Triggered by the December 22 release of the OIG report on lab spending for CY2019, I've written a set of 5 blogs.
- #1 - OIG report; Focus on 81408 as biggest genomic code
- #2 - Review of all Tier 2 payments (81400-81408)
- #3 - Review of MolDx Tier 2 payments
- #4 - Review of NGS MAC Tier 2 payments
- #5 - 81407 as the weirdest Tier 2 code
|click to enlarge|
This week, OIG released data that Tier 2 code 81408 was the highest-spending code of all genomic CPT codes (here). This code rocketed in utilization by 580X (not 580%, 580X) from 2016 to 2019. Moreover, most (or all) of that spending on 81408 was in handful of states with no edits on the code.
This led me to do a second study of Tier 2 spending more generally - all the codes from 81400 to 81408. I published that earlier (here). Spending nationawide rocketed from $190M in 2018 to almost $400M in 2019.
Now, rather than looking at "national" data, I compare MolDx MACs to other MACs. WE'LL LEARN: If MolDx edits were applied nationally, all Tier 2 spending would fall by 96%. Amazing but true.
I had previously noted that the spending for Tier 2 codes was irregularly distributed and in a limited number of states, most especially for the $2000 code, 81408 (a code never paid in the NGS MAC or MolDx MACs).
But after looking at national data for Tier 2 codes in 2018 vs 2019, I wondered how the MolDx states compared, and across all Tier 2 codes.
My Research on MolDx Rules
First: No consolidated publication. As far as I know, there's no published general MolDx "policy" for Tier 2 codes.
Second: Datamining the DEX Exchange. You can go to the DEX Exchange website owned and run by MolDx, and look up individual Tier 2 codes by gene name (by gene names indentified inside each Tier 2 code by AMA definitions). You could tally those up in a spreadsheet. However, Palmetto includes a pretty strict disclaimer about using the data (other than reading it!) (here). I looked up several genetics labs in the MolDx region, and the largest one had about 90% of its genes registered with MolDx were publicly listed on DEX as "N" nonpayable, so that suggested the edits were pretty numerous and stringent.
Third: Inferring Edits from Payment Profiles. But there's another approach. I went to the CMS cloud database for CY2018 (here), and the State data files. I downloaded all usage and spending data for all codes 81400-81408 (Tier 2 codes) for all 50 states.
Then: I then subtracted the 24 states (and DC) that aren't part of MolDx.
For this purpose, since MolDx took over TN/GA/AL in mid-2018, I left those out of those "newest" MolDx states, since MolDx didn't manage them for MolDx edits for the full year (see here).
Here is the result for MolDx Tier 2 payments in CY2018:
|MolDx Tier 2 Spending 2018|
So we can see that MolDx authorized 28,742 across all Tier 2 services in Cy2018, dollars allowed being $4.6M.
But, utilization dropped to around 1000 cases for 81405 and 81406, and payments from MolDx occurred in only 1-2 states. There was NO payments by MolDx for either 81407 or 81408.
It's possible to look up each code, each state, each lab, behind the above table. CMS public data will tell you every lab that billed, say, 81404, in what state, for how many patients. For a deeper analysis of the ratios of distribution of these tiers of payments in 2018, here.
How does this MolDx utilization of Tier 2 codes - 28,742 services, $4M - compare to national utilization of Tier 2 codes?
Pretty damn amazing. Overall, MolDx pays a huge proportion of Mopath spending, as much as 80% as recently as 2017. (NGS MAC, for example, pays almost nothing in Mopath codes, except for Cologuard in Wisconsin).
But that MolDx domination of MoPath payments comes to a halt when Tier 2 codes are involved.
For the two highest Tier 2 codes, MolDx pays nothing. For four other Tier 2 codes, MolDx pays only 2-8%, although its rules apply to about half the US population.
Net-net, if MolDx managed Tier 2 codes nationally, spending would fall over 90%. This is driven, of course, on the assumption that 81408 spending at $123M would fall to 0%, its MolDx rate. Table:
I had had an inkling of this when I looked at 81408 data for CY2018, CY2019, comparing TN-GA under Cahaba edits versus under Palmetto MolDx edits:
Payments for all Tier 2 codes in 2018 were $37M in GA and $15M in TN. This is out of keeping with MolDx edits, and I found some web source stating that MolDx wasn't applied until a few quarters after the February 2018 takeover of other Cahaba-state edits.
CMS has released national payment data for CPT codes for 2018 and 2019. That's how we know that 2019 Tier 2 payments were about $400M. But 2018 data is available in cloud database format, and 2019 data is only publicly available in pretty awful individual state spreadsheet files. My guess for 2019? Well, 2018 there were $4M of MolDx Tier 2 payments and $186M of non-MolDx payments. Since there are $390M of total payments in 2019, I'm betting MolDx payments were close to the same ($4M) and that neans that about $386M was in other states. I'm not eager to cut and paste the data from 50 files just to prove that.
CMS cloud data for 2018 lets you be even more granular than the state and MAC level, and drill down how different labs billed different patterns for the 81400-81408 code series. This is pretty detailed stuff and I've put it on a side blog here. For example, the 10 labs that did most of the billing for 81408 in 2017 (when total Tier 2 billing was $70M) did 70% of the billing for all Tier 2 genes in 2018, when billing was $190M.
NGS MAC pays even less (!!) for Tier 2 services than MolDx does. See the next blog, Blog #4.