Pathology Medical Billing Services - Compare Quotes From Proven Providers

Specimen-driven episodes of care

Each surgical case is tied to the number and type of specimens received. Coding and units often depend on tissue blocks, levels, and stains. Clear linkage from requisition to final report is essential.

Professional vs. technical components

Many pathology services allow split billing. Use modifier 26 for the professional interpretation and modifier TC for the technical component when the lab and the interpreting pathologist bill separately. Bill globally when your group owns both components and payer rules allow it.

Place of service and ownership

POS impacts payment and who is allowed to bill. Inpatient, outpatient hospital, independent lab, and outreach work can follow different rules. Confirm where the specimen was processed and who owns the equipment to support correct POS and component billing.

Client billing vs. direct-to-payer

Outreach programs often have client-bill arrangements with hospitals or physician groups. Set up clean routing so client-bill work never hits insurance and direct-to-payer work always includes complete subscriber and medical necessity data.

Surgical pathology level selection

Use the correct level (e.g., Level II–VI) based on specimen complexity, number of blocks, and work performed. Inconsistent level selection is a common audit trigger. Standardize criteria and document gross and microscopic effort in the final report.

Special stains, IHC, and ancillary studies

Special stains and immunohistochemistry are frequently under- or over-billed. Units should reflect the number of separately billed antibodies or stains performed per specimen. Avoid unbundling when a comprehensive panel code applies and be mindful of payer-specific limits.

Cytology nuances

For gynecologic cytology, follow screening versus diagnostic rules and include adequacy statements. For non-gyn cytology, match codes to specimen source and technique, and capture ancillary stains or cell block preparation when performed.

Molecular pathology and NGS panels

Tiered molecular codes and panel codes require precise documentation of the gene targets and methodology. Some payers prefer panel codes over stacking single-gene codes. Keep test menus mapped to current CPT to avoid mismatches and unnecessary denials.

Units and MUE considerations

Many pathology services are limited by Medically Unlikely Edits. Set automated checks so units for stains, IHC, FISH, and molecular tests do not exceed payer thresholds without strong supporting documentation.

Modifiers that matter

Use 26 and TC correctly for split billing. Consider 59 for distinct services only when documentation supports separate specimens, sites, or stages. Use 91 for repeat clinical lab tests when medically necessary and performed on the same day, and 76 for repeat procedures by the same physician when appropriate.

Documentation and medical necessity

Requisitions must include diagnosis, specimen source, and clinical history. Align reported diagnoses with payer LCDs and coverage policies. When coverage is limited, capture secondary diagnoses that legitimately support medical necessity.

Keeping billing in-house can work well when you have a stable team, predictable volume, and the capacity to hire, train, and cover vacations or turnover. You retain tight control over workflows but you also carry the risk and cost of staffing, QA, software, and performance management.

Outsourcing shifts those burdens to a specialized team that brings SLAs, denial management, and scalable capacity. It’s often a fit when claim volume is growing, denials are creeping up, or leadership wants to redeploy staff to patient-facing work without sacrificing cash flow.