Thursday, December 15, 2016

Medicare's CY2015 Molecular Test Payments Assessed

In early December 2016, CMS released excel data files for CY2015 CPT code utilization.  For the full data set, here.

I have pulled out the molecular codes 81161-81599, and cross-sorted it by CPT code, by Utilization, by Dollars Allowed, and by Price per Test.   See the manipulated Excel spreadsheet in the cloud, here.

I've also pulled the top ten codes in each category and added code names, here.

High Level Interesting Findings:

  • My impression is that total molecular code billing fell from about $650M in CY2014 to $480M in CY2015.
  • CMS use of the Unlisted Code rose from about $70M to $165M.
  • Tumor (somatic mutation) gene panel codes 81445/81450/81455 were barely used at all.
  • Use of CYP codes roughly halved from CY2014 to CY2015.

Overall Utilization in CY2015

This is CMS data, not representative of all clinical uses of genetics.

That said, there were only 25 codes that were used >5000 times.  They captured 95% of all CMS molecular payments.

Of the other 5% of CMS payments:  25 codes 1000-5000 times, and 90 codes < 1000 times (65 codes < 100 times).

High Utilization Codes 

Three codes were used >150,000 times.  Six codes were used > 100,000 times.

CYP Codes Down
Utilization of codes like CYP2D6 and CYP 2C19 apparently halved from CY2014 levels, as reported here.  (See also table at bottom of this blog entry).  (All tables can be clicked to enlarge.)

Unlisted Code Up
In other headlines, Unlisted Code 81479 rose to 35% of all $483M of payments, capturing $167M out of $480M.  CY2014 spending appeared to have been higher, at $650M, here.

Tumor Gene Panel Code Ignored
Code 81455 (5-50 gene panel, tumors) was used only 65 times (!).

More data cuts after the break.

High Dollar Volume Codes

Turning to dollars, only the unlisted code 81479 had > $100M in payments, and it captured 35% of all payments.

After that, four codes had $40M-$62M in payments (CYP2C19, Oncotype DX, BRCA 1-2, and CYP2C19).

High Price Per Test Codes

Of tests costing > $1000, only three had high use (Oncotype DX, BRCA 1-2, and Unlisted Code).

AMA's "Tier Two" Codes

Prices for these non-fee-schedule tests rose from $122 to $1601.

Utilization clustered in Level 2, with some use of Levels 1 and Levels 4,5.  Across all Tier 2 codes, there were 137,000 Medicare paid services for $22M total dollars, about 5% of total dollars.

Tumor Gene Panel Codes - Fuhgeddabout'em

For somatic mutations, CPT provides 81445 (solid tumor 5-50 genes), 81450 (hematopoetic, 5-50 genes), and 81455 (any tumor >50 genes).  The first two are priced by CMS at about $700, the latter is unpriced.   81455 was used only 65 times, 81450 147 times, and 81455 13 times.  For its 13 uses, 81455 was paid an average of $565.   Tumor gene panel usage may be appearing as stack codes or unlisted codes.

Admin-MAAA Codes

CMS buried the Admin MAAA codes with the 00100 series files (with Anesthesia); 2015 data reported no payments for these 00nnM codes, except $4,863 in payments for 0008M (Prosigna).

Comparison with CY2014 Data

The table below is CY2014 data - for example, in CY2015 above, use of CYP codes was halved from the levels shown here for CY2014 below.

Also, in 2014, I tallied about $650M in MoPath spending at CMS - but the newer 2015 data seems to total only about $480M.  CYP codes and Tier 2 codes both appear to have trended down.

(This is surprising enough I would want to triple-check it before betting the house on it - is there anything funky about how CMS allocated CY2014 and CY2015 claims -  but it's my impression.)

An OIG report on the CLFS, released in September 2016, reported that CMS molecular pathology test payments dropped from $466M in 2014 to $259M in 2015 - different than the $650M and $480M that I found, but in the same direction.  (For OIG report information, see links here.)