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Quarterly Updates and Claims Reprocessing for Some CLIA Procedure Codes

Last updated on 6/22/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

TMHP has updated some laboratory procedure codes to comply with Clinical Laboratory Improvement Amendment (CLIA) guidelines and to align with the Centers for Medicare & Medicaid Services.

Quarterly CLIA Updates

Effective for dates of service on or after January 1, 2018, the following procedure codes will be subject to CLIA edits:

Procedure Codes Types of Service

Laboratory Services

82542

86794

88172

G0306

G0307

Professional Component

88172

88182

88358

Claims submitted with these procedure codes for dates of service from January 1, 2018, through July 31, 2018, may be reprocessed. Affected claims may result in an additional payment or recoupment, which will be reflected on future Remittance and Status (R&S) reports.

Effective for dates of service on or after January 1, 2017, the following laboratory procedure code will be subject to CLIA edits:

Laboratory Procedure Code

G0475

Claims submitted with G0475 for dates of service from January 1, 2017, through July 31, 2018, may be reprocessed. Affected claims may result in an additional payment or recoupment, which will be reflected on future R&S reports.

Modifier QW Required

Effective for dates of service on or after January 1, 2017, the following laboratory procedure code will require the QW modifier:

Procedure Code: Modifier QW Required

G0475

Claims submitted with Modifier QW with dates of service on or after January 1, 2017, through July 31, 2018, that may have been incorrectly denied will be reprocessed. Affected claims may result in an additional payment or recoupment, which will be reflected on future R&S reports.

Effective for dates of service on or after April 1, 2018, the following laboratory procedure codes will require the QW modifier:

Procedure Code: Modifier QW Required

85025

Claims submitted with Modifier QW with dates of service on or after April 1, 2018, through July 31, 2018, that may have been incorrectly denied will be reprocessed. Affected claims may result in an additional payment or recoupment, which will be reflected on future R&S reports.

Modifier QW Not Required

Effective for dates of service on or after October 1, 2017, the following laboratory procedure code does not require the QW modifier:

Procedure Code: Modifier QW Not Required

83518

Claims submitted without Modifier QW with dates of service on or after October 1, 2017, through July 31, 2018, that may have been incorrectly denied will be reprocessed. Affected claims may result in an additional payment, which will be reflected on future R&S reports.

CLIA Requirement Removed

Effective January 1, 2018, for dates of service on or after January 1, 2018, the following technical component procedure code will no longer require CLIA certification:

Technical Component Procedure Code removed from CLIA

88184

Claims submitted with dates of service on or after January 1, 2018, through July 31, 2018, that may have been incorrectly denied will be reprocessed. Affected claims may result in an additional payment, which will be reflected on future R&S reports.

Reminder: Providers must have the required CLIA certification on file with TMHP.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.