Search 30+ common laboratory CPT codes — what each covers, the billing pitfalls, and how Medicare's fee schedule prices it.
Most clinical lab tests aren't priced like physician services. Here's the 60-second version:
Under PAMA, Medicare pays the weighted median of private-payer rates that labs report — not a resource-based fee schedule. Rates update on a 3-year cycle.
Every code's national payment amount lives in the CMS CLFS data files, updated quarterly. Always verify the current file before quoting or appealing.
Check any code's current Medicare rate in the official CMS Clinical Laboratory Fee Schedule files.
Open CMS CLFS files →In MolDx jurisdictions, molecular panels face strict coverage rules. Stacking per-organism codes (like 87798 × N) without meeting criteria is a top audit trigger.
Billing component codes alongside the panel code that includes them — payers see it, deny it, and flag the account.
Screening diagnosis on a diagnostic test (or vice versa) is the #1 lab denial driver. The diagnosis must match the test's coverage rules.
Most lab billing shortfalls trace back to compliance gaps, not payer stinginess.
Certificate of Waiver, PPM, Compliance, or Accreditation — bill only tests your certificate level covers. Billing non-waived tests on a waiver certificate is an automatic denial and a compliance risk.
Written test-ordering protocols, documented medical necessity for every order, ABN on file before non-covered testing, and specimen chain-of-custody. Auditors ask for these first.
Reconcile every remittance against the CLFS and your payer contracts. Underpayments and silent downcodes are where lab revenue quietly leaks — a monthly reconciliation worklist recovers it.
We handle laboratory billing end to end — CLFS reconciliation, MolDx compliance, panel unbundling fixes. Send your denial report for a free read.