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Lina Posted Wed 21st of December, 2016 15:18:56 PM
We are having problems with 81000 & 81002 QW , Medicare denies these code as per "PROVIDER IS NOT ELEIGBLE"
SuperCoder Answered Thu 22nd of December, 2016 02:02:19 AM

Merry Christmas!


There is CCI edit between codes 81000 and 81002 and modifier is not allowed, which means you cannot report both codes together in any circumstances. Code 81002 will be denied being a column 2 code.


For more info, this denial is received when:


  1. The DOS (date of service) of a claim is prior to the provider’s Medicare effective date
  2. The DOS is after provider’s termination date
  3. A procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification
  4. A laboratory service is missing a required modifier.


You need to do:


  • If the DOS is not correct, check DOS on the medical records and correct it.
  • If the DOS is correct, check the provider’s Medicare effective or termination date.
  • View enrollment information through the Provider Enrollment to confirm provider’s Medicare effective date.
  • Submit claims for laboratory services within the scope of the provider’s CLIA certification.
  • Verify service/procedure code is listed as approved under the scope of the provider’s certification.
  • Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests).


Please feel free to write if you have any concern or questions.



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