I noted earlier this month that CMS had (finally) released provider-specific CPT code utilization data for CY2018 - here.
In this blog, I look at the billing patterns for comprehensive genomic profiling (CGP; codes 81445, 81450, 81455) in CY2018. One middle-ranked biller is Tempus, which caught my attention, and I pulled Tempus's billing for CY2018 also.
A major reason that the CGP codes caught my attention is the recent formation of a coalition to improve access to testing, the Access to CGP group - find it here, https://accesstocgp.com/
I went to the 2018 Part B cloud database (here) and searched on the following codes:
- 81445, 5-50 tumor genes. About $600.
- 81450, 5-50 tumor genes, hematopoietic cancers, About $600.
- 81455, 51+ tumor genes. About $3000.
- 0037U, Foundation Medicine F1 (FDA) Test. About $3500.
- For 81445, there were 3,173 uses totaling $1.9M, and the highest biller was Interpace (Pittsburgh) with 627 cases.
- For 81450, there were 4,889 uses, for $3.7M, and the highest biller was Genoptix with 2,949 uses for $2.2M.
- For 81455, there were 7,476, but from only 8 labs, totalling $22M. The highest biller was Caris in Phoenix with 6,872 uses for $20M.
- Finally, Foundation Medicine 0037U received $33M for 9,884 FMI F1 cases.
Note that the MolDx program (which paid the 7,476 cases of 81455 to Caris in CY2018) normally does not use code 81455, for reasons I've never understood, and probably pays most genomic profiling venders under unlisted code 81479 plus Z codes.
In 2019, 2020 public meetings, I've heard MolDx staff say they've now stopped paying 81455 in the few cases where they might have paid it in 2017 or 2018. Their LCD for large tumor gene panels clearly instructs labs to use 81479 (molecular unlisted) not 81455 (tumor genes 51+) when you study 51+ tumor genes.
Tempus shows up in the list for billers of 81445, with 39 cases for $23,000. This goes along with something I noticed earlier this year, MoPath payments in any NGS MAC states are very tiny, with the sole exception of Cologuard, which is paid in NGS MAC state Wisconsin, but via an NCD, not local coverage.
Turning to billing by Tempus in CY2018, in this Part B database, they were paid $1.9M, of which 47% or $905K was paid for code 81211, BRCA testing. They billed in total two dozen codes, many paying less in total than $25,000.
Tempus raised an additional $200M in 4Q2020, bringing net funding to $1B (here).
Find the Data By Individual Lab for 2018
See my Excel spreadsheet in the cloud here.
I've also put screen shots below (click to enlarge), but it's going to be easier to read the cloud spreadsheet.
Readers interested in the tumor genome consortium A-CGP cited above may also be interested in a New York-based effort to document the clinical utility of whole genome sequencing - January 2015 Genomeweb article here.