Sample Coding Form

Click here to download a sample form for coding for the TearLab test.

If you are using electronic billing software, for Medicare claims check to make sure your electronic billing software allows you to enter your CLIA number in box #23, if not, ask your software provider to enable this box. Also, Medicare requires the CLIA number be transmitted electronically using an “X4” qualifier. Please confirm with your software vendor that the CLIA number is being transmitted correctly. Contact TearLab Reimbursement Support Center if you require additional assistance.

For customers with a CLIA Waiver certificate, you must use the “QW” modifier when submitting claims to Medicare for CPT 83861.

For Medicare claims, always include the ordering physician's name and NPI number in boxes #17 and #17b. Do not use a group NPI number.  All claims for Medicare covered services, including in-office clinical laboratory tests such as the tear osmolarity test - CPT 83861, that are the result of a physician's order or referral shall include the ordering/referring physician's name.


The information provided to complete the CMS 1500 form is for illustrative purposes only. Providers should follow coding conventions for diagnostic tests as well as payer instructions when selecting appropriate CPT Codes, Modifier and ICD-9-CM diagnosis codes. Private insurance coding policy may vary from payer to payer.

Disclaimer: The information provided on this website is current as of January 2017 and was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content on this website is informational only, general in nature, and does not cover all situations or all payers' rules and policies. This content is not intended to instruct hospitals and/or physicians on how to use or bill for healthcare procedures, including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that TearLab Corporation assumes will have been made prior to assigning codes or requesting payments.

Under Federal and State law, it is the individual provider's responsibility to determine appropriate coding, charges and claims for a particular service. Policies regarding appropriate coding and payment levels can vary greatly from payer to payer and change over time. TearLab Corporation recommends that providers contact their own regional payers to determine appropriate coding and charge or payment levels.

If you are a provider participating in a clinical trial, we recommend you contact your payers, including Medicare/Medicaid and private insurers, to verify correct coverage and reimbursement policies for investigational devices.

This website information represents no promise or guarantee by TearLab Corporation concerning coverage, coding, billing, and payment levels. TearLab Corporation specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information on this website.

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