Laboratory Billing Services by Specialty
Coding, claim submission, and denial follow-up for molecular, clinical, pathology, and toxicology labs.
Molecular Lab Billing
Clinical Lab Billing
Pathology Lab Billing
Toxicology Lab Billing
Each laboratory specialty bills under its own code sets, fee schedules, and payer policies. PGM's certified coders apply those rules from accession through final payment, handling payment posting, appeals, and patient statements alongside claim submission for independent laboratories nationwide. PGM was founded in 1981 and is independently owned.
Molecular and Genetic Lab Billing
Molecular lab billing requires the correct code for each test and, for many Medicare claims, a registered test identifier. The AMA CPT Editorial Panel updates molecular pathology codes annually and releases Proprietary Laboratory Analyses (PLA) codes quarterly, so code assignments change throughout the year. Medicare contractors in the MolDX program require labs to register each molecular test in the DEX Diagnostics Exchange and report its assigned Z-Code on the claim, and claims missing the Z-Code are denied. Some commercial payers have adopted Z-Code requirements as well. PGM tracks code updates, Z-Code assignments, and coverage policies for every test a lab bills.
Learn more about molecular lab billingClinical Laboratory Billing
Clinical laboratory billing covers high-volume routine testing, most of which Medicare pays under the Clinical Laboratory Fee Schedule (CLFS). Under the Protecting Access to Medicare Act (PAMA), CLFS rates are based on private payer data that applicable laboratories report to CMS, and Congress has repeatedly delayed or capped scheduled rate reductions. Because rates can shift from year to year, clinical labs need current fee schedules loaded and underpayments flagged as remittances arrive. PGM manages clinical lab claims with payer-specific edits and denial follow-up designed for high test volumes.
Learn more about clinical lab billing
PGM's certified coders and billing specialists manage the full revenue cycle for independent laboratories.
Pathology Lab Billing
Pathology lab billing spans surgical pathology, cytopathology, hematopathology, and clinical pathology, each with separate CPT code families and documentation requirements. Surgical pathology codes 88300 through 88309 are assigned by specimen level, so the code follows the specimen described in the pathology report. Medicare pays anatomic pathology under the Physician Fee Schedule, where a claim is billed as professional (modifier 26), technical (modifier TC), or global depending on who performs each part of the service. National Correct Coding Initiative (NCCI) edits add bundling rules on top. PGM codes from the pathology report and bills global, professional, and technical claims for independent labs and pathology groups.
Learn more about pathology lab billingToxicology Lab Billing
Toxicology lab billing separates drug testing into presumptive and definitive testing, and payers code the two differently. Medicare requires CPT 80305 through 80307 for presumptive tests and HCPCS G0480 through G0483 or G0659 for definitive tests, with one definitive code per date of service based on the number of drug classes tested. Commercial payers may instead accept the CPT definitive drug testing codes 80320 through 80377. Payers and federal agencies review drug testing closely for medical necessity and overutilization. PGM applies each payer's code set and drug class rules to every toxicology claim.
Learn more about toxicology lab billing
Talk With a Laboratory Billing Specialist
Frequently Asked Questions About Laboratory Billing
What do laboratory billing services include?
Laboratory billing services cover the revenue cycle from test order to final payment: coding, demographic and charge entry, claim review, claim submission, payment posting, claim tracking, denial management, patient billing, and reporting. PGM checks every claim against CPT, ICD-10, modifier, and payer-specific edits before submission and gives labs real-time claim status through its laboratory analytics platform. Labs can also test individual claims with PGM's free Medical Claim Scrubber.
Should a laboratory outsource billing or keep it in-house?
Outsourcing suits labs whose staff can't keep pace with coding updates, payer rules, and denial follow-up, or whose growth plans would outstrip current billing capacity. Keeping billing in-house preserves direct control, but the lab carries the full cost of:
- Recruiting and retaining coders with laboratory experience
- Billing software licenses and clearinghouse connections
- Coverage when billing staff leave
Before deciding, compare the lab's clean claim rate, denial rate, and days in accounts receivable against the metrics an outsourced partner commits to reporting.
How do laboratory billing companies charge for their services?
Laboratory billing companies commonly charge a percentage of collections; others charge per claim or per accession. PGM's fees are based on collections, so its revenue depends on what the lab collects. When comparing proposals, confirm which services the fee includes, such as patient billing, appeals, credentialing, and reporting.
How does a billing company receive data from a lab's LIS?
Labs with a laboratory information system (LIS) typically send patient demographics and accession charges to their billing company through an HL7 interface. PGM receives that data in real time through LIS integration, so charges enter its practice management system without manual re-entry. Labs without an LIS can send data by scan, fax, or courier, and a dedicated PGM account representative enters it.
Do laboratory billing services include patient billing?
PGM's laboratory billing services include patient billing: statements tailored to each lab, follow-up letters and calls, and a toll-free line staffed by patient billing specialists. PGM does not perform collections. When a patient cannot or will not pay, PGM works with the lab to arrange a payment plan or move the balance to a third-party collection agency.
Can a lab billing company also handle credentialing and payer enrollment?
PGM offers credentialing services alongside billing, including Medicare enrollment and revalidation, CAQH maintenance, and enrollment with commercial insurance networks. Enrollment needs to be in place before a lab bills, since payers generally deny claims for services performed before the lab's effective date.
What is the Medicare 14-day rule for laboratory tests?
The 14-day rule sets the Medicare date of service for tests on specimens collected during a hospital stay or outpatient encounter. Normally the date of service is the collection date, so the test falls under the hospital's billing and the lab seeks payment from the hospital. When a physician orders the test at least 14 days after the patient's discharge, the date of service becomes the date the test was performed, and the lab bills Medicare directly. A separate CMS exception lets labs bill Medicare directly for certain molecular pathology and advanced diagnostic tests on hospital outpatient specimens when the test is performed after discharge, its results did not guide treatment during the encounter, and the other CMS conditions are met.
When does a lab need an Advance Beneficiary Notice (ABN)?
A lab needs a valid ABN to bill a Medicare patient for a test Medicare is expected to deny as not medically necessary, such as a test ordered more often than a coverage determination allows or with a diagnosis the policy does not cover. The patient must sign the ABN before the service is provided. Because labs rarely see the patient, the ordering provider's office or draw site usually presents the notice. Each ABN must identify the specific test and give an estimated cost, and routine ABNs signed by every patient regardless of coverage are not valid.
Do Medicare patients pay coinsurance for clinical lab tests?
Medicare Part B patients generally owe no deductible or coinsurance for clinical diagnostic lab tests paid under the CLFS. A lab can bill the patient for those tests only when Medicare does not cover them, such as a denied test with a valid ABN on file. Anatomic pathology services paid under the Physician Fee Schedule carry the standard Part B deductible and 20% coinsurance, and Medicare Advantage plans may set their own lab copays.