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Medicare coverage guideline

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57084

https://www.cms.gov/medicare/medicare

Ncd/ Lcd

Medicare Parts

Medicare Hmo

Hospice

Cobra

Hcpcs codes

Cpt codes

Diagnosis

Www.cms.gov

Noridian Medicare DME

Search- lcd/ ncd

Search on google- ncd 20.4, then reach on cms website, and can download pdf,

Pfs clinical notes:

NCD 310.1, coverage analysis,

National coverage determination (NCDs)

Coverage rules that applied to all Medicare patients across the country,

Purpose is to standardize Medicare coverage Nation wide and provide information about what is and is not covered by Medicare,

Apply to specific items services:

Include indications (diseases or situations when the test will be covered)

Include limitations (diseases or situations when the test will not be covered)

May included list of ICD 10 codes that supports coverage when situations described in indications are met,

Search by name, code, or document ID,

Medicare generally does not cover testing related to screening,  Medicare's view of screening is absent signs and symptoms, 

Screening limitation in NCD and LCD are not referring to protocol screening visits,

Sometimes, the patient's underline condition will cause specific signs and symptoms that support coverage, other times, it cannot be determined if every patient will experience signs and symptoms at specific protocol visits.

Routine screening and prophylactic testing for lipid disorder are not covered by Medicare. While lipid screening may be medically appropriate,  Medicare wire statute does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use etc. test may be medically appropriate, but it will not be covered.

Medical necessity denounce code CO50,

Noridian Medicare DME

Coverage guidance coverage indications policies specific rules coding information modifiers Healthcare common procedure coding system HCPCS codes.

Medicare Coverage Determination Process

Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).

Coding Information

CPT/HCPCS Codes: 83880 NATRIURETIC PEPTIDE

ICD-10-CM Codes that Support Medical Necessity

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM (e.g., to the third to seventh character). The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Medigaps

Medigaps are health insurance policies that offer standardized benefits to work with Original Medicare (not with Medicare Advantage). They are sold by private insurance companies. If you have a Medigap, it pays part or all of certain remaining costs after Original Medicare pays first. Medigaps may cover outstanding deductibles, coinsurance, and copayments. Medigaps may also cover health care costs that Medicare does not cover at all, like care received when travelling abroad. Remember, Medigaps only work with Original Medicare. If you have a Medicare Advantage Plan, you cannot buy a Medigap.

End-Stage Renal Disease

Medicare for those with End-Stage Renal Disease (ESRD Medicare) provides you with health coverage if you have permanent kidney failure that requires dialysis or a kidney transplant. ESRD Medicare covers a range of services to treat kidney failure. In addition, you will also have coverage for all the usual services and items covered by Medicare.

ESRD Medicare eligibility

To be eligible for ESRD Medicare, you must be under 65 and diagnosed with ESRD by a doctor. Additionally, you must have enough work history to qualify for Social Security Disability Insurance (SSDI) or Social Security retirement benefits, or enough railroad work history to qualify for Railroad Retirement benefits or railroad disability annuity. You can also qualify through the work history of your spouse or parent.

COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law passed in 1986 that lets certain employees, their spouses, and their dependents keep group health plan (GHP) coverage for 18 to 36 months after they leave their job or lose coverage for certain other reasons, as long as they pay the full cost of the premium.

Under COBRA, a GHP is defined as a job-based insurance plan that provides medical benefits to employees, their spouses, and/or their dependents. Medical benefits may include:

• Inpatient and outpatient hospital care
• Physician care
• Surgery
• Prescription drugs
• Other medical benefits, such as dental and vision care.

TRICARE is a health insurance program provided by the federal government to active duty and retired military personnel and their family members. There are many different TRICARE programs. TRICARE for Life (TFL), a program for Medicare-eligible military retirees and their dependents, acts as a supplement to Medicare.

• TFL typically covers your Medicare cost-sharing (deductibles, coinsurances, and copayments).
• TFL may pay when services are not covered by Medicare or when you have used up your Medicare benefits.
  • TFL coverage and cost-sharing rules may apply.

Veterans Affairs (VA) 

If you are a veteran–meaning you served on active duty in the U.S. Armed Forces for a required period of time and received an honorable discharge or release–you may be eligible for Veterans Affairs (VA) benefits. VA benefits are administered by the federal government and include pensions, educational stipends, and health care, among other benefits. It is important to know that VA benefits do not work with Medicare, though you can be enrolled in both.

Medicare Advantage Plan

While the majority of people with Medicare get their health coverage from Original Medicare, some choose to get their benefits from a Medicare Advantage Plan, also known as a Medicare private health plan or Part C. MA Plans contract with the federal government and are paid a fixed amount per person to provide Medicare benefits.

Remember, you still have Medicare if you enroll in an MA Plan. This means that you likely pay a monthly premium for Part B (and a Part A premium, if you have one). If you are enrolled in an MA Plan, you should receive the same benefits offered by Original Medicare. Keep in mind that your MA Plan may apply different rules, costs, and restrictions, which can affect how and when you receive care. They may also offer certain benefits that Medicare does not cover, such as dental and vision care, caregiver counseling and training, and certain in-home support like housekeeping. Not all MA Plans cover additional benefits, so check with a plan directly to learn what benefits it covers.

Medicaid spend-down

https://www.medicareinteractive.org/get-answers

If you need Medicaid coverage and your income is above the Medicaid income guidelines in your state, your state may offer a Medicaid spend-down for aged, blind, and disabled (ABD) individuals who do not meet eligibility requirements. This program allows you to deduct certain medical expenses from your income so that you can qualify for ABD Medicaid. If you have medical expenses that significantly reduce your usable income, you may qualify for a Medicaid spend-down.

• Each period that you have enough medical expenses to meet your spend-down, you will have Medicaid coverage. If you do not meet your spend-down amount for a certain period of time, you will not have Medicaid coverage for that time. You can still get Medicaid coverage later if you meet your spend-down amount during another period of the year.

• Medicare will pay first for covered services, and Medicaid will pay second for qualifying costs, such as Medicare cost-sharing.

Surgery global period

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1256840

Medicare coverage determination

https://www.cms.gov/Medicare/Coverage/DeterminationProcess

Medicare Publication

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts

The global surgical package, 

also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services.

PRE-OPERATIVE PERIOD BILLING

E/M Service Resulting in the Initial Decision to Perform Surgery.

E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately.

In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery.

The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery.  When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.

DAY OF PROCEDURE BILLING

Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service. 

Use modifier “-25” with the appropriate level of E/M service.

Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated procedure.

POST-OPERATIVE PERIOD BILLING

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period.

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure. These modifiers are:

Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.

Return to the OR for a Related Procedure during the Post-Operative Period.

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period). 

The physician may also need to indicate that another procedure was performed during the post-operative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

Staged or Related Procedure or Service by the Same Physician During the Post-operative Period. Modifier “-58” (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was: • Planned prospectively or at the time of the original procedure • More extensive than the original procedure • For therapy following a diagnostic surgical procedure.

Critical Care.

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances. 

Pre-operative and post-operative critical care may be paid in addition to a global fee if:

The patient is critically ill and requires the constant attendance of the physician;

In order for these services to be paid, two reporting requirements must be met: 

CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care must be used; and 

Documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-10 code for a disease or separate injury which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.  

Billing for Bilateral Procedures.

The terminology for some procedure codes includes the terms “bilateral” (such as code 27395; Lengthening of the hamstring tendon; multiple, bilateral.) or “unilateral or bilateral” (for example, code 52290; cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). The payment adjustment rules for bilateral surgeries do not apply to procedures identified by CPT as “bilateral” or “unilateral or bilateral” since the fee schedule reflects any additional work required for bilateral surgeries.

If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier “-50.” They report such procedures as a single line item. (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)

Claims for Assistant-at-Surgery Services.

Procedures billed with the assistant-at-surgery physician modifiers “-80” (Assistant Surgeon), “-81” (Minimum assistant surgeon), “-82” (Assistant surgeon (when qualified resident surgeon not available)), or the AS modifier (physician assistants, nurse practitioners and clinical nurse specialists), are subject to the assistant-at surgery policy. Accordingly, Medicare pays claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized. 

Claims for Co-Surgeons and Team Surgeons.

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. 

each surgeon bills for the procedure with a modifier “-62” (Two surgeons). 

Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, such as, heart transplant or bilateral knee replacements. 

Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool. 

NOTE: Some procedures require modifier “-62” and will be returned without payment if it is not used by both surgeons. 

If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Field 25 of the MFSDB identifies certain services submitted with a “-66” modifier which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”

Claims for Multiple Surgeries.

Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. 

Using Modifiers “-54” and “-55”

• Surgical care only (modifier “-54”) 

• Post-operative management only (modifier “-55”)  

Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician. • Modifier “-54” does not apply to assistant-at-surgery services. • Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees.

The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.” • Use modifier “-55” with the CPT procedure code for global periods of 10- or 90-days.

Exceptions to the Use of Modifiers “-54” and “-55”

Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.

Physicians Who Furnish the Entire Global Package.

Physicians who furnish the surgery and furnish all of the usual pre-and post-operative care may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package.

Physicians Who Furnish Part of a Global Surgical Package.

More than one physician may furnish services included in the global surgical package. It is possible that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. 

How are minor procedures and endoscopies handled?

Minor procedures and endoscopies have post-operative periods of 10 days or zero days (indicated by 010 and 000, respectively). 

For 10-day post-operative period procedures, Medicare does not allow separate payment for post-operative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are generally not included in the global fee for minor procedures. 

What services are not included in the global surgery payment?

Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier “-57” (Decision for Surgery). This visit may be billed separately only for major surgical procedures.

What services are included in the global surgery payment? 

Medicare includes the following services in the global surgery payment:

Pre-operative visits after the decision is made to operate.

For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery. 

Intra-operative services that are normally a usual and necessary part of a surgical procedure.

Post-operative period of the surgery because of complications, which do not require additional trips to the operating room.

Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery.

Medicaid

https://www.medicaid.gov/medicaid/index.html

Eligibility: Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Medicaid Spend down program:

https://medicaid.utah.gov/Documents/pdfs/Medicaid_Spenddown.pdf

Medicaid for those who have low income, so there is a criteria of income or limitation of income to get eligible for Medicaid, Medicaid law allows some people with very limited income to be on Medicaid for free. If your countable income is more than the set limit for your household size, Medicaid allows you to spend down to the income limit to be eligible for Medicaid.

A spenddown is the difference between your countable income and the income limit for the medical program. Your gross income is reduced by allowable deductions and then compared to the income limit for your household size.

If your monthly health care costs are more than your monthly spenddown, it may save you money to pay your spenddown. If your spenddown amount is more than your health care costs, you cannot spenddown to receive Medicaid.

https://www.medicaid.gov/resources-for-states/downloads/macpro-ig-handling-excess-income-spenddown.pdf

Cpt Code Range

5 digits numeric and alfa numeric code.

99202-99499 Evaluation& Management

00100-01999 Anesthesia

10004-19499 Integumentary System

20100-29999 Musculoskeletal System

30000-32999 Respiratory System

33016-37799 Cardiovascular System

38100-39599 Hemic & Lymphatic System

40490-49999 Digestive System Male

50010-53899 Urinary System

54000-55980 Male Genital System

56404-58999 Female Genital System 

59000-59899 Maternity Care &Delivery

60000-60699 Endocrine System

61000-64999 Nervous System

65091-68899 Eye & Ocular Adnexa

69100-69979 Auditory System

70010-79999 Radiology

80047-89398 Pathology  & Laboratory

90281-90999 Medicine Vaccine, Toxoids, Psychiatry, Dialysis,

91010- 93998 Gastroenterology, Ophthalmology, Cardiovascular,

94002-99607 Pulmonary, Allergy, Endocrinology, Neurology, Behavioral, Chemotherapy,

ICD 10 Codes

A00–B99    Infectious/parasitic diseases      

C00–D49    Neoplasms

D50–D89    Blood diseases

E00–E89     Endocrine/metabolic diseases

F01–F99     Mental/behavioral disorders

G00–G99    Nervous system diseases

H00–H59    Eye/adnexa diseases

H60–H95    Ear/mastoid diseases

I00–I99       Circulatory system diseases

J00–J99      Respiratory system diseases

K00–K95    Digestive system diseases

L00–L99     Skin diseases

M00–M99   Musculoskeletal system diseases

N00–N99    Genitourinary system diseases

O00–O9A    Pregnancy/childbirth

Q00–Q99    Congenital malformations

R00–R99     Conditions not elsewhere classified

S00–T88     Injury, poisoning, external causes

https://www.cms.gov/medicare/medicare

https://www.cms.gov/

Medicare general Information -Medicare eligibility, Medicare parts A, B,C,D

Beneficiary Notice Initiative  BNI

Medicare Approved Facilities

Telehealth

 

Billing

Electronic Billing & EDI Transactions

Medicare claims during public health Emergency

Medicare fee for services

(SNF) Consolidated Billing-Skilled Nursing Facility

Therapy Services

CMS  Forms

Coding

Coding-  HCPCS general information

HCPCS- release and codes set

ICD 10, 

Place of  service codes,

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Website-POS-database.pdf

how to use NCCI national correct coding initiative tool

Coordination of Benefits and Recovery

COBA Trading Partners

Coverage

Medicare coverage- General Information,

Medicare Coverage Determination Process,

Medicare Dental Coverage,

Eligibility and Enrollment

Managed Care Eligibility

Medicare Original Part A, B Eligibility,

Health Plans

Medicare Health Plan General Information,

Medicare Advantage Rate

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/OONPayments.pdf

Medicare Cost Plan

Medigap - Medicare Supplement Health Insurance,

-------------------------------------------------

Noridian

med.noridianmedicare.com/web/jeb/topics/abn

Browse BY Topic -

Advance Beneficiary Notice of Noncoverage (ABN)

An ABN, Form CMS-R-131, is a standardized notice that a health care provider/supplier must give to a Medicare beneficiary, before providing certain Medicare Part B or Part A items or services.

Medical Necessity

https://med.noridianmedicare.com/web/jfb/topics/abn#medicalnecessity

Medical Necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Coverage of certain items/services is limited by the diagnosis. If the diagnosis listed on the claim is deemed not medically necessary, the procedure is denied. Limited coverage may be the result of National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The CMS Medicare Coverage Database (MCD) This link will take you to an external website. contains all NCDs and LCDs, local policy articles and proposed NCD decisions. View the CMS NCDs This link will take you to an external website.. The official versions of LCDs may be viewed by contractor, state or alphabetically.

Hospice :

GW - Service not related to the hospice patient's terminal condition.

GV - Attending physician not employed or paid under agreement by the patient's hospice provider; or hospice-employed nurse practitioner is acting as attending physician.

Observation

Observation care is a set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment.

Non Covered Services

https://med.noridianmedicare.com/web/jeb/topics/non-covered-services

Non-Covered: An item or service may be non-covered if the coverage criteria are not met per the NCD or LCD; it would be considered not reasonable or necessary. For these services that do not meet policy criteria, a mandatory Advance Beneficiary Notice of Noncoverage (ABN) is required with the GA modifier appended upon claim submission.

ED Electronic data Interchange 

Durable Medical Equipment

To help providers and suppliers gain a better understanding of the roles of billing, coverage, documentation requirements, and medical necessity when providing DMEPOS to Medicare beneficiaries, there are 57 DMEPOS Local Coverage Determinations (LCDs) as well as various other educational opportunities too.

Drugs Biological and Injections 

https://med.noridianmedicare.com/web/jeb/topics/drugs-biologicals-injections

Hospitals and providers must ensure that units of drugs or biologicals administered to patients are accurately reported in terms of the dosage/units specified in the complete HCPCS code descriptor. Prior to submitting Medicare claims for drugs or biologicals,

Telehealth

Telehealth, or sometimes referred to as Telemedicine, is the use of telecommunications technology to provide health care services to persons who are at some distance from the provider.

Modifiers

https://med.noridianmedicare.com/web/jeb/topics/modifiers

Modifiers can be two digit numbers, two character modifiers, or alpha-numeric indicators. Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered.

Preventive Care Services

Medicare pays for many preventive services to keep beneficiaries healthy. Preventive services can find health problems early, when treatment works best, and can keep them from getting certain diseases. 

Browse By Specialty

Ambulatory Surgical Center

An ASC is defined as an entity that operates exclusively for furnishing outpatient surgical services to patients. 

Laboratory

Diagnostic X-ray, laboratory, and other diagnostic tests, including materials and the services of technicians, are covered under the Medicare program. Some clinical laboratory procedures or tests require Food and Drug Administration (FDA) approval before coverage is provided.

Mental Health

Psychiatry and Psychotherapy Services

Medicare covers annual depression screening for adults in the primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up.

Medicare Part B covers medically necessary outpatient mental health benefits for psychiatric services for the diagnosis and treatment.

Palmetto

https://www.palmettogba.com/

Jurisdiction part B- Topics - clams - Denial Resolution

https://www.palmettogba.com/palmetto/jjb.nsf/DIDC/8EELKZ1352~Claims~Denial%20Resolution

CLIA

Your CLIA number must be submitted on claims for clinical laboratory tests, including tests that are classified as 'CLIA-waived.' Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.

Some clinical laboratory tests must also be submitted with HCPCS modifier QW. The Food and Drug Administration (FDA) determines which laboratory tests are waived. Please note that not all CLIA-waived tests require HCPCS modifier QW.