Wednesday, September 1, 2021

Use of the Category III Codes in CY2019 - Who Got Paid for Them?

Earlier I posted that on August 31, 2021, CMS released CY2019 utilization data by provider (or lab or IDTF), and by CPT code.

Here, I culled the data for all Category III codes (searched as all codes containing "T.")

There were 11,000 unique lines where a provider was paid for a Category III code.  Total payments were about $240M.  

The largest was iRhythm, paid $57M for code 0297T, followed by Cardionet, paid $8.9M for 0297T.   While the 3rd-largest line was code 0379T at $4M (remote visual field assessment), the 4th and 5th lines were again 0297T, about about $3M each.  Thus, by line five, 31% of all Cat III payments were accounted for, and most were for cardiac patch-based monitoring, 0297T. 

After that, the next ten or fifteen top payments went to code 0191T, an ophthalmic surgery code (anterior chamber drainage device).

See my extracted cloud database here.   I've sorted one page by "dollars" and one page by "CPT code" in order.

More About Category III Codes - 90% Never Paid by Medicare

In another analysis, only 26 unique Category III codes were reported in the database.  While there were 785,797 total services, 95% of all services went to the top 7 CPT codes.  (And 70% of all services went to the "iRhythm" codes, 0296-97-98T.)   

I'm not sure the total Category III codes active in CY2019, but now in CY2019, there are about 350.   This suggests that in a year, CMS makes a payment only on about 10% of all Category III codes, and never pays for about 90% of them.   

click to enlarge

In addition to "tail" here, ~300 codes had 0 pmts (not shown)


The Penny Puzzle

I noticed there were a number of payments of 1 penny per patient, and I first guessed that this was a nasty MAC paying 1 penny to just clear the claim out of its computers and move on.   All the penny claims were in New Jersey (Novitas MAC).  

However, these penny claims turn out to reflect CHARGES of one penny - the doctors billed one penny, so Medicare paid them one penny.   This involved about 700 claims for 0296T (an Irhythm code) in New Jersey, most of the penny-billing docs being in Morristown or Mendham or New Arlington NJ.  No idea what this means.  

That's penny billing for Cat III codes.  I went back to the CMS data source and searched paid claims for one penny services.  About 90 CPT codes received payments (for some docs) of one penny, totalling 25,000 payments of one penny.   0296T, the main T code on the list, is not even very high up at #741 payments of one penny.   J7613, albuterol, inhalation, had 2803 payments of one penny, and g0444, annual depression screening, had 2553 payments of one penny.   Ipratropium inhalation J7644 and denosumab injection J0897, had 1986 and 1506 payments of one penny, respectively.   The 90 CPT codes getting 25,000 payments of one penny were distributed across some 700 docs.  

Half of all these 700 docs getting a penny payment (for any of those 90 CPT codes) were in just five states, PA, RI, WV, FL, NJ (with percentages PA 14%, RI 11%, WV 7%, FL 7%, and NJ 7%).