Friday, September 25, 2020

CMS Releases National Data File for CY2019: 81408 Is The Fraudomatic Code in Some States - Submit Your Claims Tonight!

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:

MoPath Codes

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.

For a breakdown of 2019 81479 spending (95% in MolDx states), here.

Above, I've described Human MoPath codes (e.g. 812xx, 813xx, 814xx, 815xx).  There are also microbiology MoPath codes (I believe 87471-801 and 87900-904).  Those tally $365,864,197.  I briefly describe in a separate blog here.

Most PLA Codes Unused

Total PLA code spending was $116M, but if you leave off the top 2 (FMI and Oncotype Prostate) the total PLA spending plummets to $16M out of the $1.6B for MoPath - a rounding error.

The highest "administrative MAAA" code was 0003M, at #18, with only $18,781 allowed for 42 services.  Click to enlarge, but most of the numbers will still be pretty small.

The Reward For Most Unbelievable Code Goes to - 81408

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:

81408 seems to be the most popular code with fraudsters, based on other analyses I've been doing.  There are only 24 allowable rare genes listed under 81408 - little gems like "LAMA2 congential muscular dystrophy, full sequence" and CEP290, Joubert syndrome, full sequence (a cerebellar malformation that cause gross maldevelopment in infancy with mean age at death age 7.

Fraudulent payments in CY2018 should have been released by now in an annual CMS database containing physician/lab payments.  However, CY2018 is not being released - perhaps because of the coming election and the fact the egregious Operation Double Helix overpayments were occurring on this administration's watch.  Here.

In 1HCY2016 PAMA data, reported to CMS in 1Q2017, nationwide commercial payer payments for 81408 were $28,800,000 for 16,159 cases, with a price range from $2.16 to $22,547 and a median of $2000, which set the CLFS for CY2018-2020.  Double the cases and dollar volume to approximate commercial payments for 81408 in CY2016.  It's unknown how many of these are legit uses of the orphan genes stored under 81408 or how many might have been concerning but simply autopaid at a percent charges.  Excel.