In this blog, I'll focus on molecular CPT code data, with some brief references to data from CY2016 made available last November (here).
As a baseline from the prior year, for code range 81162-81599, I tallied $479,894,633 in "payments allowed" in 2016, which was about the same as in 2015. (Sharp, $100M-level cutbacks in pharmacogenetic spending was enough to level the annual year-to-year total of all MoPath payments for a while.)
- Update: Separately, OIG published its fourth annual review of CMS lab payments, which includes hospital outpatient reference labs not included in the Part B data. Since it includes outpatient reference labs its numbers are always a bit higher. Here.
Total MoPath Spending Rises, $480M to $644M
For CY2017, the new data, for molecular pathology I tally $644,228,102, a 34% increase year-on-year.
For all lab spending in this code series, $6.9B. For example, chem panel code 80053 had 29M uses for $322M dollars at $11 a test. Net-net, MoPath is circa 10% of lab spending in 2017 data.
10 Codes Get 73% of Spending
As in recent years, MoPath spending is highly concentrated. Although CMS lists about 175 codes, the top 10 codes get 73% of all spending. At $118M, Cologuard was 18% of all spending, about tied with the unlisted code 81479. Oncotype Dx and BRCA 81162 followed with 10% and 8% of spending, respectively. See table below.
|CY2017 Top Ten MoPath Codes (Total Spend $644M)|
|click to enlarge - Dot Plot of 2017 Allowed Payments by Code|
In CY2016 CMS data, Cologuard was only $62M, on par with BRCA and Oncotype Dx. In CY2017, it was almost $120M. Correspondingly: At end 2016, Exact Science's stock price was about $19, at end 2017, about $50. (Today it's $76, with a market cap of $9B).
Note that 2016 to 2017 spending rose from $480M to $644M, or +$164M, of which about $60M was accounted for by the growth in Cologuard alone.
BRCA Coding Shifts
BRCA spending totaled $75M, with $52M now being spent under consolidated BRCA code 81162, which pays a few hundred dollars less than the legacy stack coding approach to BRCA (81211+81213), which garnered only about $9M in CY2017. BRCA panel codes 81432/33, received about $13M for about 12,000 cases. The shift to 81162 coding impacts CMS spending in 2018-2020, since (legacy 81211+81213) pricing is stable during this period while 81162 pricing drops 10% per year under PAMA.
There is a major revamping of the BRCA code set for CY2019, but coding to services like BRCA1 alone or BRCA2 alone are next to nothing, at least in CMS data.
|click to enlarge|
Unlisted Code 81479
The second highest code was the Unlisted Code for Mopath, 81479. At least as of a year ago, nearly all 81479 spending came through MolDx MACs, and almost none elsewhere. CMS has now asked MACs to report use of unlisted codes by labs (here). Use of unlisted codes is incompatible with the payment system set up by PAMA. Use of 81479 rose a little from 2016, $108M, to 2017, $118M.
Tier 2 Codes
Collectively, the Tier 2 codes (level 1-9) garnered $72M.
|click to enlarge - Mopath Tier 2, Level 1-9|
Tumor Panel Codes
Tumor panel codes for CY2017...81445 had 1,428 uses for $807,000. 81450 had 3,378 uses for $2.2M. 81455 had 4,351 uses for $2.8M. Together these tumor panel codes were about $6M or just about 1% of genetic/genomic spending at CMS. Note that 2017 is the same year that CMS proposed its complex NCD on NGS panels in cancer.
There were no payments for 81415 (exome) or 81425 (genome).
In the data above, I haven't included PLA codes and Admin MAAA codes, which CMS has in a separate spreadsheet. Impact would be minimal.
It's no masterpiece, but I've included the worksheets used, in the cloud here.