strep test after a level two E/M. (We have a Clinical Laboratory Improvement Act [CLIA] waiver.) The test was positive for streptococcus A; the internist prescribed oral antibiotics and sent the patient home. I reported 87780 and 99212, and got a denial. What went wrong? Maine Subscriber Answer: The claim was likely denied because you forgot to append modifier QW (CLIA-waived test) to the strep test code. Modifier QW alerts Medicare that you have CLIA waived status; submit a claim without QW on CLIA-waived tests, and expect denials. When you resubmit the claim, report the following: • 87880-QW (Infectious agent detection by immunoassay with direct optical observation; streptococcus, group A]) for the strep test • 041.01 (Streptococcus; group A) appended to 87880 to represent the patient's strep • 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision making) for the E/M • 462 (Acute pharyngitis) appended to 99212 to represent the patient's presenting symptom. Don't forget: In addition to appending modifier QW, be sure to write your CLIA waiver number in item 23 of the CMS-1500 form.
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