Tuesday, October 29, 2019

Very Brief Blog: Snapshot of CY2018 MoPath Payments at CMS

Each fall, CMS releases CPT code payments for Part B in the prior year (for CY2018, here).

I've done a quick review of MoPath spending in CY2018.  Cloud excel here.

By my tally,  MoPath payments (81162-81599, plus U and M codes) was about $1,151,475,000.  This compares to $480M in the same data for CY2017, so PAMA 2018 did not kill MoPath.

As in prior years, the billing is highly concentrated.

Out of 204 codes, the top 5 gathered 50% of payments.   The top three were Cologuard (81528, 335,455 uses, $171M; see also here), Unlisted Code 81479 (used almost exclusively in MolDx states, 89,721 uses, $136M) and MoPath Tier 9 (62,280, $123M). 

click to enlarge  -MoPath CMS Pt B CY2018

Corus CAD
The 9th largest test was Corus CAD, at $30M - at the end of 2018, coverage was discontinued and the company quickly folded, here.

PLA Codes
The largest PLA code, 0037U, FMI F1 CDx, gathered $37M.  It was active beginning April 2018 and under NCD coverage (the CMS NGS NCD) for three quarters of 2018.  The $37M represents circa 10,000 patients.  (PLA Excel here; See additional PLA chart at bottom).

GSP Codes
Among GSP codes, 81432/81433 (HBOC panels) were used in 19,448 and 16,492 patients, respectively, for $16M and $9M (total $25M).   5-50 gene tumor panel 81445 was used 3,244 times for about $2M.  81455 (50+ tumor genes) was used 7,494 times for $21M.  While MolDx generally insists "we don't pay for 81455," 7,006 of the 7,494 payments (94%) were in Noridian Jurisdiction E under MolDx, suggesting the Z-code and master edit system is somewhat leaky.

Whole exome 81415 was paid 1 time; whole genome 81425 paid 0 times.

CMS data shows claims paid and gives no insight into denial rates.  Based on 2018 data, XIFIN showed that payor denial rates for 81445, 81450, 81455 ranged from 82%-96% (here).

BRCA Codes

CY2018 was the first year in which CPT codes 81211/81213, legacy BRCA codes, were deleted and replaced by less expensive code 81162.  Although BRCA remains a top-ten revenue item in MoPath, revenues trended downward due to this coding/pricing change.  See article on Myriad revenue changes due to coding, Genomeweb, 11/5/2019, here.

Tier 2 Watch

Tier 2 codes altogether tallied $190M uses, bigger than Cologuard.  Most of this was 81408, Tier 2, Level 9 (big genes).

click to enlarge - MoPath Tier 2

Despite the profusion of CPT codes and PLA codes, 25-30% of payments still flow through an unlisted code.

Each fall, OIG releases a report on CLFS spending in the context of PAMA implementation.  The 2017 reported appeared in 9/2018, but the 2018 report has not appeared yet.  That report includes hospital outpatient labs, which my Part B data does not.


PLA Code Concentration

2 codes were 98% of PLA code usage (CMS listed about 40 codes in CY2018 data).  In round numbers, FMI F1 CDx was 90% of PLA usage and Oncotype Prostate was the next 10%.

Most PLA codes had no usage followed by some that had a few dozen uses or less. PLA Excel here.



Unlisted code 81479 is used almost exclusively in MolDx states.  In the MolDx master edit file of all Z codes (received through FOIA), there are 13,000 lines, of which 5000 lines track to 81479 (probably meaning that 5000 Z codes are assigned to 81479).

Exact Sciences is working on an improved Cologuard test; here.

Opko 4KScore, code 81539, had 25,572 uses for $19.4M.  Early press here.  Parent company Opko was recently down 30% (here).

Category I MAAA Codes (excluding PLA  or Admin MAAA codes, the U and M codes) tallied $443M, though a large share was Cologuard 81528 and no other tests approached its volume or revenue. Leaving out Cologuard (which has a huge volume at about $500), the average MAAA paid $2500.  The average 81479 payment was $1500, while the average 81599 payment was $4000.

Category I MAAA Codes