Skip to main content
Medclaim Services Logo

Menu

Free Billing Audit

Specialties

Laboratory Billing Services

A laboratory bills thousands of low-value claims for patients it never sees, from requisitions written by someone else. Payment depends on the test matching the lab's CLIA certificate, the ordering provider's diagnosis matching coverage policy, panels being billed only when complete, and the right party being billed: the payer, the patient or the referring client.

  • Tests edited against your CLIA certificate before submission
  • Diagnosis codes linked to NCD and LCD coverage for each test
  • Client and patient billing separated from payer claims
Request a Free Billing Audit

Lab codes, CLIA modifiers and molecular tiers

How laboratory services are coded, from routine panels to genetic tests.

Laboratory code families and modifiers with billing notes
Codes or modifiersWhat they coverBilling notes
80047 to 80081Organ and disease panels, such as the basic and comprehensive metabolic panels and the lipid panel.When every test in a panel is performed, the panel code is billed; components are billed alone when the panel is incomplete, or with a modifier for repeat testing.
QWCLIA-waived test.Required by Medicare on many waived tests, while others have their own codes; the certificate must cover the test billed.
CLIA certificate typesCertificate of waiver, provider-performed microscopy, registration, compliance and accreditation.Claims are edited against the certificate number and the complexity of each test.
81105 to 81479Molecular pathology: Tier 1 codes and Tier 2 codes (81400 to 81408), each Tier 2 code covering a list of procedures.Some contractors require tests to be registered with a test identifier before claims are paid.
81490 to 81599, PLA codesMultianalyte assays with algorithmic analyses, and Proprietary Laboratory Analyses codes.PLA codes describe proprietary tests.
80305 to 80307, G0480 to G0483Presumptive drug screening and Medicare definitive drug testing by drug class count.Specimen validity testing is included and not billed separately.
90, 36415Reference laboratory modifier, and routine venipuncture.The referring lab uses 90 when an outside lab performs the test; venipuncture is billed by whoever drew the specimen.

CPT is a registered trademark of the American Medical Association.

Official sources: CMS Claims Processing Manual, chapter 16 (laboratory) (external site), CMS Claims Processing Manual, chapter 30 (ABNs) (external site), eCFR: 42 CFR 414.510 (lab date of service) (external site), CMS NCCI Policy Manual, chapter 10 (pathology and laboratory) (external site), eCFR: 42 CFR 493.2 (CLIA certificate types) (external site), CMS Medicare Coverage Database: LCD L35160 (MolDX test identifiers) (external site), CMS coverage database: article A58917 (external site)

The requisition decides whether a lab gets paid

The lab cannot fix a weak order after the fact. Medicare covers many tests only for diagnoses listed in a national coverage determination, such as lipid panels or hemoglobin A1c, or in a local coverage determination, and the diagnosis must come from the ordering provider. When a test is likely not to meet those rules, a signed advance beneficiary notice is needed before the test is furnished, far enough ahead for the patient to decide, for the lab to bill the patient.

Medicare pays lab tests under the Clinical Laboratory Fee Schedule, with rates based on private payer data reported under PAMA. Congress has repeatedly changed the reporting dates and the limits on rate reductions, so we track the current schedule rather than quote rates.

Labs also sit inside other providers' workflows. Date-of-service rules for specimens collected during hospital care decide whether the hospital or the lab bills certain tests, reference lab work is billed with its own modifier, and labs generally must bill Medicare directly rather than through the referring practice.

Official source: CMS: Clinical Laboratory Fee Schedule (external site)

Client billing, patient billing and standing orders

Many labs bill some tests to the referring practice under a client agreement rather than to insurance. That is allowed for many commercial and self-pay arrangements, but Medicare generally requires the lab that performs the test to bill Medicare directly. Client pricing also needs a compliance review before it is offered, and each client account needs clear rules on which tests go to which party.

Standing orders are another risk area. The denials and audit findings we see come from orders that are not tied to one patient, run on with no end date, or repeat the same panel for every patient regardless of need. We review recurring order patterns with your clients and ask for patient-specific orders before they turn into denials or audit findings.

Rejected claim patterns for labs

  • Test not covered for the diagnosis

    The ordering diagnosis is not on the NCD or LCD covered list, and no ABN was signed before collection.

  • CLIA certificate does not cover the test

    A moderate or high complexity test billed under a certificate of waiver, or a missing CLIA number.

  • Panel billed incomplete, or components unbundled

    A panel billed without all its components, or components billed one by one when the panel applies.

  • Frequency limits exceeded

    Repeat testing sooner than the coverage policy allows without a documented reason.

  • Requisition without a valid ordering NPI

    The requisition has no ordering NPI, or names a provider who is not enrolled to order tests for that payer.

  • Molecular test not registered

    A genetic test billed without the identifier the contractor requires.

Working lab claims at volume

  1. Step 1: Screen requisitions at accession

    Missing diagnoses, ordering NPIs and ABNs are flagged when the specimen arrives, while the client can still fix them.

  2. Step 2: Run coverage and CLIA edits

    Each test is checked against NCDs, LCDs, frequency limits and your CLIA certificate before billing.

  3. Step 3: Route each charge to the right party

    Payer claims, patient statements and client invoices are separated by test and account.

  4. Step 4: Work denials by test and client

    Denials are grouped by test, payer and referring client to find the order patterns behind them.

Frequently asked questions

Can a lab add a diagnosis code that is not on the requisition?

No. The diagnosis must come from the ordering provider. If it is missing or unclear, the lab must ask the ordering provider rather than assign one.

When should a lab use an ABN?

When a Medicare test may not be covered, for example because the diagnosis is not on the coverage list or the test is too frequent. The ABN must be signed before the test is furnished for the patient to be billed if Medicare denies it.

Can we bill the components of a panel individually?

Not when all components of a panel were performed; the panel code is billed instead. If not every component was done, the individual tests are billed.

Why are our molecular test claims denied?

Often because the test is not registered with the identifier the contractor requires, the code does not match the test, or the payer's policy does not cover it for the diagnosis given.

Why do Medicare lab rates keep changing?

They are set under the Clinical Laboratory Fee Schedule using private payer data, and the reporting schedule and limits on reductions have been changed several times by law. We track the current status.

Official source: CMS: Clinical Laboratory Fee Schedule (external site)

Related services and specialties

See all specialties

Find the requisition problems behind your denials

A free audit groups your lab denials by test, payer and referring client, and checks CLIA and coverage edits.

Request a Free Billing Audit