On September 16, 2020, I noted that CMS had released Excel spreadsheets of Part B spending by CPT code for every state - here. On September 22, I released some deep dive analysis of MoPath spending by state - showing massive increases in fraudulent spending, in some cases, the states and CPT codes where the spending was concentrated. Here. I noted that the most egregious cases - the ones that popped out high to the naked eye, like Florida, D.C., and Oklahoma - were either under the Novitas or FCSO MACs, both subsidiaries of Florida BCBS.
- New! CMS has now released a consolidated file of national Part B spending, by CPT code, for CY2019. Find the original CMS website data here.
- I make no promises for transparency or clarity but I've put all my worksheets for this blog in the cloud too, here.
The files can maddeningly tedious because they are broken into dozens and dozens of individually tiny files (e.g. 13 kb, 21 kb) with short runs of CPT/HCPCS codes.
Luckily PATH series codes, including "U" or PLA codes, are in one file named Y2019_0001U.xlsx on the CMS website linked above.
All Pathology, Lab Medicine
I sorted all the Path/Lab codes by TOTAL (this sums technical component, professional component, other, where they exist). Total Path/Lab dollars allowed were $7,133,811.
Sorting by "Allowed charges," the top 15 codes were paid 56% of the total or $4.0M.
The highest code was 88305 (surgical biopsy) with 20M services and $1B in dollars allowed.
The next highest code was 80053 (routine chemistry panel), with 29M services and $342M dollars allowed. As you can see by eyeball, with around 30M services and around 300M dollars that's in the ballpark of $10 per service.
Three MoPath codes were in the top 15: 81408 (Tier 2 Level 9), 81528 (Exact Cologard, circa $500 per case, 482K cases and $245M, sounds right). Followed by 81479 (mopath unlisted code, used almost exclusively in MolDx states in other recent years), at 109,555 services and $202M cryptically spent dollars - cryptic, at least, to the public with this CMS file. Click to enlarge:
I merged all the PLA ("U") codes with MoPath (81162-81599).
Allowed charges was a collosal $1.7B - last year in 2018 it was about $1B.
The top 15 codes concentrated 78% of payments, or $1.3B.
The largest code was 81408 - Tier 2, Level 9, $2000 each, 146K services for $290M allowed charges. That's likely due to stupendous growth in payments for this code in Novitas/First Coast states like FL, DC, OK (here).
Next was Cologard at $245M.
Next was Unlisted Code, 81479, traditionally used only in MolDx states, at $202M. Then BRCA testing (BRCA1-2 & Dup Del), 81162, for 60,000 services for about $120M allowed charges. Finally, in the top 5, was 81519, Oncotype Dx, with 22,000 services at $85M. Click to enlarge.
Here's the basics:
2017 - 5,817 cases, $9,550,000 dollars
2018 - 62,000 cases, $123,000,000 dollars
2019 - 146,000 cases, $290,000,000 dollars
What code are we talking about? 81408! This is AMA CPT Tier 2, Level 9, CMS price $2000.
That's 14X growth 2017-2018, and 32X growth 2017-2019. If spending on this unbelievably rare code set had been kept at 2017 levels, national MoPath spending in 2019 would have been nearly $300M dollars lower.
It's pretty tedious to do 81408 spending in CY2019 by MAC - you'd use the 50 state spreadsheets one at a time - but it would probably show that some MACs were completely resistant to this fraud and others gushed out money like a firehose. For example, I quickly found that despite TWO YEARS of explosive fraudulent use of this code, according to the CMS Coverage Database, the Novitas MAC still has a billing article A52986 that says "81408 has no edit codes at this time." Ya think? I think they already noticed that. This clipping next is from TODAY. Wake up and smell the coffers being drained.
Click to enlarge, but it may give you nightmares: