Laboratory billing for independent clinical labs and physician office labs: test orders and the diagnosis behind them, Medicare’s lab coverage rules, ABNs, panels, CLIA-waived tests, and patient balances, billed from the requisition to the final payment.
A lab claim is only as good as the order behind it. Each test is billed from a complete requisition with the ordering practitioner and diagnosis, checked against Medicare’s coverage rules and each plan’s policies, coded as a panel when every component was run, and followed until it is paid or correctly billed to the patient.
$1.4B
in improper Medicare payments to independent clinical laboratories in CMS’s 2025 review, a 26.7% improper payment rate
96.4%
of those laboratory errors were missing or insufficient documentation
A lab rarely sees the patient’s chart. It bills on what the requisition says: the ordering practitioner, the tests and the diagnosis codes. When Medicare reviews a lab claim, it looks for an order and for the ordering practitioner’s records showing why the test was needed. If those are missing or do not support the test, the payment is taken back from the lab, not the practitioner.
The order and the diagnosis decide the claim. That is why we check every requisition for a complete order and a covered diagnosis, and ask for an ABN when one is needed, before the test is billed.
Lab claims are many, small and quick to deny. Most problems start before the test is run. Here is where each breaks, and what we do about it.
Pays forTests ordered by the practitioner treating the patient, with a diagnosis that supports them.
Where it breaks
What we do
Pays forTests that meet Medicare’s national lab coverage rules, local policies and each plan’s own policies.
Where it breaks
What we do
Pays forPanels, individual tests, specimen collection and repeat tests, coded and modified for each payer.
Where it breaks
What we do
Medicare pays for a diagnostic lab test only when it is ordered by the physician or practitioner treating the patient, who uses the result to manage the patient’s care (42 CFR 410.32). The lab bills on the order and the diagnosis the practitioner supplies, and must keep them. For many common tests, such as blood counts, lipid panels, thyroid tests and glycated hemoglobin, national coverage determinations list the diagnoses Medicare covers; local policies add more tests.
When a test is likely not covered for the diagnosis given, the patient can sign an Advance Beneficiary Notice before the specimen is collected. The claim then goes out with modifier GA, and the patient can be billed if Medicare denies it. Without the notice, the lab usually cannot collect from either.
What we do: we check each requisition for a complete order and a diagnosis that matches the coverage rule for each test. Where one does not, we flag it so an ABN can be obtained or the practitioner can be asked for the missing information, before the test is billed.
Lab claims draw on a long list of test codes, but a short list of rules decides most of them. These are the codes we see most, with what payers check on each.
| Code | What it covers | What payers look for |
|---|---|---|
| 8004880053 | Basic and comprehensive metabolic panels | Billed as the panel when every component was run. |
| 80061 | Lipid panel | The diagnosis on the coverage rule; screening once every 5 years for Medicare. |
| 85025 | Complete blood count with differential | A covered diagnosis under the blood count coverage rule. |
| 83036 | Glycated hemoglobin (HbA1c) | Frequency limits for monitoring diabetes. |
| 84443 | Thyroid stimulating hormone | A covered diagnosis under the thyroid testing coverage rule. |
| 8100181003 | Urinalysis, automated with and without microscopy | The diagnosis and, for waived tests, QW. |
| 87635 | SARS-CoV-2 amplified probe test | The plan's current coverage and the order. |
| 36415 | Venipuncture | Once per patient encounter, however many tubes are drawn. |
Medicare: a waived test performed under a certificate of waiver.
The same test repeated on the same day to get a new result, not a rerun.
A test sent to an outside lab and billed by the referring lab.
Medicare: a test that may not be covered, with a signed notice.
Medicare: a test expected to be denied, with no signed notice.
A test that edits would bundle but was distinct on this date. Our modifier 59 guide
Sources: Medicare Claims Processing Manual, chapter 16; Medicare NCD Manual, section 190 (lab NCDs); Medicare NCCI Policy Manual, chapter X (pathology and laboratory). CPT is a registered trademark of the American Medical Association; the descriptions above are summaries. Reviewed October 2026.
It is not for every practice. If you are a hospital-employed group whose billing the hospital handles, you do not need us. And if your in-house team keeps denials low and receivables current, keep them, and consider a periodic billing audit instead.
We look at your clean-claim rate, your denials by payer and reason, order completeness, diagnosis coverage, ABN use and panel coding, and your aging receivables, and tell you what we find, whether or not you go further with us.
We get access to your practice management system and clearinghouse, load each payer's authorization and bundling rules and your fee schedules, list your ordering practices and how requisitions reach you, and agree how escalations work. Most practices are live within one to two weeks.
Tests and collections are coded and claims submitted within 24 hours. Rejections are corrected the same day, remittances posted as they arrive, orders, diagnoses and coverage rules checked, and denials worked to their cause, all inside your system.
A report you can read in ten minutes: what was billed and collected by payer, site and service line, what was denied and why, authorizations pending, and what is aging.
You do not change systems to work with Summit Billing Solutions. We work in the software you already use and through your existing clearinghouse. The systems below are the medical practice systems we work in most; tell us what you use, and we will confirm how we would work in it.
95-98%
First-pass claim rate
24 hrs
Claims submitted within
28
Average days in A/R
Lab claims are numerous and individually small, so the cost of billing them adds up quickly. A fee that is a share of collections keeps that cost in line with what the tests actually pay.
Summit Billing Solutions charges between 3% and 9% of monthly collections. Your rate depends on test volume and mix, how many ordering practices send you work, your Medicare share and the state of the receivables, which we see in the free account review.
3% to 9%
of monthly collections
We bill for more than 40 specialties, for practices in all 50 states, from Salem, New Hampshire. Each one has its own codes, modifiers and payer rules.
A free account review looks at your clean-claim rate, your denials by payer and reason, order completeness, diagnosis coverage, ABN use and panel coding, and your aging receivables, and tells you what we would change. No cost, no obligation, and no pressure to continue. What the review covers, step by step, is on the free account review page.
50A Northwestern Dr Ste 3, Salem, NH 03079-4827
603-207-3172
(866) 906-3116
info@summitbillingsolutions.com
Mon - Fri @ 9am - 5pm
