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.
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.