Friday, May 27, 2022

MolDx Coverage Article for BRCA (81162) Scheduled for Retirement; New Article Deletes 81162

One of the largest codes in the Medicare system for genetics/genomics is BRCA 1&2 testing, code 81162.  The highest paid codes have been 81479, $290M, 81528, Cologuard $210M, 81408 Tier 2 $207M, and then BRCA 1&2 81162 at $85M for 46,788 services in CY2020.

Currently, MolDx covers BRCA testing (81162) under billing and coding article A56854 (here).

81162 is prominently listed at the top of this article's covered codes (for LCD L36082).   However, A56854 is listed for FUTURE RETIREMENT on July 3.  

So what happens next?  

The replacement LCD appears to be L38966 and billing article A58652.  (For full links see my prior blog on this new LCD and article here.)  This billing article, which goes into effect on July 3, has conspicuously deleted BRCA 1&2 81162 ($1824) from the public list of codes covered under the policy, but it does include BRCA 84132 ($679).

I wondered if perhaps BRCA 81162 was absent because it is not "a panel" but codes like BRCA familial variant ARE in the covered codes list, and that certainly isn't a panel.


In Medicare Part B 2020 data, there were 45,000 Medicare uses of 81162 for $80M and there were only 10,000 Medicare uses of 81432 for only $8M.