MedCare MSO provides specialized molecular medical billing services to ensure compliance with regulations and maximize revenue. Our billing process has been honed over the years until it is a highly efficient system.
Genetic testing is a rapidly developing field and one of the things that make medical billing so complicated is that the billing codes just can’t keep up. Molecular testing is providing answers to ever more questions and helping physicians make important decisions, but it can be expensive, so insurers are resistant to approving tests.
To be successful at molecular lab billing, you have to know the billing codes, but also have experience with all the details that must be included. It also helps to have experience working with insurers. A claim that is denied or rejected needs to be appealed, and there’s a much better chance of getting paid for it if your biller knows just what to tell the insurer to establish medical necessity.
MedCare MSO offers specialized molecular, genetic, and diagnostic laboratory billing services to ensure claims are properly coded and submitted in a timely manner and with all supporting documentation. Our certified medical billing specialists are experts at what they do, and they stay on top of all changes to CPT codes. Our specialized knowledge and experience mean we submit accurate claims the first time and see increased collections on A/R accounts.
Constant changes in the field mean the CPT codes update regularly, making it difficult for in-house billers to keep up with the latest changes. In some cases, one code can be applied to ten different genes, but in others the gene isn’t specified so the claim has to be billed with an unlisted code. On top of that, there is another layer of management to deal with in the MolDX organizations and coding requirements.
Those facts all combine to indicate one thing: outsourcing the medical billing for molecular testing is a great solution for labs. The staff get a break from dealing with claims and the dedicated billing team at MedCare MSO gets claims paid.
Molecular pathology codes fall in the 81105 to 81479 range and are divided into Tier 1 codes for specific well-studied genes, Tier 2 codes for less common genes, Genomic Sequencing Procedure codes for next-generation sequencing panels, and Proprietary Laboratory Analyses codes for lab-specific tests. When no specific code applies, CPT 81479 (unlisted molecular pathology procedure) is used.
Tier 1 codes (81105 to 81383) cover commonly ordered gene-specific tests with established clinical use, such as BRCA1, EGFR, and KRAS analysis. Tier 2 codes (81400 to 81408) cover less common genes grouped by level of technical complexity. Code selection depends on the specific gene analyzed, not the condition being tested for.
Yes. The AMA adds hundreds of new codes annually, with a significant portion covering molecular diagnostics and proprietary lab analyses. MedCare MSO’s certified coding team reviews CPT updates each year and updates billing workflows accordingly so molecular testing claims are never submitted with outdated codes that trigger automatic payer denials.
Yes. The Protecting Access to Medicare Act (PAMA) requires labs to report private payer rate data to CMS, which directly determines Medicare reimbursement rates for clinical and molecular tests. MedCare MSO helps labs navigate PAMA reporting requirements and monitors rate changes so reimbursement expectations are adjusted before they impact cash flow.
Yes. MedCare MSO’s billing platform integrates with your Laboratory Information System to pull accession numbers, specimen types, and ordered tests directly into the billing workflow. This eliminates manual charge entry, reduces the risk of unbilled tests, and ensures CPT and ICD-10 codes are applied to every specimen before claims are submitted.
When the ordering physician interprets results separately from the lab performing the test, MedCare MSO applies modifier 26 for the professional component and modifier TC for the technical component, billing each to the correct entity. Incorrect component splitting is one of the most common denial triggers in molecular lab billing.
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