Thursday, October 19, 2017

A Visual View of The Weird Intersection of BRCA Coding and PAMA Pricing

In an earlier blog we presented lab-specific CMS payment data for BRCA testing (here) and how to explain CMS's topsy-turvy BRCA pricing to a sixth-grader (here).

PAMA and the various combinations of 8 BRCA-related codes makes it even weirder than it used to be. 

I've assembled the BRCA services and coding options in the picture below, along with PAMA data for utilization and newly released PAMA median prices.  (Note, I've doubled the PAMA utilization to extrapolate from the sixth-month survey to a 12-month year.)  Click to enlarge, review, then continue.

click to enlarge

As observers have noted, under PAMA, the price of the most common BRCA billing code, 81211, actually rises somewhat (up by $200 to $2395) while the price of BRCA uncommon Dup Del analysis stays about the same, code 81213.   The consolidated or comprehensive BRCA billing code 81162 falls from $2503 to $1615, so it may be a less popular option than it was before. 

But wait, there's a whole 'nother level of weirdness, as the pricing for single-gene BRCA1 sequencing plummets to $75 and single-gene BRCA2 sequencing plummets to $185.   (Note that these codes got only a couple dozen uses in the PAMA year, whereas BRCA1-2 sequencing was about 200,000 uses.) 

This means there are several ways to build up coding for exactly the same major BRCA services: "Full sequencing of BRCA1 and BRCA2 and analysis of both common and uncommon deletions."

The most code-efficient way (which seems like correct coding to my eye) is 81162, paying $1615.   However, look harder and you'll find the highest sum comes from billing as BRCA 1-2 sequencing (81211, $2395) and uncommon deletion analysis (81213, +$553), totaling an impressive $2948, almost double the value we get for using the parent code 81162. 

But look closely and there's a third option, to order BRCA1 sequencing alone, with its common dup-del analysis, 81214, a frugal $75, and then order BRCA2 sequencing, 81216, for a still budget-friendly $185.  You're almost done: just order 81213 to wrap up those uncommon DupDels ($553).   Your shopping cart gives you all those BRCA services, soup to nuts, and costs you only $813, half the price of 81162, and only about a quarter of the most costly coding option for the same sequencing reports.  It's like those sales that get you one-way to Europe for $250.

To my eye, the simple coding is 81162.  I've said that.   But if you're going to break up 81162 into 81211+81213 (if you're gonna say that is kosher coding), why not do it again, and break up the 81211 into its component codes of 81214+81216?

More About BRCA Coding: Quest, AMA CPT, NCCI, and 3 Year Spending Options

Quest indicates that BRCA coding is ambiguous, allowing either 81211+81213 unbundled stack coding or use of the comprehensive code 81162.  See the Quest website here (sampled 10/30/2017; screen shot below).

There's no question that some of BRCA coding proposal was "tabled" by the powers that be when it reached the September 2017 AMA CPT meeting:

There's also no question that there is a public, national CMS NCCI Edit against unbundling and code stacking of 81211+81213, although it's not applied in some MACs (see here):

The next table shows CMS spending on BRCA testing in 2018, 2019, 2020 under three different coding approaches.   I've assumed 20,000 cases per year, about the 2016 rate.  Click to enlarge.

click to enlarge
CMS mostly pays for BRCA testing the most costly of all possible ways, by code stacking 81211+81213, despite CCI instructions not to pay this way.   This means the upcoming three year spend will be $176,930,400.   However, if CMS only enforced its own CCI edit, already on the books, and required use of comprehensive code 81162, spending would fall to $122,109,000, or a savings of $54,821,400

This is a big deal.  There's never supposed to be multiple ways to code the same service with AMA CPT codes.   (And I haven't even raised the issue of submitting gene panel AMA CPT codes where they are a better fit than code stacking individual genes.)

It's easy to imagine that CMS could simply throw up its hands at the brouhaha over AMA instructions and ambiguous use of 81211 and 81162, and many multiple coding methods.  CMS  could deal with the AMA problem and remove these two codes easily from the CMS fee schedule, because they are redundant.  Then CMS providers would not have comprehensive coding options, but, providers could account for full BRCA sequencing and full DUP DEL analysis by coding 81214+81216+81213, for total CMS payments of only $114,824,200, or CMS savings of $62,106,200 in three years.