Laboratory RCM

Laboratory & Pathology Billing Services

Navigating the intricate landscape of lab billing — from high-volume clinical chemistry to advanced molecular diagnostics — with PAMA-compliant pricing and LIS-integrated workflows.

98.9% Molecular Billing Accuracy
100% LIS Integration Support
PAMA Full Compliance & Reporting
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The Challenge

Laboratory Billing Has Its Own Rulebook

Lab billing operates under a completely different payment framework than physician services. CLFS-based pricing, ABN requirements, panel unbundling rules, and PAMA reporting obligations create a compliance maze that requires dedicated expertise.

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PAMA Price Transparency

The Protecting Access to Medicare Act reshaped lab reimbursement. We manage CLFS rate calculations, private payer weighted median reporting, and help labs navigate the phase-in of market-based rates that have reduced Medicare payments significantly.

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Molecular Diagnostics Coding

Molecular and genomic testing (81400-81479 and PLA codes) are among the fastest-evolving areas in lab billing. New codes are added quarterly, and many advanced tests lack established coverage policies — requiring proactive medical necessity documentation.

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ABN & Medical Necessity

Every non-covered or frequency-limited test requires a properly executed Advance Beneficiary Notice. We manage ABN workflows, NCD/LCD frequency limitations, and ensure diagnosis code specificity meets medical necessity requirements for every test ordered.

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Panel & Profile Rules

CMS panel coding rules require that individual components be rolled into panel codes (80047-80081) when thresholds are met. Conversely, automated test panels must not be reported as panels when fewer components are medically necessary. We optimize both directions.

Molecular & Clinical

Expert Billing Across All Lab Disciplines

Whether you operate a high-volume reference lab, hospital core lab, or specialized molecular diagnostics facility, our team understands the distinct billing workflows for each discipline.

  • Clinical chemistry & hematology — high-volume automated testing with panel optimization and frequency compliance
  • Anatomic pathology — surgical pathology (88300-88309), special stains, IHC, flow cytometry, and professional interpretation billing
  • Molecular diagnostics — NGS panels, companion diagnostics, pharmacogenomics, and hereditary cancer screening with proper GSP/GSA coding
  • Microbiology & infectious disease — culture identification, susceptibility panels, and molecular ID (87471-87801)
  • Cytology & cytogenetics — Pap smear coding, FISH analysis, and chromosome studies
  • Toxicology & drug testing — presumptive (80305-80307) vs. definitive (G0480-G0483) with proper medical necessity documentation
Clinical laboratory technician processing samples
Medicare CLFS

Navigating the Clinical Lab Fee Schedule

The Medicare Clinical Laboratory Fee Schedule is the benchmark for lab reimbursement nationwide. Understanding its nuances is critical to maintaining healthy margins.

  • CLFS rate monitoring — tracking annual rate changes, new code pricing, and crosswalk/gapfill determinations for novel tests
  • ADLT designation — assisting labs with Advanced Diagnostic Laboratory Test applications for unique molecular assays with breakthrough pricing
  • New code applications — supporting PLA (Proprietary Lab Analysis) code requests through the AMA for lab-specific tests
  • 14-day rule compliance — ensuring hospital outpatient labs correctly bundle tests ordered within 14 days of an outpatient encounter

Payor-Specific Expertise

Lab billing varies dramatically by payer. Medicare, Medicaid, and commercial plans each have different coverage policies, frequency limits, and prior authorization requirements. We maintain current coverage databases for every major payer to prevent denials before claims are submitted.

32% Molecular Claim Denial Reduction
99.1% PAMA Reporting Compliance
$1.2M Avg. Annual Revenue Recovered
15 Days Average Days in AR
FAQ

Laboratory Billing Questions Answered

For novel molecular tests, we develop comprehensive billing strategies including proper CPT/PLA code selection, proactive Letters of Medical Necessity, pre-service peer-to-peer reviews when available, and structured appeal templates supported by published clinical evidence. We also assist with coverage policy development by compiling clinical utility data for payer submissions.
Yes, we integrate with all major LIS platforms including Sunquest, Cerner PathNet, EPIC Beaker, Orchard Harvest, and specialty molecular LIMS. Our integration captures test orders, results, and ABN documentation to automate charge capture and reduce manual billing errors.
We maintain complete records of private payer payment rates required for PAMA data reporting. When reporting periods open, we compile weighted median calculations by test code, validate data integrity, and ensure timely submission to CMS. We also model the impact of upcoming CLFS rate adjustments on your revenue.
Drug testing billing is under intense scrutiny. We ensure proper differentiation between presumptive screening and definitive confirmation, appropriate test ordering based on clinical indication, medical necessity documentation for each analyte class, and compliance with state and federal regulations on standing order limitations.
We manage billing for referred-out specimens including proper identification of the performing vs. ordering lab, specimen collection code billing (36415, 99000), and compliance with the prohibition on marking up reference lab charges under Medicare. We also optimize your send-out test menu to maximize in-house revenue retention.
We manage the full AP professional billing workflow — from surgical pathology interpretation levels (88302-88309) through special stains (88312-88314), immunohistochemistry (88341-88344), flow cytometry (88184-88189), and consultation coding (88321-88325). We ensure the pathologist's work is fully captured based on specimen complexity and reporting requirements.