Brief Your Billing & Coding Staff on New Medicare HCPCS & CLIA Code Changes

Several significant coding changes in the Healthcare Common Procedure Coding System (HCPCS) and Clinical Laboratory Improvement Amendments (CLIA) that may affect your Medicare reimbursements have taken effect since the start of 2022. To avoid claims denials and improper billings, lab compliance officers and managers need to ensure billing and coding staff is aware of, and has adjusted to, all recent coding changes. These changes are summarized in the Centers for Medicare & Medicaid Services (CMS) transmittal, “HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: April 2023, MLN Matters Number: MM13024.”¹ Here’s a quick briefing of all the essential changes that you can share with your billing staff:

What’s At Stake

Under CLIA regulations, labs must be appropriately certified for each test they perform. CMS edits each claim for a test that’s considered a CLIA laboratory test for a HCPCS code at the lab’s CLIA certificate level to ensure that Medicare pays only for lab tests that are performed in appropriately certified facilities. If the HCPCS code is for a test that’s not appropriate for the lab of that CLIA certification level to perform, the edit will reject the claim.

Discontinued HCPCS Codes

The new CMS MM13024 transmittal lists HCPCS codes that have recently been discontinued and should no longer be used.

Discontinued HCPCS Codes

New HCPCS Codes

MM13024 also lists new HCPCS codes that are subject to CLIA edits. According to CMS, for these HCPCS code tests to be payable by Medicare, the lab must have one of the following:

• CLIA certificate of registration (certificate type code 9)
• CLIA certificate of compliance (certificate type code 1)
• CLIA certificate of accreditation (certificate type code 3)

New HCPCS Codes Subject to CLIA Edits

Takeaway

The lists don’t include new HCPCS codes for waived tests or provider-performed microscopy procedures. Rule: The listed tests aren’t payable to a facility that doesn’t have a valid, current, CLIA certificate, or that only has a current CLIA certificate of waiver (certificate type code 2) or a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4). Exception: A facility with a current certificate type code 2 or 4 may be paid if it bills the appropriate HCPCS service code with a QW modifier.

Bottom Line: It’s up to you to ensure that the HCPCS codes you’ve billed to Medicare since February 2022 are in line with your CLIA certification. CMS notes that Medicare Administrative Contractors (MACs) won’t search their files either to retract payment for claims already paid, or to pay claims retroactively. However, MACs will adjust any claims that you bring to their attention.

References:

1. https://www.cms.gov/files/document/mm13024-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-april-2023.pdf