Friday, January 15, 2021

Very Brief Blog: In Midst of Pandemic, Novitas MAC Tightens Rules for Respiratory Illness Testing

MolDx and Viral Panel Codes

On Monday, January 11, 2022, the MolDx MAC system held a contractor advisory meeting in which a half-dozen experts discussed uses of microbiology panel testing (respiratory, GI, meningitis, etc).  The discussion was somewhat extended and I don't have short bullet-point takeaways from it.   Panelists emphasized that different syndromes were different, different panels and settings were different, patients were individualized, etc.   At some point Noridian will post a transcript of the session. The MolDx system may be considering revising its policy (policies) for panel testing, which currently focus coverage on 5-pathogen-and-less panels.

Novitas Launches Proposed LCD for Viral Panel Codes

The Novitas MAC has released a new policy on respiratory pathogen molecular testing. with a public meeting to be held on January 29, and a comment period open until February 27.

See the Novitas LCD here (DL38916) and the billing article here (DA58575).  

LCD DL38916 Is Very Concise

The coverage section is very concise.  

  • Respiratory panels of 5 and less are covered (1) when timely results can be delivered in an outpatient setting, and (2) clinical management can result in an improved health outcome.

This coverage section has the pro's and con's of 21st Century Cures reforms for LCD structure and process.  The LCD coverage section is supposed state what is covered, why, and when, and not need updating very often.   An attached billing article gives details such as covered CPT code numbers.

In this case, the coverage section is fairly ridiculous, not defining "timely result" and leaving to the reader to figure out when "clinical management results in an improved outcome" to allow even the 3-5 panel tests.

The LCD goes on when an extensive literature review and discussion, including a summary of guidelines.

Novitas held a contractor advisory committee public meeting on respiratory panels in June, 2019, which leaves an audio file and transcript - home page here.  In the LCD, they record CAC members were polled and responded the panels are accurate and may improve outcomes.  The advisory meeting was held long before the COVID pandemic.

Billing Article DA58575

Note that the coding section has covered codes - group 1 - and non covered codes - group 2.   Covered codes including 86731, respiratory pathogens, N=3-5.  2022 codes will be added, including 87428, 87636, 87637, 0240U, 0241U.

The billing article lists a series of non-covered codes, including the standard codes for respiratory pathogens, 6-11 and 12-25 targets (87632, 87633) and a list of 7 non-covered PLA codes for large panels (larger than 5 targets, often around 20). 

The article adds no more to the LCD's superficial rules that results must be timely and can improve patient care.

Zip File

I've put the LCD, article, and 2019 transcript in one cloud zip file here.

You Tell Me: Trends in 87633

87631, '32, and '33 are a triplet of codes for respiratory virus panels, 3-5, 6-11, and 12-25 pathogens.

Interestingly, these codes drop in Medicare utilization from 2018 to 2019.

  • In 2017, national utilization of 87633 was $28M.  
  • In 2018, national utilization of 87633 was $42M.   
    • Remarkably, a great preponderance was in California, with $26M.
  • In 2019, national utilization of 87633 was only $31M.   
    • The delta might be accounted for by the drop of utilization in California, which fell from $26M in 2018 (part of $42M) to only $15M in 2019 (part of $31M).
    • Almost all the utilization in 87633 in 2019 was in So Cal ($15M).   

The national drop from 2018 ($42M) to 2019 ($31M) was probably due to introduction of a MolDx/Noridian LCD, L36315, in mid-2019, which blocks payment to California labs for 87633.

Who Were the Leading Providers of 87633?  Mostly So Cal

Going back to CY2018, when there was $41M of spending on 87633 and $25M in California, the top providers (each with over $1M allowed) were mostly in Southern California.

The top 11 providers (out of 230 providers) billing for 87633, provided $21M of 87633, or about half the national volume.

click to enlarge - CY2018 providers of 87633 (national) - most in SoCal