Friday, June 16, 2017

Brief Blog: CMS Posts Comprehensive Part B Provider Data Set for CY2015; 81479 Case Study

On June 15, CMS posted the fourth annual comprehensive data set of claims and payments to Part B providers.  See the home page for the annual data sets here and the 2015 data set here.

As described here in a recent blog, the data can be downloaded as very large 2 GB files incompatible with Excel and requiring database management software.  However, CMS also provides an extremely user-friendly online data screening and sorting webpage.   For a discussion of the value of the dataset (using 2014 data), here.  For my brief overview of how to use the dataset step-by-step, here.

For example, in one second, you can find that 22 entities billed CMS in 2015 for 81211 - BRCA sequencing - with from 11 to 13,717 claims paid per entity.[*]   In a minute or two, one could track 81211 payments (or any other code of interest) for any or all providers sequentially in each year from 2012 to 2015.

For an example of dataset use, see below the break.

Case Study: Medicare's Use of the Unlisted Molecular Pathology Code (81479)

From 2014 to 2015, Medicare's use of the molecular test unlisted code (81479) rose considerably, reaching $166M which was right at 1/3 of all molecular pathology payments.

In two or three minutes, we can identify the US payments by provider name under code 81479.

For example, Ambry Genetics received about $31.7M across 8,676 beneficiaries, which was 19% of US 81479 payments.  Of 51 labs listed, the top 15 had 99% of 81479 payments.

80% of all 81479 payments were to California labs.  But the third-highest payments for 81479 went to AssureX in Ohio (later acquired by Myriad), with $21.3M for the year for 9,787 beneficiaries, or about 815 patients per month.

6 entities had over $10M in 81479 payments, ranging from $11.8M to $31.7M, and making up 74% of all 81479 payments.  And so on.  Just 14 data lines account for 98% of 81479 spending, almost 1/3 of US mopath payments.

Click to enlarge:

We can sort payments by state organized by CMS MAC contractor.  Almost all the 81479 payments go to MolDX states (99.7%).

Going back to the highest-paid 81479 provider, another minute or two of effort gives us Ambry Genetics' 2015 Medicare payments (in terms of dollars allowed), which appear to total around $38M, of which around 83% or $31.7M are unlisted code as already mentioned.

After that, $3.8M was paid to Ambry for PMS2 sequencing (81317), and about $2.4M for Tier 2 codes (levels 5,4,7,2,6).  By the time you reach just the 7th code under which Ambry was paid, it's 99% of Ambry payments.  However, over four-fifths of the dollar volume is hidden within the unlisted code.

Click to enlarge:


[*] The data does not include providers of a CPT code with 10 or less claims.

The CMS webpage is powered by "Socrata," here.

In CY2015, CMS payments for the GSP tumor panel codes were almost nil - $145,000 total to five entities, of which 3 were paid less than $10,000 for the year.  This $145K is 0.03 percent of the $480M in CY2015 molecular payments (here).