Overview

Defensible Healthcare Billing: Pathology and Laboratory provides a structured, audit-focused framework for understanding reimbursement risk in modern laboratory services. Written by Linda Myrick, CPC, CPC-I, this volume moves beyond code memorization to examine how laboratory billing patterns are evaluated through data modeling, utilization analytics, and regulatory oversight. Unlike encounter-driven specialties, laboratory services are high-volume, frequency-sensitive, and statistically monitored. Small documentation weaknesses, when repeated across large claim populations, can escalate into extrapolated financial exposure. This book introduces the Structural Risk Model of Laboratory Billing-a practical framework that explains how payer analytics identify outliers, how replication risk develops, and how minor misalignments become systemic liability. The text addresses core audit domains, including order validation, medical necessity logic, diagnosis alignment, frequency controls, panel reporting, and unbundling risk, reflex testing governance, technical and professional component billing, molecular and high-complexity testing oversight, CLIA compliance, specimen integrity, and documentation alignment across records. Each chapter connects operational workflow decisions to downstream audit exposure, helping readers understand not only how to submit accurate claims but how to defend them under scrutiny. Section I establishes structural foundations, emphasizing pattern awareness and preventive monitoring. Section II explores the escalation pathway from data modeling and focused probe reviews to extrapolation, appeals strategy, and government investigation risk. Realistic case illustrations demonstrate how otherwise reasonable services can become vulnerable when documentation discipline and system configuration fail to align. Written in a code-agnostic educational format, this book does not reproduce proprietary manuals or fee schedules. Instead, it equips billing professionals, compliance officers, laboratory administrators, auditors, and healthcare executives with defensible decision logic grounded in audit reality. Defensible Healthcare Billing: Pathology and Laboratory is an essential resource for professionals seeking to strengthen compliance infrastructure, reduce statistical visibility, and build sustainable, audit-resistant laboratory billing practices in an increasingly data-driven reimbursement environment.

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