Very Brief Blog: Medicare's 2018 Spending for CYP (PGx) Codes; Falling 2018-2019

The entry point for this blog is that I noticed a drop in national Part B spending for the most frequent pharmacogenetics codes (81225, 81226) between 2018 and 2019.  2018 Part B payments were $28M (81225, $10M, 81226, $18M) while 2019 Part B payments were $20M (81225, $8M, 81226 $12M)

Data analysis shows the change moving into 2019 was driven mostly by changing payments in Georgia, after the MAC transferred from "Cahaba MAC" to "Palmetto MAC," which introduced MolDx Z-codes and edits.

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In CY2018, Medicare spent $33M on CPT codes 81225-81231 (CYP genes), of which $28M went to the top two codes, 81225/81226 which are CYP2C19 and CYP2D6.

I looked at the state and MAC distribution of CMS payments for these two codes.

For both CYP 2C19, $10M, and CYP 2D6, $17M, about 55-60% of payments went to providers in Georgia and Tennessee:

If we look at MAC level payments, these were dominated by the Cahaba MAC (over 50%), followed by either the Novitas MACs or the MolDx system MACs:

Cahaba, with 7% of the US Part B, paid a disproportionate number of PGx claims in 2018, over half of US claims for either 81225 or 81226.  

Transitions 2018, 2019

Georgia had a large portion of 81225/26 CYP payments in CY2018, but the dollar volume fell from $12.9M in CY2018 to only $1.5M in CY2019.   This was related to the transition from Cahaba PGx edits to Palmetto MolDx PGx edits.

CY2018, left.   CY2019, right. (Georgia only)

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Rather than focus on PGx...

If instead we used all non-proprietary genetic CPT codes (811xx, 812xx, 813xx, 814xx), there were $736M dollars paid in CY2018, of which $128M were paid by Cahaba (18%).   In CY2018, $104M/$735M or 14% of all US non-proprietary genetics were paid to labs in Georgia, which has 3% of the FFS Medicare population. 

Using 2018 CMS cloud data for state files, and 2019 CMS excel data for state files, and using codes 811xx-814xx, we see $104M in payments in Georgia in CY2018, and $11.5M in CY2019.

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Palmetto (MolDx) took over GA/TN in 2018,  but based on comparison of payments 2017-2018-2019, it appears that MolDx edits weren't fully implemented into well into 2018 (here). I've listed the payments under Cahaba, the 2017/partial 2018 contractor. Palmetto would have introduced a highly restrictive PGx policy at some point before the end of CY2018.  Palmetto updated its PGx policy in its MolDx regions in mid 2020.

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When AMA and CMS transitioned from "stack codes" for mopath payments to specific CPT codes (such as for "CYP2C19") in 2013, there was a huge boom in PGx/CYP payments, which suddenly came to comprise half or more of CMS mopath payments around 2014.  

CMS rapidly rolled down LCDs that controlled PGx/CYP payments, and these payments fell drastically from 2014 to 2015 to 2016, as shown in the bar chart below.  (I've pulled this slide from an available lecture, and haven't revisited the original data today).

CYP (PGx) Pt B Spending Falls Sharply 2014-2015-2016