Molecular diagnostic laboratories are at the forefront of personalized medicine, offering advanced testing such as genetic screening, PCR-based diagnostics, cancer genomics, and infectious disease detection. These labs provide vital data that guide early detection, treatment selection, and disease monitoring.

However, molecular lab billing is highly specialized. It involves high-cost procedures, frequent payer policy updates, and complex coding rules, especially when it comes to panel tests, modifier use, and prior authorization. Without expert billing support, labs often face claim denials, payment delays, and compliance audits.

At Progressive RCM, we help molecular labs navigate these challenges by offering end-to-end revenue cycle management designed to ensure fast, full reimbursement while maintaining compliance with CMS and commercial payer requirements.

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Why Molecular Lab Billing Is So Complex

1. Rapidly Evolving CPT Codes

Molecular diagnostics use specialized CPT codes that are frequently updated or split. Many tests are billed using tiered codes (e.g., 81400–81408) or PLA codes (Proprietary Laboratory Analyses), and require proper coding for each component of a panel.

2. Payer Policy Variability

Private and government payers may:

• Limit coverage to specific ICD-10 codes

• Require documentation of medical necessity

• Deny coverage for screening tests or unvalidated biomarkers

• Have separate rules for Medicare LCDs (Local Coverage Determinations)

Keeping track of payer guidelines is crucial.

3. Prior Authorization Requirements

Many molecular tests (e.g., pharmacogenomics, hereditary cancer panels) require prior authorization or genetic counseling documentation. Failure to obtain this results in non-reimbursed claims.

4. Bundling and Panel Testing Confusion

Payers may bundle panel tests into a single code or expect individual CPTs. Labs must decide whether to bill tests separately or use panels and ensure compliant modifier use (e.g., 59, XE).

5. High-Cost Tests with Risk of Write-Offs

Some tests cost labs hundreds or thousands of dollars, making proper billing essential. Even a small error in coding or documentation can result in significant revenue loss.

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Common CPT, HCPCS, and ICD-10 Codes in Molecular Lab Billing

✅ CPT Codes:

• 81220 – BCR-ABL1 gene rearrangement

• 81225 – CYP2C19 gene analysis (pharmacogenetics)

• 81229 – CFTR (cystic fibrosis) mutation analysis

• 81355 – TP53 gene analysis (cancer)

• 81401–81408 – Tier 2 molecular pathology codes

• 81420 – Fetal chromosomal aneuploidy

• 81445 – Hereditary breast cancer panel

• 87635 – COVID-19 PCR testing

• 87900–87904 – Viral load testing (HIV, HCV)

✅ HCPCS Codes:

• G0452 – Molecular pathology interpretation

• G0480–G0483 – Drug testing

• U0003/U0004 – COVID-19 lab tests (non-CDC)

• S3854 – BRCA1/BRCA2 testing

✅ ICD-10 Codes (Examples):

• Z15.01 – Genetic susceptibility to breast cancer

• C50.919 – Malignant neoplasm of unspecified breast

• Z13.79 – Encounter for genetic screening

• F32.9 – Major depressive disorder (for pharmacogenomic testing)

• Z11.59 – Encounter for screening for other viral diseases

• B20 – HIV disease

• R79.89 – Other specified abnormal findings of blood chemistry

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Our Molecular Lab Billing Services

At Progressive RCM, we provide a full suite of molecular lab billing services, from code validation to denial appeals, built around maximizing revenue for complex testing workflows.

✅ Test Verification and Code Assignment

• Match lab tests with correct CPT/PLA/HCPCS codes

• Identify bundling vs. separate code billing

• Assign proper modifiers (59, 91, 76) as needed

✅ Prior Authorization and Eligibility

• Verify coverage and prior authorization needs

• Submit PA requests with supporting documentation

• Track approvals and denials from payers

✅ Clean Claim Submission

• Submit claims within 24–48 hours of test completion

• Customize claim forms for Medicare, Medicaid, and commercial payers

• Avoid denials through claim scrubbing and code validation

✅ Documentation and Compliance

• Match test results with supporting diagnosis codes

• Ensure compliance with CMS LCD/NCD policies

• Provide audit readiness documentation for high-risk codes

✅ Payment Posting and Reconciliation

• Post ERA/EOBs promptly

• Flag and correct underpayments

• Reconcile lab cost vs. reimbursement to identify loss points

✅ Denial Management and Appeals

• Track denial reasons: coverage limits, bundling, missing documentation

• File timely appeals with necessary documentation

• Review and adjust billing workflows based on denial trends

✅ Reporting and KPI Dashboards

• Revenue by payer, CPT, and referring provider

• Denial rates and turnaround time

• Net collection rate

• Profit margin per test or panel

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Why Choose Progressive RCM for Molecular Lab Billing?

✅ Molecular Pathology Billing Specialists
We have certified coders trained in genetic testing, pharmacogenomics, and molecular diagnostics, ready to manage evolving code sets and policies.

✅ Full Compliance with Medicare and LCD Guidelines
We stay updated with CMS policies, including MolDX program requirements, and help ensure full documentation support.

✅ Customizable Solutions for All Lab Sizes
Whether you’re a high-volume national lab or a start-up molecular diagnostic center, we tailor solutions for your size and testing volume.

✅ Transparent Communication and Reporting
We provide real-time dashboards, monthly financial reports, and compliance summaries so you know where every claim stands.

✅ Boost Revenue While Lowering Risk
Our approach improves first-pass acceptance rates, reduces write-offs, and prevents compliance penalties or payer clawbacks.

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KPIs We Monitor for Molecular Labs

• Claim acceptance rate

• Average reimbursement per test

• Denial rate by CPT and payer

• Days in AR (accounts receivable)

• Reimbursement to cost ratio

• Prior authorization turnaround time

• Clean claim rate

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Final Thoughts

Billing for molecular labs demands precision — just like the testing itself. From navigating complex CPT codes and Medicare policies to managing prior authorizations and bundled panels, accurate billing is essential to ensuring your lab is profitable and compliant.

At Progressive RCM, we act as an extension of your laboratory team — offering the billing expertise, payer knowledge, and compliance tools needed to help your lab succeed in a highly competitive and regulated industry.