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Billing Guidelines for Pathology Lab Owners – How to Get More Reimbursements

by | Feb 7, 2023

billing guidelines

There are various methods followed while billing pathology services. In addition, the methods depend on the agreements between labs and providers. In general, the revenue cycle process of laboratory billing revolves around the interactions between providers, labs, and insurance payers. Staying accustomed to pathology billing guidelines makes the revenue cycle process run smoothly. As a result, pathologists can streamline the billing cycle to avoid claim denials. Now, let’s look into some CPT codes and modifiers which can help pathologists submit clean claims and optimize financial performance.

Pathology CPT Codes and Modifiers

Clinical lab tests or examinations are billed according to their relevant medical codes (CPT 80000 series). In addition, there are different codes and modifiers according to the examinations physicians recommend. Also, the pathology coding depends on the contractual agreement between the physicians and the facility. However, the crucial determinant of billing and coding for pathologists depends on the nature of agreement with the Medi-Cal program. Further, the facilities which are not under the contract with Medi-Cal need to make an agreement with the physician.

The pathology coding guidelines according to the Department of Health Care Services are as under:

Split-Billable Services

There is no need to use modifiers for professional and technical components. Likewise, modifier 26 can be added to define professional component and modifier TC can be used for technical component billing.

Not Split-Billable Services

To ensure separate reimbursements for services, keep in mind that not split billable services do not allow it. So, these services cannot be separately billed and submitted for reimbursements. 


The modifiers elaborate the medical claims to ensure the correct percentage of reimbursements for billed components. In addition, pathology billing guidelines for getting payments of lab tests and examinations require use of modifiers. Not every service requires a modifier for billing but there are some codes which should be billed with modifiers. As a result, labs can create an efficient billing process to get payments on time. Here are some key points related to modifiers:

  • Modifier 26 represents a professional component in split billing.
  • Modifier TC is a technical component.
  • Modifiers 26 and/or modifier TC must not be billed with modifier 99 because it will lead to claim denial.
  • Billing Proprietary Laboratory Analyses (PLA) codes, 33, 90, and 99 modifiers are used with the claims.
  • The instructions related to PLA codes are updated by the Department of Health Care Services (DHCS) according to the federal or state laws.
  • Modifier 90 depicts the service is performed by an outside laboratory but billed by another provider. Every provider cannot use it. Only specified providers may use it.
  • Modifier 99 shows two or more modifiers are necessary to define the procedure.
  • Modifier 33 defines services based on the evidence and recommended by the US Preventive Services Task Force.

Use Pathology Coding Guidelines to Grow Your Revenue

Identifying areas of growth is an important component of running a successful business. In addition, correct pathology CPT codes lead to timely payments from payers. Also, it increases the profitability of laboratories and ensures financial success. Similarly, labs need to focus on the revenue cycle performance and keep track of payments. As a result, it helps pathologists to make better financial decisions. So, there are some factors which help labs to get consistent cash flows and optimal reimbursements from payers.

Clean Claim Submissions

Accurate lab billing results in clean claim submissions and on-time payments. Also, it reduces the chances of claim denials and revenue losses. So, make sure the coding is accurate with proper modifiers to minimize the chances of errors.

Eligibility Verification

Laboratories can automate the process of eligibility verification or consult with lab billing companies which offer this service. As a result, pathologists can save their time and ensure a seamless process of verification.

Quick Claims Processing

The chances of getting paid on time increases with timely submission of claims. In addition, faster claim processing results in full payments from insurance companies. As a result, labs can get paid and substantially improve the bottom line.

Outsource Lab Billing to Experts

Understanding the pathology billing guidelines is essential to make sure labs are going in the right direction. In addition, laboratories need to increase revenue and improve workflow efficiencies at the same time. To do this, pathologists should dedicate their time and efforts to make their business successful. So, outsourcing the revenue cycle of your labs helps improve revenue growth. Laboratory Billing Services help pathologists optimize the financial performance and drive efficiency in the workflows.

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