Thursday, July 27, 2017

Brief Blog: 2014-2015 Evolution of Part B Payments for BRCA Testing

The Medicare Part B provider database (here) gives us a window into CMS payments for BRCA testing in recent years. I show data for 2014 and 2015; similar public data is online for 2012-2013 but in a less user-friendly format.   Details after the break.

The data table in the cloud here, or click to enlarge the table below.

Coding in 2014-2015 and in 2016-2017
In 2014 and 2015, there were two relevant codes, 81211 (BRCA 1-2 sequencing and common Dup Del) and 81213 (uncommon Dup Del).   Today, there are additional codes for BRCA related panel (81432) and panel Dup Del (81433) and one code for a comprehensive two-gene panel of BRCA 1-2 plus Dup Del (81162).

Medicare Payments for BRCA Testing 2014-2015

  • As "dollars allowed," Medicare payments in 2014 were $43M
    • with 85.5% or about $37M to the largest provider.   
  • Payments in 2015 were $52M, 20% higher
    • with 72.9% or about $38M to the largest provider.
Most providers performed about a 1:1 ratio of 81211 and 81213, but some small providers did only 81211.  

The biggest gain year-on-year in market share was GeneDx, doubling from 8% to 16% of the Medicare Part B market.  Labcorp changed its billing laboratory from Dublin, Ohio, in 2014, to Raritan, NJ, in 2015.

As part of the code research, I looked through Correct Coding edits, using the April 2017 version on the CMS website.   There's an edit that I don't understand, and it is listed as being in place since April 2013.  It seems to block use of 81213 when 81211 is used "as mutually exclusive procedures."

I've included a screen shot below, since even as a Medicare expert, I find the edit puzzling -- and moreover,  it doesn't seem to be applied in practice by MACs, since they pay huge numbers of claims that list 81211 & 81213 together:

After January 1, 2015, arguably, simultaneous use of 81211+81213 might be replaced by better coding with single use of 81162.  But I'm unsure why an edit against use of 81211+81213 was put in place in 2013,and if it is there, why it doesn't affect the two codes billing and paying together.