Laboratory billing services that protect every claim your lab runs
Clinical labs run a volume business. A CBC pays around ten dollars, a venipuncture pays three — so there is no room for rework. We handle CLIA edits, NCCI scrubbing, medical necessity, denials, and AR for labs across the USA.
Independent labs · Physician office labs · Hospital outreach · Toxicology · Molecular & pathology
Lab billing is where small errors become large losses
Every rejected claim, every missing diagnosis code, every CLIA edit that kicks a file back costs more to fix than the test paid in the first place. billingandcoding.us provides laboratory billing services to independent clinical labs, physician office labs, hospital outreach programs, toxicology and molecular labs, and pathology groups. Our coders and billers work in laboratory revenue cycle management every day, so the payer edits and documentation problems that stall a general billing team are routine work for us.
Three structural problems no other specialty has
You never see the patient
The specimen arrives with a requisition filled out by someone else's front desk. A lapsed policy number, a misspelled name, a missing date of birth — whatever is wrong on that form becomes the lab's rejection to fix, and there's no patient at the window to ask.
Medical necessity lives elsewhere
Coverage is established in the ordering provider's chart, not yours. Medicare's lab NCDs and each MAC's local policies list the exact ICD-10 codes that support tests like glucose, lipids, and thyroid studies. A missing or non-covered diagnosis means a CO-50 denial you must chase upstream.
PAMA squeezed the fee schedule
PAMA tied the Clinical Laboratory Fee Schedule to reported private payer rates, cutting many high-volume tests. Hospitals face OPPS packaging, 14X specimen-only claims, and the 14-day rule deciding who bills molecular tests on stored specimens.
The denial patterns that bury in-house teams
Each of these is manageable. Together, at volume, they overwhelm a general billing department.
Medical necessity
Vitamin D 82306, A1c 83036, and drug testing deny constantly when the diagnosis misses the MAC's covered list or a frequency limit is exceeded.
CLIA errors
Claims without a valid CLIA number in Item 23 of the CMS-1500 bounce back — and tests outside your certificate type deny outright.
Bundling & NCCI
Billing 80048 alongside 80053 triggers an edit — the BMP sits inside the CMP. Payers also rebundle individually billed analytes into panel rates.
Duplicate repeats
A second troponin or glucose the same day denies as a duplicate unless modifier 91 is appended — and 91 is not valid for reruns, QC, or confirmations.
Toxicology units
Medicare pays definitive drug testing through G0480–G0483 by drug class count, and MUE limits catch overreported units.
Ordering provider gaps
Claims that lack the ordering physician's name and NPI come back as rejections before they're ever adjudicated.
Molecular & genetic PA
Carelon and EviCore run authorization programs for major payers — and the lab ends up coordinating clinical documentation it doesn't own.
Small balances
Medicare pays lab tests at 100% of the fee schedule with no coinsurance, but commercial deductibles leave thousands of balances too small to chase one at a time.
Built around the requisition — because that's where revenue is won or lost
Charges flow from your LIS through an interface or structured export. Before anything goes out, we verify eligibility, check for a signed order and a usable diagnosis, confirm the CLIA number matches the performing site, and run every claim through NCCI, MUE, and payer-specific edits. Then the cycle runs on a schedule you can see:
Claims submission
Charges are entered and released within one to two business days of result finalization. Independent lab claims go out under place of service 81 with the ordering provider's NPI attached. Referred tests carry modifier 90, and we watch Medicare's referring-laboratory rules — including the 70/30 restriction — so the right entity bills. Clean electronic Medicare claims reach the payment floor at about two weeks; our job is making the first submission the one that pays.
Payment posting
ERAs post automatically, but automation only helps if someone reads the exceptions. We reconcile payments against the Clinical Laboratory Fee Schedule and your commercial contract rates, flag underpayments for recovery, and keep client-bill accounts separated from third-party claims so monthly invoicing to referring practices stays clean.
Denial management
We work denials by category, not claim by claim. CO-50 denials route two ways: a signed ABN shifts the balance correctly to the patient; otherwise we pull records from the ordering provider and appeal with the specific LCD language that supports coverage. CLIA rejections get fixed at the setup level so they stop recurring, and bundling denials are checked against current NCCI tables — a surprising number turn out to be payer errors. Every denial feeds a monthly root-cause report.
AR follow-up
Lab AR is a math problem: thousands of claims, most under fifty dollars. We stratify by payer, age, and balance — high-value molecular and pathology claims get worked one by one, routine chemistry moves through batch status checks. Timely filing is tracked per payer (Medicare allows twelve months; many commercial plans cut that to 90 or 180 days), secondaries go out as primaries pay, and aged backlogs run as a separate cleanup project.
The full 80047–89398 range, plus the HCPCS and PLA codes beside it
A technically perfect CPT code still denies if the supporting diagnosis isn't there — so we keep ICD-10 pairing current against each MAC's covered-diagnosis lists, and register DEX Z-codes for molecular claims in MolDX jurisdictions (which some national commercial payers now require as well).
Routine chemistry, hematology & urinalysis
Infectious disease & molecular
Toxicology
Modifier work
Laboratory billing sits under more federal scrutiny than most specialties
The OIG Work Plan has repeatedly targeted definitive drug testing and genetic testing billing, and EKRA put percentage-based lab sales commissions under criminal exposure across all payers — not just federal programs. We help clients stay on the right side of those lines: ABN workflows for tests likely to fail medical necessity, standing-order audits so open-ended orders get renewed and linked to a diagnosis, test menus reconciled against the lab's CLIA certificate type, and record retention that holds up when a MAC or commercial auditor asks for documentation.
"When we see a risky billing pattern, we say so. A billing company that only submits what it's handed isn't protecting you."
We work inside the systems labs actually use
If your LIS and billing system aren't talking to each other, we have set up HL7 interfaces and structured exports before — and we can tell you quickly whether your current stack is the problem or just misconfigured.
The case for outsourcing is arithmetic
An in-house team carries salaries, benefits, software seats, clearinghouse fees, and turnover risk — and lab billing knowledge is hard to hire, because most billers train in physician offices where none of these rules apply. Outsourcing converts that fixed cost into a percentage of what actually collects, scales with your test volume instead of your headcount, and puts denial patterns in front of people who have seen them across dozens of labs rather than one. It also gives ownership something in-house billing rarely produces: reporting honest enough to make decisions with.
Practical reasons, not slogans
- Billers assigned to laboratory work — not a general pool rotating between specialties
- A named account manager and direct answers when something goes wrong
- Monthly reporting that shows denial reasons and AR aging instead of vanity numbers
- Coding kept current with CPT, HCPCS, and NCCI updates every quarter
- HIPAA-compliant processes across the whole workflow
- Recommendations in writing — including the ones that reduce our own fee, like fixing a requisition form so fewer claims need rework
Laboratory billing services in the USA — at any volume
A few hundred requisitions a month or tens of thousands, the workflow scales either way.
What lab directors ask us first
Do you bill both clinical laboratory and anatomic pathology?
Our requisitions come in with missing or vague diagnosis codes. How do you handle that?
Can you manage Medicare's G-codes for definitive drug testing?
Do you handle prior authorizations for genetic and molecular tests?
Which billing systems and LIS platforms do you support?
How do you charge for laboratory billing services?
Can you clean up our existing accounts receivable?
How long does it take to switch from our current billing company?
Send us a recent aging report. We'll tell you what we see.
If your denial rate is creeping up, your AR over 90 days keeps growing, or you simply don't know how your lab's billing is performing — we'll review it and give you a straight assessment of what's collectible. No obligation attached.
Schedule a free billing review