Internal Medicine Coding Alert

Question: Our practice recently received a certificate of waiver from the Centers for Medicare and Medicaid Services (CMS), so we can now administer tests under the Clinical Laboratory Improvement Amendments (CLIA). What pregnancy tests can we now perform, and how do we go about reporting them?  

Mississippi Subscriber

Answer: When a practice receives a CLIA waiver, CMS allows it to administer tests that, in CMS's words, "the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) have determined to be so simple that there is little risk of error." (See https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Certificate_of_-Waiver_Laboratory_Project.html for more information on the project).

With a CLIA waiver, your practice can now perform several pregnancy tests, including 81025 (Urine pregnancy test, by visual color comparison methods) and 84703 (Gonadotropin, chorionic (hCG); qualitative). But you need to follow several steps to accurately document their use:

1. Report the appropriate CPT^® test code.
2. Append the procedure code with HCPCS modifier -QW (CLIA waived test) when needed. Coding alert: Some tests, like 81025, do not require the modifier. For a full list of CLIA-waived tests, including those that require the QW modifier, go to https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf
3. Link the CPT^® code to the ICD-10 diagnosis code. In the case of pregnancy testing, this would mean using Z32.00 (Encounter for pregnancy test, result unknown), Z32.01 (Encounter for pregnancy test, result positive), or Z32.02 (Encounter for pregnancy test, result negative).
4. Record your CLIA number on the claim form.

In addition to administering pregnancy tests, your office can now also administer up to 100 other tests in-house, including lipid profiles, drug tests, and urine tests for a number of diseases. If you are billing Medicare for the test, however, you should check with your Medicare Administrative Contractor (MAC) beforehand for full claims instructions.

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