Can a Physician Bill for Laboratory Services? (Answered)

Laboratory tests sit at the front of most care plans. A CBC, a lipid panel, a strep screen. These results guide the visit and the next steps. The practical question for many practices is simple to ask and careful to answer:

Short answer: sometimes. It depends on who performed the test, where it was done, your certifications, and what the payer allows.

Here is the idea in clear terms:

• If your practice performs the test and your CLIA certificate covers that test, you can usually bill for it.
• If an outside lab performs the test, billing may belong to that lab. Some payers allow a physician to submit the claim in limited situations with special rules.
• When hospital services are involved, the payer’s date of service policy can decide who bills.
• Every payer has its own manual. Your claim must match those rules to get paid.

In this guide you will see the common scenarios, quick examples, and a simple checklist you can use before you submit a claim. The goal is to bill only when you should, avoid claim denials, and stay compliant without guesswork.

Can a Physician Bill for Laboratory Services?

If the lab work happens inside the physician’s office and meets all legal and certification requirements, then the physician can bill payers directly. But if the lab sends the test to an outside facility, the physician usually can’t bill for it. In that case, the independent lab handles the billing. When in doubt, match the claim to three anchors every time. Who did the test, where it was done, and what your CLIA certificate and payer policy allow.

When you can bill from the practice

• The test was performed in your office by your staff.
• Your CLIA certificate matches the test complexity, for example waived or moderate.
• You used your own supplies and equipment, and documentation shows the order, the performance of the test, and the result.
• The payer’s policy allows the practice to submit the claim for that test.

When you should not bill from the practice

• The specimen was collected in your office but the testing was done by an outside or independent lab. In most cases the outside lab bills the test.
• Your practice does not hold the correct CLIA certificate for that test.
• A hospital setting or special payer rule shifts billing to the hospital or the lab.
• You only performed the collection. In that case, you usually bill the allowed collection code, for example venipuncture, and the outside lab bills the test itself.

Understanding Lab Billing in a Physician’s Office

Many practices run a small set of tests in the office. These quick checks guide same-day decisions and are usually simple to perform.

• Common in-office tests
• Urinalysis
• Finger-stick glucose
• Rapid strep
• COVID-19 antigen
• Pregnancy tests

Most of these are CLIA-waived. If your practice holds the right CLIA certificate and follows the test instructions, you may both perform and bill these services from your office.

What this means for billing

➜ You can bill when your staff performed the test in your office and your CLIA certificate covers that test type. Use the correct code for the test, keep the order and result in the chart, and follow the payer’s policy.

➜ You should not bill the test when you only collected the specimen and sent it to an outside or reference lab. In that situation the outside lab usually bills the test, and your practice may bill the allowed collection code if covered.

➜ CLIA matters. No CLIA certificate or the wrong certificate level means you should not bill the test from the practice, even if the specimen was collected in your office.

Here’s a plain rule to remember for you:

If your team did the testing and your CLIA certificate and payer rules line up, you can bill it from the practice. If an outside lab did the testing, that lab usually bills, and you only bill the collection when allowed.

Billing Scenarios: when can a physician lab?

Use these walk-throughs to teach your team the logic behind each claim. Each example follows the same flow: what happened, who should bill, and the reason it works that way.

Scenario 1. Rapid flu test in your office

What happened: A family clinic runs a rapid flu test during the visit. The practice holds a valid CLIA waiver.

Who bills: The physician practice bills the test.

Why: Your staff performed the test on your equipment, and your CLIA certificate covers it. Documentation shows the order, performance, and result, so the claim matches payer policy.

Teaching note: Keep the test kit lot number and internal quality control in the chart. It supports medical necessity and clean audits.

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Scenario 2. Blood draw sent to a reference lab

What happened: Your MA draws blood in the clinic and sends the tubes to a national lab for testing.

Who bills: The reference lab bills the tests. The physician practice may bill the allowed specimen collection code if the payer covers it.

Why: The outside lab performed the analytic work. Billing follows the entity that produced the result, not the place of collection.

Teaching note: Do not submit the lab codes from your NPI when the work was performed elsewhere. That creates denials and refund risk.

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Scenario 3. Dermatology group with an onsite pathology lab

What happened: A dermatology group operates an onsite high complexity pathology lab with proper CLIA certification and qualified personnel.

Who bills: The group or its lab entity bills the pathology tests.

Why: The testing and interpretation occurred within the certified lab under the group’s control. When structure, licensure, and payer enrollment align, the lab’s claims are appropriate.

Teaching note: Make sure the CLIA level matches the test menu, the pathologist signs out results, and the lab is enrolled with payers as required.

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Scenario 4. In-office rapid antigen followed by a send-out PCR

What happened: You perform a rapid strep or COVID antigen test in the office. Because of symptoms or policy, you also send a specimen for PCR to a reference lab.

Who bills: Your practice bills the rapid test. The reference lab bills the PCR.

Why: Each party bills only for the work it performed. The two tests answer different clinical questions and are billed by the entity that ran each test.

Teaching note: Your note should explain why both tests were needed on the same date. That prevents duplicate or incidental edit denials.

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Scenario 5. Hospital visit with a specimen tested after discharge

What happened: A specimen is collected during a hospital outpatient encounter, then tested later by an outside lab.

Who bills: Depending on payer policy, billing may shift to the hospital or the lab based on date-of-service rules.

Why: Some policies tie the lab service to the hospital encounter date, which can reassign who is allowed to submit the claim.

Teaching note: When a hospital touch is involved, confirm the payer’s date-of-service rule before filing. It avoids rejections and rebills.

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Scenario 6. You only collect the specimen

What happened: Your team collects a Pap smear, a biopsy, or blood, then sends it out.

Who bills: You bill only the collection or the procedure you performed, such as the biopsy. The outside lab bills the laboratory test and any interpretation.

Why: Collection and analytic testing are separate services. Billing follows the work performed by each party.

Teaching note: For pathology, remember that a lab may bill a professional component, a technical component, or a global service. Your claim should reflect the procedure you performed, not the lab’s work.

Quick list of healthcare entities that can legally bill for lab services:

• Independent Clinical Laboratories: Must have CLIA certification and usually bill directly.
• Physician Offices: Only when they perform the test themselves and have proper certification.
• Hospital Labs: Often billed under the hospital’s facility fees.
• Group Practices: May bill for labs if owned by the group and done under their supervision.

Important Note: Collecting just a sample doesn’t give billing rights for the actual lab test.

Laboratory Billing Regulations Physicians Must Follow

Billing for lab services involves strict federal and payer-specific rules. Here’s a breakdown:

1). CLIA requirements

Think of CLIA as your permission slip to run and bill lab tests. Your certificate must match the complexity of every test on your menu. If you hold a CLIA waived certificate, a rapid strep run in your office is fine to bill. If you try a moderate complexity test without the right certificate, you should not run it and you should not file a claim. To stay safe, compare each test to your CLIA level, keep the certificate number handy for claims, and make sure staff know which tests are allowed.

2). Medicare coverage and medical necessity

Medicare Part B pays for outpatient lab tests only when they are medically needed, correctly coded, and supported in the note. A lipid panel ordered as a routine screen without a covered reason may deny, while the same panel tied to diabetes management with the right ICD-10 is usually payable. The fix is simple. Always link the test to the diagnosis that explains why you needed it, and check any local coverage policy that lists required diagnoses or limits on how often the test can be done.

3). Anti-kickback and Stark rules

These rules protect patients and your practice. Do not accept money, supplies, or favors in return for sending specimens to a lab, and do not refer to an entity you own unless an exception applies. For example, if a lab offers free swabs for your referrals, you should decline. If your group owns a lab, confirm that your setup fits an allowed exception such as the in-office ancillary pathway. When relationships change, pause and get a legal review before you adjust your referral pattern.

4). Anti-markup and purchased test rules

Billing should reflect who did the work. When an outside lab performs the technical or professional part, your ability to bill may be limited, and you may not bill for more than your cost. In most cases the performing lab should bill. If a payer allows you to submit a purchased test, follow that plan’s price limits and disclosure rules exactly. A good habit is to ask yourself who produced the result. If it was not your team, let the lab bill unless the payer gives a clear path for you to do so.

5). Date-of-service and site-of-service policies

Hospital encounters add a timing twist. Some payers decide who can bill based on when and where the specimen was collected versus when it was tested. A specimen collected in a hospital outpatient clinic may have to be billed through the hospital even if a reference lab performs the test later. To avoid rejections, check the payer’s date-of-service policy first, then coordinate with the hospital or the reference lab so only one claim goes out and it goes to the right place.

6). Private payer manuals

Every health plan writes its own playbook. One plan may let you bill in-office antigen tests without a modifier. Another may require a specific modifier or set a frequency limit. The easiest way to keep up is to save the policies for your top payers, update them each year, and train staff on the small differences that matter. When a denial appears, look up the plan’s manual, adjust the claim to match the rule, and add that tip to your internal cheat sheet for next time.

FAQs for Physician Lab Billing

Let us answer a few quick questions about laboratory billing for physicians and physician offices. 

1. How lab reimbursement works in a physician setting?

Reimbursement depends on the test and the payer. Here’s how it generally works:

• Medicare: pays based on the Clinical Lab Fee Schedule (CLFS)
• Private payers: negotiate their own rates
• Bundled payments: Some lab services may be part of a global visit payment (like in surgeries)
• Carve-outs: Some tests may be billed separately even during hospital stays

For example:

• Rapid strep test (CPT 87880) reimburses around $15–$25 from Medicare (but it can vary based on geographic location and other factors).
• Urinalysis (CPT 81002) may reimburse $4–$10

2. When should physicians not bill for lab services?

There are clear red flags when billing is not allowed:

• The lab test was performed by an outside reference lab
• You don’t have the required CLIA certification
• The test is not covered under the patient’s insurance
• You didn’t order the test or can’t show medical necessity
• You’re referring lab work to a lab you own and don’t meet Stark exceptions

When in doubt, consult a compliance expert.

3. Can a nurse practitioner bill for laboratory services?

Yes, a nurse practitioner (NP) can bill for lab services. They must practice within their state’s legal scope. They need to operate independently or under required supervision. The NP must follow Clinical Laboratory Improvement Amendments (CLIA) rules. They must also meet billing and credentialing requirements of Medicare or other payers. Their practice or facility must have the proper CLIA certificate for the tests performed.

4. Can physicians bill for laboratory specimen collection, such as drawing blood?

Yes, physicians can bill for specimen collection procedures. For example, CPT code 36415 is commonly used to report routine venipuncture (blood draw). However, it’s important to note that this code is often considered a bundled service and may not be reimbursed separately. This depends on the payer’s policy and the context of the patient encounter (e.g., part of a larger office visit or lab panel).

5. Do all laboratory tests require a CLIA certificate?

All clinical laboratory testing on humans in the United States requires a CLIA certificate. This applies to all tests, from complex molecular tests to basic, waived tests. Waived tests include fingerstick glucose testing. Even waived tests need at least a CLIA Certificate of Waiver. Laboratories must have the correct CLIA certification that must match the test complexity.

6. Are laboratory tests billed under Medicare Part A or Part B?

Most outpatient laboratory tests are billed under Medicare Part B, which covers medically necessary diagnostic services. These include blood tests, urinalysis, and other common diagnostics performed outside of an inpatient hospital stay. Lab tests done during inpatient hospital stays are usually included in Medicare Part A payments. These payments are part of the diagnosis-related group (DRG) reimbursement to the hospital.

7. Can a physician bill for laboratory tests that were performed by another provider or laboratory?

No, a physician cannot bill for laboratory tests that were performed by another provider or a separate laboratory. According to Medicare and most payer guidelines, only the entity that actually performs the test is allowed to submit the claim for payment. Physicians may order the test, but the performing lab with the appropriate CLIA certification must handle the billing.