Clinical laboratories are essential to modern healthcare, providing diagnostic testing that informs nearly 70% of medical decisions. But behind every test is a billing process that’s often far more complex than the analysis itself. Clinical lab billing requires deep knowledge of CPT/HCPCS codes, payer policies, compliance rules, and laboratory-specific documentation standards.

At Progressive RCM, we specialize in providing tailored lab billing services that reduce denials, ensure clean claims, and accelerate cash flow — whether you operate a toxicology lab, pathology lab, molecular diagnostics lab, or general reference lab.

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Why Clinical Laboratory Billing Is Complex

Billing for lab services involves multiple layers of compliance, coding, and payer-specific nuances. Here’s why it’s uniquely challenging:

1. High Volume, Low Margin Testing

Labs often handle thousands of tests daily, but margins are thin. Even small coding errors or claim delays can significantly affect revenue.

2. Code Selection and Bundling Rules

Proper use of CPT, HCPCS, and ICD-10 codes is crucial. Some lab tests are bundled, while others require separate billing. Understanding NCCI edits is essential to avoid denials.

3. Medical Necessity and Coverage Policies

Payers require documentation proving a test’s medical necessity. LCDs and NCDs from CMS are constantly evolving, making compliance critical.

4. Prior Authorization Requirements

Some payers require prior auth for genetic testing, drug screenings, and molecular diagnostics — skipping this step leads to automatic denials.

5. Specimen Handling and Transportation

Billing for specimen collection (CPT 36415) and transportation (HCPCS G2023, G2024) depends on the testing site and payer rules.

6. COVID-19 and Molecular Testing Complexity

COVID-19, PCR, and molecular diagnostic tests have specific codes, coverage timelines, and emergency guidance from CMS and commercial payers.

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Progressive RCM’s Clinical Lab Billing Services

We provide complete revenue cycle management for independent labs, reference labs, and hospital-based diagnostics labs.

✅ Accurate Lab Coding & Charge Capture

We assign proper CPT and HCPCS codes based on the test type, including:

• 80048–80076 – Panels (metabolic, hepatic, etc.)

• 82306 – Vitamin D

• 82565 – Creatinine

• 82607 – Vitamin B12

• 82947 – Glucose

• 87426 – SARS-CoV-2 (COVID-19) antigen

• G2023 / G2024 – Specimen collection

• 80305–80307 – Drug testing

• 814xx – Molecular pathology and genetic testing

Our team applies ICD-10 diagnosis codes that support medical necessity per payer policies.

✅ Real-Time Eligibility & Prior Authorization

We verify patient eligibility and determine if prior authorization is needed for complex or high-cost tests, such as:

• Genetic panels

• Pharmacogenomics

• Molecular diagnostics

• Cancer screenings

• Allergy testing

This ensures fewer denials and smoother reimbursement.

✅ Claims Submission & Scrubbing

We submit all claims within 24–48 hours and use advanced scrubbing to detect and fix coding errors, modifier issues, and bundling conflicts before submission.

✅ Denial Management & Appeals

We review every denied claim, determine root causes (medical necessity, missing codes, etc.), and reprocess or appeal with necessary documentation.

✅ Payment Posting & Reconciliation

Our payment team posts payer and patient payments daily, identifies underpayments, and reconciles amounts against payer contracts to detect shortfalls.

✅ Patient Statements & Collections

Clear, professional billing statements are sent to patients with easy payment options, improving the patient experience and increasing collections.

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Types of Labs We Support

We provide billing support to a wide variety of lab types:

• Toxicology Labs

• Molecular Diagnostics Labs

• Genetic Testing Labs

• Clinical Chemistry Labs

• Pathology Labs

• COVID-19 Testing Labs

• Hospital-Based and Reference Labs

• Mobile Collection Units

Each lab type requires a different billing strategy, which our team tailors accordingly.

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Our Lab Billing Workflow

1. Test Order Review & Eligibility Check
   Ensure accurate test requisition and payer eligibility before processing.

2. Charge Entry & Coding
   Assign CPT, HCPCS, and ICD-10 codes with correct modifiers and panels.

3. Claim Scrubbing & Submission
   Electronic submission with pre-scrub for errors and payer-specific edits.

4. Payment Posting & Reporting
   Post remittances and compare with expected reimbursement rates.

5. AR Follow-Up & Denial Management
   Rebill or appeal any unpaid or denied claims quickly and with proper documentation.

6. Compliance Monitoring
   Ensure billing complies with CLIA, CMS, and OIG guidelines.

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Why Choose Progressive RCM for Lab Billing?

✅ Lab-Specific Coding Experts
Our coders are trained specifically in lab CPT/HCPCS codes, ICD-10 pairing, and panel vs. individual test billing.

✅ Real-Time Compliance Updates
We stay current with LCD/NCD changes, payer policies, and CMS updates — especially for COVID-19 and molecular testing.

✅ Revenue Integrity Focus
We audit charge capture to prevent underbilling and ensure maximum reimbursement without overcoding.

✅ CLIA Compliance Support
We help ensure tests are billed in accordance with CLIA certification levels and test complexity rules.

✅ Fast Turnaround Time
Claims are processed quickly to reduce your Days in AR and improve cash flow.

✅ EMR/LIS Integration
We work with LabDaq, Orchard, AdvancedMD, Kareo, LIS systems, and hospital EMRs.

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Key Metrics We Track

• First-pass claim acceptance rate

• Denial rate by test type

• Days in A/R

• Net collection ratio

• Claims rejected due to medical necessity

• CLIA certification compliance rates

• Average reimbursement by payer

We use these insights to enhance your lab’s financial performance and reduce billing risk.

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SEO Keywords Used:

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Final Thoughts

Laboratory billing is one of the most regulated and fast-moving parts of healthcare revenue cycle management. With changing payer rules, coding complexity, and audit risks, your lab’s financial health depends on accurate and compliant billing.

At Progressive RCM, we offer expert clinical lab billing solutions to ensure timely reimbursements, reduce denials, and help your lab grow — whether you perform routine chemistry or advanced molecular diagnostics