Monday, July 15, 2019

Very Brief Blog: CMS Releases Physician and Lab Claims Data for CY2017

Each year, CMS releases CPT code based claims data for Part B in three formats:
  • National Part B data
  • State Specific Part B Data
  • Part B Data for each physician & lab by CPT code
National Part B data tends to come out in late summer or in the fall.  So does State-specific data, which is really MAC data broken out into state-sized spreadsheets (Noridian Oregon, Noridian Washington, Noridian Idaho, etc.)   For example, CY2018 data will come out in 2H2019.

Physician and lab data is released on a slower schedule, with a delay of about 18 months.  CMS has just released claims data for CY2017 by physician or lab. 

The home page for this annual data is here:

And the CY2017 data can be found here:

Click through via "interactive dataset" and "view data" and you'll reach a giant cloud database.   The key thing is to use the search panels at the right of the cloud table (for example, search by lab name, and get every CPT code and volume it was paid; search by CPT, and see every physician or lab paid for that CPT).   Use the Export button to export as an Excel spreadsheet. 

MoPath Codes in Cloud

I've put a 1500 line spreadsheet (150 kb) of all the labs billing all the CPT codes 811XX to 81599, in the cloud here.  Have fun!  (It would also be manageable to download all the lab codes into Excel - 8XXXX - about 800,000 lines and 100 MB.)

Of course, you could download anything of interest - cataract operations, prostatectomies, psychotherapy visits, etc.  

First Snapshot: 81162

Going back to the CMS cloud data, within a few seconds, I pulled all labs in the database billing BRCA 1&2 (81162) in CY2017 and downloaded in Excel:

CMS Payments for 81162 (by Lab) CY2017

Entities at Lower End of Net Revenue in CY2017

In CY2017, Tempus Labs did not seem to have much CMS revenue yet, NPI 1740733708, with 26 payments for CPT 81445 (5-50 tumor genes) at $602 allowed (charge $3800), and 18 payments for 88342 (immunohistochem) at about $100 each.

Nanthealth Labs, NPI 1295026938, had payments for 21-23 units each of 81235 (EGFR), 81401 (Mopath level 2), and 81479 (Mopath procedure), with allowed charges of $332, $129, $144, respectively.

Billing by Unlisted Code 81479

CMS paid $115M under Unlisted Code 81479, and 95% of the top 99% of payments went to MolDx states.

Of this $115M, $32M or 28% went to Assurex, for 14,733 tests at $2,180 allowed payment per test.

click to enlarge
Billing by Foundation Medicine in CY2017

Recall that in CY2017, FMI did not yet have its NCD for coverage (which was proposed only in November 2017), and it had never gotten much Medicare payments in his home MAC in Massachusetts.

FMI opened a satellite lab in North Carolina, where the Palmetto MAC paid it for 1,687 services at $3416 each (charge $5800).  Net-net, FMI garnered only $700,000 on its home court in Massachusetts, but at the Palmetto MAC, in NC, it earned $6.2M:

click to enlarge

FMI was acquired by Roche in June 2018 for a total company value of $5.4B (here), or a multiple of 777 times its CY2017 Medicare Part B revenue.

Use of Somatic Panel Testing Still Modest in CY2017

Although 2017 was the year CMS unveiled its proposed NCD for somatic panel testing by NGS, usage was still pretty small in 2017. 

CMS paid for 1,302 cases of 81445 (5-50 genes) and 4,338 cases of 81455 (51+ genes), along with another 1,600 cases of FMI Foundation One paid by MolDx as 81479.   Still, these tallied only $3.5M of direct payments for 81445/81455, and another $5.7M of FMI payments as 81479.

My point is, this all totals less than $10M out of the roughly $500M CMS spend on molecular diagnostics in CY2017.  For comparison, in 2017 CMS paid Exact Sciences $118M for 231,000 cases of ColoGuard, at an average payment of $502.

Click to enlarge / 81445, 81455

Lab Industry in General: The Full Set of all 80,000-series Codes

I downloaded all the 8xxxx code date for 2017, an 800,000 line, 80MB file my laptop just barely handles and slowly.

But some big-data trivia.

I tallied $6.85B in payments.  About 30 claim lines (provider x CPT) paid over $10M.  The highest was Exact Sciences, paid $118.6M.  Among the top ten pay lines, most were specialty genomics (e.g. Genomic Health), but Inform Diagnostics garnered position 7 with $20.5M for 88305 (surg path) and LapCorp got position 9 with $16M for 84443, thyroid.  LabCorp also got positions 13 and 14 for Vitamin D and for Lipids, respectively, at about $13M each.

Just 40 of the 860,000 total paylines (0.005%) accounted for 10% of all payments.

click to enlarge (Top pay lines, entity X code)
Individual Providers and the 80,000-series Codes

The first individual provider on the pay line chart was a Memphis pathologist at line 132 with $3.9M for 87507, digestive tract pathogen.  The second individual provider was line 189 for 80307, testing for presence of drug, $2.9M.   The highest individual pay line for surg path (and it might represent some kind of group practice?) was line 257 with a Baltimore pathologist and $2.2M for 88305 x 34,000 units (surg path).


Sorting the 860,000 lines by self-reported gender, lines 1-475990 are male, and lines 475991-778211 are female, a ratio of about 60:40.  But the average male pay line was $3,586 and the average female pay line was $2476. 


Six entities garnered between $1M and $4M for immunohistochemistry 88432 (first slide of case).  Interestingly, only 3 entities billed over $1M for 88341 (additional IHC slides), with only 3-7 average slides per case.   Only a handful of higher-billing providers of 88341 billed >10 slides per bene, but one provider billed ~5000 slides for 26 bene's (~200 slides per bene) using 88341, which is difficult to understand.

About ten providers had $100,000-$500,000 in payments for 88344 (multiplex IHC slides).

All About Arsenic Testing

Something - old Columbo episodes? - triggered my interest in arsenic testing (81275).

If you are a Medicare beneficiary, there is about 1 chance in 2000 you will get an arsenic test in any given year.  Read on!

CMS paid for 21,276 units of arsenic testing at about 100 labs, and almost never more than once per patient.  Payment per test is $26.   Arsenic testing is highly concentrated, with LabCorp NC receiving $104,000, Genova Dx receiving $85,000, and Unilab receiving $27,000.  These are 19%, 16%, and 5%, or 40% of all US testing.   Total payments were $544,092. 

LabCorp garnered $154,000 from arsenic testing and Quest $108,000, together holding almost exactly 50% of the arsenic marketplace in the over-65 population.   For this test, LabCorp billed from 13 locations and Quest from 17 locations.  68% of LabCorp billings were from NC.  No Quest location had more than 20% of testing.

81275 and Old Lace

National Part B data files are here.   State level aka "carrier level" data is here.