Lab Testing Types & Billing Rules

The Eight Types

Types of Laboratory Testing

The major test families and what makes each one billable.

Clinical Chemistry

Metabolic panels, lipid panels, A1C, thyroid tests. Blood work billed mostly as panels (80048, 80053, 80061) - unbundling panels into components is a classic denial trigger.

Hematology

CBC (85025), coagulation studies, ESR. Straightforward billing, but frequency limits apply - repeat CBCs without documented reason get questioned.

Microbiology

Cultures and sensitivities. Lower dollar per test, but volume adds up. Medical necessity hinges on signs of infection in the record.

Molecular / PCR

Respiratory panels (87631-87633), UTI panels, wound pathogen panels, multiplex PCR. The highest-scrutiny category in lab billing - payers routinely demand records.

Genetic Testing

Hereditary panels (81105-81479), pharmacogenomics. Often needs prior auth. Payers apply strict coverage policies - test must change management.

Toxicology

Drug screens: presumptive (80305-80307) and definitive (G0480-G0483). Definitive testing without a documented reason for the presumptive result is a top denial.

Immunology / Serology

Antibody tests, infectious disease markers. Straightforward when the diagnosis supports the test.

Pathology

Histopathology (88300-88309), cytopathology. Billed per specimen and per level - specimen counts must match the pathology report.

Billing Watch-Outs

Billing Rules by Test Type

Where each category loses money.

Test type	Example CPT	Billing watch-out
Chemistry panels	80048, 80053, 80061, 83036	Bill the panel code, not the components. Component stacking past panel definitions triggers unbundling edits.
Molecular respiratory	87631-87633, 87635	Payers request records on nearly every panel. Standing orders without patient-specific justification get denied.
Molecular UTI / wound	87480-87801 range	Medical necessity documentation must show symptoms or risk factors. Screening panels without symptoms rarely survive review.
Genetic panels	81105-81479	Prior auth is common. Family history alone often fails coverage - the test must guide treatment.
Toxicology definitive	G0480-G0483	Definitive testing needs a documented medical reason beyond the presumptive screen result.
Pathology levels	88300-88309	Level must match the specimen complexity in the report. Upcoded levels are audit bait.

Molecular Scrutiny

Why Molecular Labs Get Audited

Molecular testing is the most reviewed lab category. Here is what payers look for.

Standing orders that test every patient with the same panel regardless of symptoms
Panels billed when only one or two targets were clinically indicated
Missing physician orders or orders signed after the date of service
Medical records that do not document the signs, symptoms or risk factors justifying the panel
Our defense: patient-specific orders, symptom documentation checks and LCD coverage verification before billing

FAQ

Questions, Answered

Straight answers, no jargon.

What is the difference between presumptive and definitive drug testing?

Presumptive testing (80305-80307) is the initial screen. Definitive testing (G0480-G0483) confirms and quantifies. Payers expect a documented reason for moving from presumptive to definitive - usually an unexpected screen result.

Why do payers request records for molecular panels?

Because panel costs are high and ordering patterns vary widely. Payers verify that the patient's symptoms justified the panel and that a physician ordered it for that specific patient.

Can a lab bill both a panel code and its component codes?

No. That is unbundling. When a panel code exists for the tests performed, bill the panel code only.

What is an LCD in lab billing?

A Local Coverage Determination is the MAC's written policy saying which diagnoses support which tests. Billing a test for a diagnosis the LCD does not list is a predictable denial.

Do genetic tests need prior authorization?

Very often, yes. Most payers require auth for hereditary and pharmacogenomic panels, and coverage usually requires that results will change clinical management.

How It Works

From Leaking Revenue to Steady Cash Flow in 4 Steps

The same proven process behind every lab engagement.

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Lab Testing Types