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QW Modifier Required for Procedure Code 87801

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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.

Following changes to the Clinical Laboratory Improvement Amendments (CLIA) regulations, the Centers for Medicare & Medicaid Services (CMS) has released updated guidance for COVID-19 test billing.

Effective for dates of service on or after March 30, 2021, procedure code 87801 for infectious agent detection by nucleic acid (DNA or RNA), multiple organisms, and the amplified probe technique will require the modifier QW when billed for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.

Affected claims submitted with dates of service on or after March 30, 2021, may be reprocessed. When the claims are reprocessed, providers may receive additional payment, which will be reflected on Remittance and Status Reports.

For more information about procedure code 87801, providers can refer to the current Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, section 2.2.13, “Microbiology,” and the current Children with Special Health Care Needs Services Program Provider Manual, Laboratory Services Handbook, section 25.2.11, “Microbiology.”

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

For more information, call the the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.