Saturday, September 26, 2020

2019 Medicare Molecular Microbiology Spending: $365M and Overview

In a recent blog, I reviewed CY2019 Medicare pathology & laboratory spending, which is about $7B, focusing on human molecular pathology (e.g. 812xx 813xx 814xx 815xx) which was about $1.7B.  Here The Part B data doesn't include hospital outpatient or hospital outreach claims.   I added a deep dive on 81479 (unlisted code) here.

The Molecular Pathogen Code Series

In this article, I'll briefly describe an area that some readers are less familiar with, molecular microbiology payments.  These are CPT codes 87471-87801, then skip to 87900-904.

In my hands, for CY2019 Part B, these tally $365,846,197 allowed charges, or $365M.

Using the same metrics, CY2018 was $294,470,931 (growth +24%).

Charges Are Highly Concentrated

As occurs in other areas of lab medicine, charges are enormously concentrated.  

Of 87 codes, 27% of payments go to ONE code, and over half of payments go to only 5 codes.  

The highest paying code is 87798, pathogen, other, amplified probe, with 2.6M services and $100M of allowed charges (27% of total).  It's about $39 a pop.  

The second-highest paid code is 87633, respiratory panel, 12-25 probes, with $34M for only 74,000 services, because it's $459 a pop.

Data Display; Cloud Raw Data

I've put a screen shot below (click to enlarge) and I've put my working Excel file in the cloud here.


A lot of microbiology spending goes through pretty non-specific codes.  This was a problem in the human molecular pathology realm, due to hundreds of millions of dollars of fraud being driven through 81408, a non-specific complex gene code (see my 2019 analysis here ending with a focus on 81408 and is problems.)

87798, the highest-dollar microbiology code at $100M, has no LCD or article at all at most MACs, suggesting it will auto-pay.  (And the only articles that even mention 87798, do so solely in the context of Zika testing (!) or GU testing; see A55326, A55327, A56791 (retired).)   

87633, the second highest-code, has Medicare Coverage Database edits only at the MolDx MACs (WPS, CGS, Noridian, Palmetto).  Screenshot below taken 9/27/2020.

Payments, at least through 2017, were incredibly concentrated.  For the 12-25 pathogen panels for GI and for RESP, 87633 and 87507, about half of all the nationwide Part B payments went to 4-5 providers, and not particularly large places (not Quest, etc).