Wednesday, May 23, 2018

CMS Releases Provider & Lab Specific Utilization by CPT Code for 2016

Beginning in 2014, CMS has annually released comprehensive data of Medicare payments to each physician and lab in the U.S. based on CPT codes. 

On May 23, 2018, CMS released this data for CY2016 for Part B data.  Data for each year from CY2012 to CY2016 are available.

  • See the CMS database webpage here; click on CY 2016.

Or on this webpage, click on "Interactive Dataset."  Finally, get to a webpage where you click "View Data" box to see the full dataset in a web view.  You can filter and view data on line, or filter to a subset of data and then export (download) in Excel.
  • As a sample view into the database, I filtered for labs using any of these codes (81162, 81211, 81213).  81162 is the comprehensive code for BRCA 1&2&DupDel analysis.  81211 is BRCA 1&2 sequencing and 81213 is BRCA 1&2 DupDel analysis only.  (Note: These codes are being markedly revamped for the CY2019 codebooks).  
    • Total Part B BRCA spend was $67M.
  • Alternately, you could filter for the whole code range of Mopath CPT codes, which gives a 1500 line Excel spreadsheet (180 kb).  
    • Total Part B Mopath spend was $463M.
In the cloud:
  • See an Excel spreadsheet of this filtered BRCA data in the cloud, here.
  • See an Excel spreadsheet of all MoPath data in the cloud, here.
  • See a 100MB Excel spreadsheet of all Lab Code data in the cloud, here.
  •    For the latter, Google allows download but probably not view.


Total payments for these BRCA codes was $67M.   Total payments to Myriad Genetics were $32M, or 47% of the Medicare total BRCA payments.  The data is granular: for example, there were exactly 4,218 payments to Myriad for code 81213.

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CMS did an elaborate NCD for NGS testing in cancer last winter, finalizing it in March.  For CY2016, there were only 6,889 services for gene panel testing under codes 81445, '50, '55.  Payments totalled $4.0M, or less than 1% of CMS MoPath payments.   Of that, almost 75% went to only two payment lines.   These were Caris 81445 ($792,000) and Genoptix 81450 ($2.1M). 

In addition, Foundation Medicine was paid under different NPIs for its Cambridge MA and Morrisville NC labs.  While it billed a few small codes (81275, Kras, $78,000) from Cambridge MA,  its payments were largest for 81479, $3146, for 622 units of service, totalling $2,124,752, billed in North Carolina.   Added with the 81445-55 data, this brings 2016 Medicare payments for gene panel testing in tumors to only 7500 uses among circa 30M patients in Medicare Part B.


All Mopath codes tallied $463M. 

Exact Sciences Cologuard and Genomic Health Oncotype DX Breast were nearly tied for the top position, at $62M and $60M respectively.  Exact was paid for 123,729 patients.  These two tests at these two companies garnered about 25% of all Medicare mopath payments. 

Next, Crescendo Vectra test had 49,702 payments for $29M.  Assurex test was paid via the "81479" unlisted code, with 13,062 payments for $2,181, totalling $28M.  

12 codes were paid $10M or more, and these 12 codes garnered 65% of all payments for MoPath.

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Download the 100 Mb spreadsheet if you like.  This is all CPT codes in the 80,000 series X all submitting providers.  The spreadsheet has about 90,000 rows.   I tally payments at $5.8B. 

80053, Comprehensive Metabolic Panel, had the most billings one code at one provider location, at 1,319,197 services provided by Labcorp, with a submitted charge of $45.26 and average payment of $9.10.

I get the highest average "submitted charge" for a lab test as $15,759.52 for code 81445 from Caris.  CMS average payment was $430.55.   Castle Biosciences was paid $1.3M for 330 cases of 84999, submitted charge $8024 and payment $4100.