Pathology Billing Services
The specialty world of pathology billing comprises tiered tests, reflex algorithms, molecular panels, anatomic and clinical coding, reference lab processes, and sophisticated payer regulations. Denials or underpayments can be sparked by little errors, including the incorrect specimen modifier, a missed panel code, or a mismatched diagnosis. We at Sirius Solutions Global focus on pathology billing services that catch the whole clinical and financial worth of every test while keeping you audit-ready and compliant.
Our Pathology Billing Services end-to-end, specialty-focused
We based our pathology services offering on the actual processes laboratories use. You will get:
1. Lab & Specimen Charge Capture
Precision mapping from lab orders to billable expenses, including reflex/addon logic, specimen-specific modifiers, and collection/supply fees.
2. Anatomic Pathology Coding & Case-Level Capture
To make sure CPT/ICD mappings mirror the actual procedures and diagnoses—from biopsies and excisions to histochemistry and immunohistochemistry—specialist coders examine final pathology reports.
3. Molecular & Genetic Test Billing
Deal with NGS, companion diagnostics, and pharmacogenomics, including payer-specific bundling, prior authorizations, and accurate allocation of lab-specific codes as well as complex molecular panels.
4. Reference Lab & Send-Out Management
Manage intercompany pricing and adjustments, coordinate sendout billing, and make sure outsourced testing is accurately attributed to payers.
5. Eligibility, Benefits & Prior Authorization
Real-time eligibility verification together with prior authorization control for high-cost tests helps us to gather medical records and payer follow-through.
6. Claim Scrubbing & Submission
Catch payer-specific changes (medical necessity, bundling, modifier mismatches) before claims go out using AI-assisted, rules-driven scrubbing.
7. Denial Management & Appeals
Root cause analysis of denials (medical need, coding, clinical records, or payer systems) and appeals with clinical attachments where necessary.
8. Payment Posting & Reconciliation
Contract validation, automated follow-up processes, and quick ERA/EOB postings enable underpayment detection.
9. Reporting & Lab-Focused KPIs
Dashboard for net collection rate, A/R days, top deniers, sendout performance, and test profitability by CPT panel.
10. Compliance & Audit Support
Designed to pass audits are documentation bundles and chart-ready data for medical necessity, test justification, and lab operating procedures.
Common pathology denial drivers (and how we fix them)
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Missing or wrong specimen modifiers → we confirm the specimen source against the order and report.
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Unbundling/bundling errors on reflex tests → we apply payer rules and attach clinical logic for appeals.
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Incorrect send-out payer attribution → we reconcile lab contracts and ensure the right payer is billed.
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Medical necessity denials for high-cost molecular tests → we package supporting clinical notes and lab rationale to succeed on appeal.
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Underpayments from contract misapplied rates → we check invoices versus contracted fee schedules and recoup shortages.
Why pathology billing needs a specialist
Pathology billing isn’t “regular” medical billing. It’s laboratory billing with extra rules:
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Tests come in panels and tiers (reflex testing, add-on tests, send-outs).
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Molecular and genetic testing uses evolving CPT/HCPCS and payer rules.
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Anatomic pathology requires linking specimen source, biopsy type, and procedure codes.
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Reference labs bring separate billing flows, courier fees, and contractual pricing.
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Result-driven coding (e.g., additional stains or molecular work after review) must be captured as add-ons and documented.
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Payer medical necessity reviews for high-cost panels are common.
All that means pathology revenue is fragile unless you have coders who know both the lab and the payers plus systems that automate the repetitive checks.
Who benefits most from our pathology billing services?
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Independent anatomic pathology groups and AP/CP labs
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Hospital-based pathology departments and academic centers
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Reference labs and specialty testing centers
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Molecular diagnostics & genetic testing companies
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Integrated health systems with centralized lab operations
Onboarding practical and low friction
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Discovery & sample audit — we look for quick wins (missed panels, recurring deniers).
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Workflow mapping & EHR/LIS integration — we connect charge capture and lab systems.
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Parallel testing — we process claims side-by-side until accuracy is proven.
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Go-live with ongoing optimization — weekly reviews at first, then monthly KPI reviews.
AI + human expertise — how we actually reduce denials
We use automation where it saves time and humans where judgment matters:
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Pre-submission AI scrubs catch mismatched specimen modifiers or missing add-on codes.
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Machine learning highlights tests with high denial risk (e.g., new molecular panels), so coders can preempt issues.
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Our coders interpret pathology reports and ensure the coded claim reflects the final clinical decision.
Bottom line: automation reduces repetitive errors; senior coders prevent clinically nuanced mistakes.
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Let’s protect your lab revenue and give your team breathing room
Pathology delivers answers for clinicians and patients. Billing should be the invisible engine that pays the bills and frees your team to focus on care. If your lab is fighting denials, losing revenue on send-outs, or spending too much time reconciling underpayments, we can help. Contact Sirius Solutions Global for a free pathology billing assessment and baseline audit. We’ll show you where revenue is leaking and how to plug the holes with clear next steps and projected outcomes.