Thursday, July 28, 2022

Medicare Releases Detailed Database for 2020 Part B Claims Payments

Each year, sometime between June and October, CMS releases a detailed database of all physician paid claims for the calendar year, 18 months prior.  Accordingly, in July 2022, CMS has released this granular data for CY2020.

Find the database here.  It's a cloud database (click VIEW DATA) which can be sorted by doctor name, NPI, specialty, state, CPT code, or more, and any combination of the above.  For example, you could get all the labs that billed Medicare Part B for 81162 BRCA testing in 2020, or all the providers who did cataract surgery.

For example, if you look up CPT codes 81410, 81411 for aortic genetics, 40% of the US services were paid to one lab, in Lafayette, CO.  One can download all the lab codes by every lab and provider (quite a large file) or all the genetic codes 81000-81600, which are quite manageable in Excel.  

The whole database is about 1M lines.  Just pulling down genetic CPT codes (basically 812xx, 813xx, 814xx, 815xx), the data is 3400 lines.  Dollar volume is $1.365M.  Note, however, this series of codes omits a few large PLA codes like Foundation Medicine.   Still, within the domain of codes I checked, Exact Sciences Cologuard is dominant at $208M (15%).   Amazingly, given the huge number of CPT codes in recent years, 4 of the top 6 codes are nonspecific codes (81479, 81599), paid to CareDx, Genomic Health, Guardant, Caris, and Castle.   All the unlisted code payments are in MolDx states.

In the 3400 line database, the top 6 codes are about 40% of all payments.

With the caveat that PLA codes are missing, see the two-page Excel in the cloud here.

CPT code 81408 was almost unknown in the Medicare population through 2017, picked up somewhat in 2018 and drastically in 2019 (approaching $300M).   In 2020, payments are down to $206M.   Commonly, labs that bill 81408 for Medicare patients bill in units of 2, but one lab billed 3.8 uses of this genetic test in the elderly per patient.

Nearly all of the 81408 billing was in Novitas or First Coast jurisdictions (94%).   However, in 2020, there's a California lab that was paid $11.5M for 81408, billing 2 claims per Medicare patient.  This is a little surprising because MolDx usually has a "no pay unless approved" policy for genetics.  I couldn't identify the named lab in question in the MolDx DEX directory, which seemed odd, but sometimes there are DBA doing-business-as factors that make name tracing difficult.