HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)

by  Jared Staheli
July 10th, 2015

At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject to CLIA edits by providing an updated listing of these tests to the Medicare contractors on an annual basis via a Recurring Update Notification. A facility that submits a claim for any test mentioned in the HCPCS codes that are subject to CLIA edits list must have either a valid, current CLIA certificate of registration (certificate type 9), a CLIA certificate of compliance (certificate type 1), or a CLIA certificate of accreditation (certificate type 3).

For a list of the specific HCPCS codes subject to CLIA edits refer to the following Internet site: http://www.cms.hhs.gov/CLIA/downloads/Subject.to.CLIA.pdf

In addition, the CMS identifies the new HCPCS codes in the 80000 series that are excluded from CLIA edits by providing an updated listing of these tests to the Medicare contractors on an annual basis via a Recurring Update Notification. No CLIA certificate is required for a claim submitted for any test mentioned in the HCPCS codes in the 80000 series that are excluded from CLIA edits list.

For a list of the specific HCPCS codes in the 80000 series that are excluded from CLIA edits refer to the following Internet site: http://www.cms.hhs.gov/CLIA/downloads/cpt4exc.pdf

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 16