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QW Modifier Required for Procedure Code 81515

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after January 1, 2025, Clinical Laboratory Improvement Amendment (CLIA) procedure code 81515 will be a benefit of Texas Medicaid. Procedure code 81515 will require the QW modifier. 

For more information, providers can refer to the Texas Medicaid Provider Procedures Manual, Healthy Texas Women Program Handbook, section 2.3, “Services, Benefits, Limitations, and Prior Authorization.”

Reminder: Providers must have the required CLIA certification on file, and they must use the QW modifier when it is required, per the Centers for Medicare & Medicaid Services (CMS). Claims will be denied if the QW modifier is not present on applicable CLIA-waived tests. Refer to the CMS CLIA website for information about CLIA-waived tests, provider certifications, and billing requirements.

For more information, call the TMHP Contact Center at 800-925-9126.