Since 2014, CMS has released massive data files on the utilization of CPT codes by physicians and labs by calendar year, typically in May on an 18 month delay. The 2018 data should have appeared in May 2020...or over the summer...it was late (blog here).
Well, the CY2018 data is now released at the utilization and payment website here.
- I've put an Excel copy of the entire 80,000 series lab & path codes in the cloud here. It's pretty massive (100 mb).
- I've put a copy of the 81100-81599 series (molecular human codes) plus the three most used PLA codes (0037U, 45U, 47U) in the cloud here. This mopath file is more manageable at 300kb, 2700 lines.
- Finally, I've put a copy of the nonspecific codes (8140X Tier 2 plus 81479, 81599) in the cloud here. Amazingly, spending through these nonspecific codes tallies $340M. It's a small file at95 kb.
- The $300M on nonspecific codes in 2018 is nearly as large as the whole molecular spending budget just several years ago (circa $500M in 2016 and 2017).
- For Molec Microbiology, see FN1.
My biggest take-home lesson
In 2018, nearly $300M went out under nonspecific codes 81408 and 81479.
Specifically, I get $123M (81408) + $148M (81479) or $271M out of $1.1B total mopath spending (25%).
If you add in all the 8140X (Tier 2) nonspecific codes, the nonspecific code payments are $339M out of $1.1B, just about one-third.
We Learn More About 81408
A few months ago, CMS released gross national Medicare Part B spending on molecular code 81408 (Tier 2 Level 9 code, mostly ultra rare genes for epilepsy in babies, etc) in CY2019. Here. It \was stunning. Spending on that code rose from $490,000 in 2016 to nearly $300,000,000 in 2019. See table:
Now, get data for exactly which doctors and labs in which cities garnered payments for 81408 in CY2018, when usage of 81408 was $123,000,000. We see that payments to major genetics venders (Labcorp, Quest, Myriad, Ambry, Invitae, Bioreference) were essentially nil for code 81408. And it wasn't payable in any MACs except Novitas and First Coast, the two MACs which didn't have any edits on this $2000 service (as documented by statements in their LCDs - "We have no edits on this code.")
Other labs in the chart, such as Spectrum and Metric, also show up in DOJ press releases eg this one here. In the press release, DOJ asserts or alleges: "[Payments] in exchange for referrals and DNA samples based on a percentage of the revenue the laboratories received from federal health care programs, including Medicare. Once the amount of the bribe was calculated, [persons] drafted and submitted sham invoices to the laboratories that backed into the agreed upon bribe amount and attempted to conceal the scheme through describing various services provided at hourly rates."
I corresponded with CMS staff on the delayed release of 2018 billing data in 9/2020, here.