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Specialty billing

Laboratory billing services

Laboratory billing is coding and claiming each test a lab runs with the diagnosis that justifies it, the provider who ordered it and the lab’s CLIA number, so the payer can match the test to its order.

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Laboratory

What a lab claim carries

  • The orderNPIThe ordering provider, enrolled in Medicare
  • The labCLIAA certificate that covers the test; QW if waived
  • The diagnosisICD-10GAOn the covered list, or an ABN signed
For a Medicare patient, each of these is checked before it goes.

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Check what a lab claim needs

The order, the lab’s certificate and the diagnosis each put something on the claim.

What does this lab claim need?

Medicare and others

Tick what is true for the test.

The claim carries

  1. 1The ordering provider’s NPI, matching the order
  2. 2An ordering provider enrolled in Medicare
  3. 3The lab’s CLIA number, on a certificate that covers the test
  4. 4Modifier GA: the patient signed an ABN, so they can be billed if Medicare denies it

Why is laboratory billing hard?

  • Coverage depends on the diagnosis

    For many tests, Medicare and other payers list the diagnoses they cover. A test ordered with a diagnosis outside that list is denied, and a Medicare patient can be billed for it only if they signed an Advance Beneficiary Notice before the test.

  • Every claim carries the order

    A lab claim names the provider who ordered the test, by NPI, and Medicare denies it when that provider isn’t enrolled in Medicare. The order’s details have to match what the claim says.

  • CLIA rules on every test

    Medicare claims for lab tests carry the lab’s CLIA certificate number, and the certificate has to cover the test billed. Waived tests billed to Medicare need the QW modifier.

  • Two sets of drug testing codes

    Presumptive drug screens are billed with 80305–80307, and definitive tests by the number of drug classes: G0480–G0483 for Medicare, 80320–80377 for many other payers. Payers also limit how often each is paid.

  • Molecular tests need more than a code

    Molecular tests have their own CPT codes (81105–81479) and proprietary laboratory analysis codes ending in U, and some Medicare contractors also want the lab’s test registered with an identifier before they pay.

What Beeline handles for laboratories

Laboratory billing questions

Why does a CLIA number go on a lab claim?
CLIA, the Clinical Laboratory Improvement Amendments, requires every lab that tests human specimens for diagnosis or treatment to hold a CLIA certificate. Medicare claims for lab tests must include the lab’s CLIA number, and the type of certificate has to cover the tests billed: a lab with a certificate of waiver can bill only waived tests, with the QW modifier.
What is an Advance Beneficiary Notice for lab tests?
An ABN is a form a Medicare patient signs before a test that Medicare may not cover for their diagnosis. With a signed ABN, the claim is sent with modifier GA and, if Medicare denies it, the patient can be billed. Without one, the lab generally can’t bill the patient for a test Medicare denied as not medically necessary.
What is the difference between presumptive and definitive drug testing?
A presumptive test shows whether a drug class may be present, usually by immunoassay, and is billed with 80305, 80306 or 80307 depending on the method. A definitive test identifies the specific drugs, usually by mass spectrometry, and is billed by the number of drug classes tested: G0480–G0483 for Medicare, 80320–80377 for many other payers.

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