The upcoming ICD-10 codes for 2026 promise pertinent changes for revenue cycle departments. To help your leadership prepare and make positive strategic choices that support the financial health of your organization, we’ve compiled this summary of the newest ICD-10 code updates. Delaying implementing these changes can have a significant negative impact on your organization and team. This includes increased stress for your staff, worsening denial rates, and increasing costs of training and
Your pathologists are diagnosing cancer. But your billing team? They’re diagnosing something else entirely: denials, underpayments, and revenue holes no one can seem to plug.
If that hits a little too close to home, you’re not alone.
We’ve worked with pathology labs across the U.S. – hospital-based, private groups, national reference labs – to know the symptoms: clean claims on paper but shrinking cash flow; pathology coding that looks fine until an audit hits; contract rates that haven’t changed in 5 years, but test complexity has doubled.
Before you hire another FTE or switch your pathology billing company again, run through this checklist. You’ll find out exactly where your pathology revenue cycle is bleeding – and how to fix it.
Let’s be honest: pathology billing isn’t just billing. It’s a battlefield.
If your medical billing partner isn’t a pathology billing company, they’re likely missing revenue opportunities you don’t even know exist.
Any of this sound familiar?
3Gen Consulting’s pathology billing services use AI-powered claim scrubbing, modifier audits, test panel logic, and denial trend analysis to capture every reimbursable dollar while keeping you fully compliant.
Let’s talk about the invisible revenue killer: pathology coding.
Pathology coding is one of the most overlooked revenue drains. Coders must go beyond basic CPT knowledge – they must understand stains, panels, molecular techniques, and payor nuances.
Ask yourself:
Even the cleanest billing process can’t save incomplete or inaccurate coding. If your team isn’t fluent in pathology coding nuance, you’re flying blind. With 3Gen’s team of certified pathology coders, clients achieve 95%+ accuracy, layered QA, audit-ready documentation, and real-time dashboards.
When’s the last time you renegotiated your payer contracts?
Most pathology groups haven’t touched their payer contracts in years. Meanwhile, payers tweak fee schedules, apply edits, and bundle services that should be billed separately.
Time to self-audit:
Contracts are no longer “set and forget.” If you’re not renegotiating smarter and backing it up with data, you’re likely being underpaid for advanced pathology services. Our payer contracting team uses denial trends, test-level reimbursement data, and MRF benchmarking to arm you with hard facts to negotiate smarter.
Risk adjustment coding isn’t just for primary care. If your pathology lab serves Medicare Advantage or ACO populations, you’re sitting on untapped value. Pathology findings often uncover conditions that impact HCC coding and RAF scores – but most labs aren’t capturing them.
Here’s what to ask:
3Gen Consulting’s RiskGen-i platform integrates seamlessly with your LIS and EHR to identify, code, and track pathology-related risk conditions, aligning pathology with value-based care incentives.
The scariest phrase in revenue cycle today: payer audit.
From CMS RADV audits to private payer clawbacks, pathology is under the microscope. And if your documentation, modifiers, or LCD coverage aren’t airtight, you’re exposed.
Sound familiar?
Compliance isn’t a checkbox. It’s a daily discipline – especially in pathology, where coding and documentation must be bulletproof. 3Gen Consulting supports labs with real-time denial analytics, audit response prep, and compliance documentation support, so you’re never caught off guard.
Final Diagnosis
It’s time to ask: Is your current pathology RCM partner keeping up – or holding you back? Most generic medical billing companies lack the clinical knowledge and test-level nuance needed to optimize pathology revenue. That’s where 3Gen Consulting steps in – with pathology-trained billers, coders, and contracting experts who understand your lab like it’s their own.
Want to see what your pathology revenue cycle is really doing behind the scenes? Let 3Gen Consulting run a free pathology medical billing health check. No fluff. No obligation. Just data-backed insight from a pathology billing company that knows your specialty. Book Your RCM Checkup Today.
U.S. clinical labs face mounting regulatory challenges and shifting payer dynamics that are fundamentally changing how laboratory revenue cycle management (RCM) must be handled. Staying ahead means mastering compliance, optimizing payor contracting, and modernizing medical billing for laboratories to protect revenue and reduce expensive denials. If you manage a clinical lab, you’ve likely experienced how yesterday’s billing strategies no longer deliver. To survive – and thrive – you need to rethink your approach.
The regulatory spotlight on clinical laboratories in the U.S. is intensifying. The Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), and new federal mandates have made lab RCM
A healthy patient financial experience is critical for pediatric providers. Errors in pediatric billing, coding or documentation can lead to unfavorable outcomes such as unnecessary denials, prior authorization issues, and delayed billing – all of which can cause financial stress and extra strain on families with the added risk of reduced reimbursement for practices.
To support accurate billing practices, the American Academy of Pediatrics (AAP) has released its 2025 Coding for Pediatric Preventive Care guide [1]. This document serves as a valuable resource for training and educating team members involved in pediatric billing services. We’ve compiled a summary of the most important sections for your review. For more detailed information, you can access the full pediatric medical billing document on the AAP website.
Preventive medicine service codes (99381–99385 for new patients and 99391–99395 for established patients) form the foundation for billing well-child visits. These codes encompass comprehensive evaluations that include age-appropriate medical history, physical examinations, and anticipatory guidance. Unlike traditional Evaluation and Management (E/M) codes, preventive codes are not time-dependent – code selection is based on the scope of services provided, not the length of the visit.
Accurate use of ICD-10 codes, such as Z00.121 for preventive visits with abnormal findings, also supports clean claim submissions. Understanding these nuances is critical to prevent unnecessary denials and underpayments. Partnering with pediatric billing companies who specialize in preventive care coding can further enhance reimbursement accuracy and financial performance.
Counseling codes (99401–99404) are used for time-based health promotion discussions on topics such as nutrition, safety, and pediatric mental health. These codes require documentation of the time spent but should not be billed in conjunction with preventive visits – a common error in pediatric medical billing. To ensure compliance with pediatric billing services, here are key points your billers should keep in mind:
Because pediatric visits often involve extensive counseling, it’s essential that billers are properly trained to distinguish between preventive services and problem-focused care. Accurate coding is key to staying compliant and avoiding billing errors with pediatric billing services.
Health Risk Assessments (HRAs) for pediatric patients are specialized tools designed to evaluate the overall health and well-being of children and adolescents are an essential part of pediatric billing workflows. These assessments help healthcare providers identify potential physical, developmental, behavioral, and social risks early, enabling timely interventions to promote healthy growth and development.
CPT Codes for Health Risk Assessments
Sometimes used if specific behavioral health risks are assessed:
Outsourcing to pediatric billing companies with expertise in HRAs can help navigate payer-specific requirements and reduce denial risk.
Vaccine billing is one of the most complex parts of pediatric billing. It depends on factors such as the child’s age and specific visit components – like multivalent vaccines. Navigating state-specific program requirements, Medicaid reimbursement guidelines, and frequent CPT updates (including those for COVID-19 and RSV vaccines) can be challenging.
One of the key benefits of working with pediatric billing companies is their expertise in maintaining accurate documentation and ensuring compliance with the continually evolving immunization policies, helping to optimize reimbursement and reduce errors.
Coding for labs in pediatric medical billing varies based on the testing location. When tests are performed in-house, your staff should bill for both the venipuncture procedure (36415) and the laboratory test. If the testing is outsourced, only the specimen collection code (99000 or 36415) should be billed. Additionally, staff must be well-trained in accurate ICD-10 code linkage to help minimize denials and ensure compliance with pediatric billing services.
There are many intricacies involved in pediatric billing – one of the most common being whether both a preventive and sick visit can be billed on the same day.
According to AMA CPT guidelines, if a provider addresses a new or existing condition that requires significant additional work beyond routine preventive care, both services may be billed together. To do so, the provider must document key elements of evaluation and management (E/M), such as prescribing treatment, adjusting medications, or performing a detailed assessment.
This situation frequently arises during well-child visits when a provider also manages chronic conditions like asthma, addresses behavioral concerns alongside ADHD screening, or evaluates acute issues such as a persistent cough. In these cases, modifier -25 must be appended to the E/M code to indicate a separately identifiable service performed on the same day.
Clear communication with families is essential. Many parents assume all services during a preventive visit are fully covered. Staff should be trained to explain that when problem-focused care is provided in addition to preventive services, copays or out-of-pocket costs may apply. Consider using signage or patient handouts to help set expectations and reduce billing misunderstandings.
As you review the AAP guidelines, be sure to explore the included vignettes – they offer valuable insight into pediatric coding for real-world scenarios.
At 3Gen Consulting, we deliver comprehensive pediatric billing services with specialized expertise in preventive care, immunization billing, and risk adjustment coding. Whether you’re strengthening internal teams or evaluating pediatric billing companies to enhance your revenue cycle, we’re ready to support you. Contact us today to learn how we can help.
[1] American Academy of Pediatrics, “Coding For Pediatric Preventive Care 2025,” 15 February 2025. Available: https://downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf.
The healthcare revenue cycle is undergoing significant transformation, driven by evolving regulations, shifting payer policies, and increasing administrative burdens. For revenue cycle leaders, these changes present both challenges and opportunities, especially in optimizing medical billing accuracy and choosing a medical billing outsourcing company partner.
With the current administration promising more deregulation in
