QW Modifier applies to the services when the Physician performs CLIA waived test. This article covers a complete description of Modifier QW and when to use it.
QW Modifier Description
QW Modifier appends with Physician performs CLIA-waived (Clinical Laboratory Improvement Amendments) test.
Laboratory procedure testing is regulated through CLIA by the Centers for Medicare & Medicaid Services (CMS). The primary purpose of CLIA testing is to enhance the quality of laboratory and pathology procedure codes. The CLIA may need specialized certification for the facility to perform specific tests.
CLIA has particular protocols to follow when the Physician performs even one test, including waived tests on materials obtained from the human body to prevent or treat any disease. The impairment of information for the diagnosis or the assessment of the health of human beings to meet specific federal requirements.
The QW modifier must append to the service when any facility performs these tests, including physician office laboratories under CLIA. The facility must need a certificate and apply for the CLIA program.
FDA approves new waived tests regularly, and tests become valid once they get approval from the CLIA program. CLIA certification may require for each location where testing performs by the Physician. The Exception also considers the laboratory location, which does not have fixed sites or laboratories within the hospital.
For Instance, FDA issues one individual EUA for infectious agent antigen detection by immunoassay technique, qualitative or semi-quantitative for SARS-CoV-2 and influenza virus types A and B authorized for use at the POC setting. The HCPCS code 87428QW describes this EUA test.
The CLIA needs a valid CLIA certificate when the facility performs laboratory tests. The Medicare and Medicaid insurance must ensure the laboratory test claims are reasonable under the CLIA certificate or not.
CPT code 87811 with QW Modifier requires a valid, current CLIA certificate of waiver, which is effective from service date October 6, 2020, when facility bills to the insurance.
CPT code 887428 with modifier QW requires a valid, current CLIA certificate of waiver, which is effective from service date November 10, 2020, when facility bills to the insurance. MAC will adjust the claim when they find any claim already paid or retroactively pay claims.
What Is QW Modifier?
QW Modifier is CLIA waived tests approved by CDC and FDA when performed by the Physician utilizing the special kits to complete the lab’s test and may need modifier QW when submitted to the insurance.
When To Use QW Modifier
QW Modifier is used to specify when the Physician performing the diagnostic lab service has held the wavier test certification, which is the Clinical Laboratory Improvement Amendment (CLIA) waived test. This database includes all the requirements and standards according to the CLIA. Reporting the code with modifier QW is appropriate when the provider meets these standards.
Only HCPCS and CPT codes are applicable when listed in the database and may or may not require submission with the QW modifier.
QW Modifier Guidelines
The specific list of CPT codes requires modifier QW when the Physician performs laboratory procedures waive in the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) regulates laboratory tests as waived tests.
QW Modifier must submit in first order when bills to insurance.
CPT code must list on the CMS CLIA web page to determine if applicable when submitted to the insurance.
CLAI waived CPT code updates quarterly by Palmetto GBA, and they publish the information on the website when it is available.
The CLIA certificate may require the claims for CLIA-waived tests, and this information is submitted electronically on 2300 or 2400, REF/X4, 02. In contrast, paper claims submitted to the insurance may submit via CMS 1500 form in column 23.
If any Lab test does not list on the CLIA waived test database, then CLIA regulation requires the following certificates to perform the test legally:
- Certificate of Waiver
- Certificate of Accreditation
- Certificate of Physician Performed Microscopy Procedures (PPMP)
- Certificate of Registration
The Certificate of Waiver and PPMP may have confined limits of tests when performed by the Physician.
That patient is not liable when the insurance denies service under the CLIA certificate, and The provider may be responsible for the payment.
If the provider has one NPI number covering multiple lab procedures sites, it may require a separate CLAI number for each location. CLIA number may require the provider to represent the site.
The following are the CPT codes utilize special kits when the provider performs Performed Microscopy Procedures (PPMP) and bills to insurance:
83001, 83002, 83036, 83518, 82044, 82055, 82120, 82273, 82274 83605, 80061, 82950, 82951, 82952, 82985, 83718, 83986, 86294, 86308, 86318, 86618, 86701, 87077, 80101, 81003, 81007,82010, 82465, 82523, 82570, 82679, CPT 82947, 84460, 84478, 84703, 85014, 85018, 85610, 87210, 87449, 87804, and 87880.
If the provider utilizes the kits, it is appropriate to bill with QW Modifier.
The following are the CPT codes does not utilize special kits when the provider performs Performed Microscopy Procedures (PPMP) and bills to insurance:
80061, 80101, 81003, 81007,82010, 82044, 85014, 85018, 85610, 86294, 86308, 86318, 82679, 82947, 82950, 82951, 82952, 82985, 83001, 83002, 83036, 82055, 82120, 82273, 82274, 82465, 82523, 82570, 83518, 83605, 83718, 83986, 84460, 84478, 84703, 86618, 86701, 87077, 87210, 87449, 87804, and 8788.
If the provider does not utilize the kits, it is appropriate to bill without a QW modifier.
QW Modifier Examples
The following are examples of when the QW Modifier appends with CPT codes:
A 44-year-old female with a PMH of HTN (not on meds for the past month) presents with stroke-like symptoms. The patient states that she noticed difficulty writing while working as a security guard, described as being unable to properly grip the pen and feeling like she had to “shake out” her arm.
She also developed difficulties with speech around that time, with her coworkers and family members noticing that she was “speaking as if she were drunk.” Symptoms have been constant but waxing and waning in intensity since onset.
The patient denies new focal weakness or numbness, though she notes that she has right some right leg weakness at baseline. He denies previously experiencing similar symptoms. The physician ordered to obtain CT head, Pathology, and lab test CBC, CMP, and Lipid Panel.
Anticipate admission for further monitoring, possible neurology evaluation, and likely brain MRI.
The physician orders a comprehensive metabolic panel, which is available on the CLIA website. It is appropriate to report with modifier QW.
The patient is a 27-year-old female with no medical history and complaints of nausea, vomiting, and diarrhea since last night. States this evening, she is feeling weak and dehydrated.
She has vomited multiple times today and has been intolerant of solids or liquids. LMP did not know she was on OCPs. The patient is not Covid vaccinated. Symptoms are consistent with a viral illness, possibly Covid.
The patient who is tachycardic up to 120s will give IV fluids, Zofran, and Pepcid. The Physician orders lab panels like CBC, CMP, and Lipid.
The physician orders a complete blood count with a specialized kit. It is appropriate to report with modifier QW.
A 39-year-old male with h/o asthma and never admitted or intubated for this, triggers are weather changes and fumes, and he notes they are painting in his building right now, which has made things worse). He also has sarcoidosis on chronic prednisone and chronic leukopenia.
He is coming in with two days of sob and chest pain. States it feels similar to his sarcoidosis exacerbation. He takes 10 mg daily prednisone but bumps it up to 20 mg of prednisone as he asks to take an extra dose of it whenever he feels his sarcoidosis flaring up.
He uses albuterol for his asthma, and he used it today, but it did not help—the physician plan to order a Lipid profile, MRI, and CT.
The Physician performs the lipid panel test with a specialized test kit, and It is appropriate to report CPT 80061 with modifier QW for reimbursement.
Does 81002 Need A QW Modifier?
CPT 81002 does not require QW Modifier because it is a simple test, and there is no need for a specialized kit.
Does 87804 Need A QW Modifier?
QW Modifier may apply to CPT code 87804. Reporting with a QW modifier is appropriate when physicians utilize special kits under CLIA-waived test standards. Otherwise, it may bill without modifier QW.