Wednesday, May 10, 2023

Big News: CMS Releases Physician/Lab Database for CY2021; Boom in 81408 Ongoing

Each year since about 2016, CMS has realized a huge annual cloud database of all CPT & HCPCS codes paid to physicians and labs.   It comes out anytime between May and August, and this year, it's issued on May 10, 2023 for CY2021.

This data is titled, Medicare Physician & Other Practitioners - by Provider and Service.  Basically, you can search every CPT code (all the imaging codes; all the pathology codes; the BRCA code, etc) and see what any and all providers were paid for that code in Medicare Part B in CY2021.  

Find CY2021 data here:

The full 2021 claim data set is 10M lines and 3GB.  However, you'll want to filter for subsets, like genetics.

Using the Data

It's a bit of a learning curve to learn to use this cloud database, but basically, the key commands are FILTER and then EXPORT.   

For example, if I filter on code 81162 - BRCA full sequencing - I get only 44 rows, which I can export in Excel and study.  

If I filter with the command "starts with 814" I get 1189 rows.  Which are all the codes and providers paid for 814nn, or CPT genomic sequencing procedures.  

When you have the filter you want, click on "Export."  Note, this gives you a csv file which you'll want to save as an Excel (or Google Sheets) file.

81408 Watch

For several full years, I've made watching the flow of payments under code 81408 and other Tier 2 codes.  

These codes, from 81400 to 81408, are issued by AMA CPT to track sequencing of clinically rare genes.   The amazing, amazing thing is that, most of the labs that bill 81408 at all ($2000, full sequencing, rare gene) bill it in multiples of 2 for every Medicare patient and ALSO bill the whole series of 81400-81408 on every patient.  This is, to borrow a CMS term, "medically unlikely."

Medicare Part B ayments in 2021 for 81408 were $282M.  Payments, again as in a series of past years, are almost entirely in Florida and Texas.   (Based on past research, I and colleagues belive the one lab listed in "state of CA" has its NPI there but actually bills in another less-controlled state.  For example, MolDx edits would never allow payment of 81408).

One entity was paid $105M for 81408 or 37% of all 81408 uses nationwide.  The top five entities (of 80 entities) got over 60% of the 81408 payments.

Big busy genetics labs, like Ambry, Invitae, etc, were absent from the roster of 81408 recipients, as were Quest and Labcorp.  Click to enlarge.

In simple excel spreadsheets for CY2021, released by CMS around October 29, 2021, we already had seen that spending for 81408 was very high at $283M (the highest-paid code, somewhat above Cologuard 81528).    For my 10/2022 analysis of CMS data for CY2021, see here.

As I've reported over the several years, one can look up genetic labs reported in DOJ press releases as indicted or convicted for improper billing, and those genetic labs almost invariably have predominant billing of 814nn codes.   Of course, I can't make any assumptions about other labs with mostly 814nn billing patterns at Medicare.

Why Tier 2 Code Fraud is Distinctive

For those labs who have been indicted or pled guilty or been convicted of lab fraud, in genetic testing, they usually are seen to mostly bill Tier 2 codes, all of them, and in multiples.  This is different than other kinds of common improper billing, such as electric wheelchairs.   If  a MAC gets 100 claims for 80 year olds around a state who need electric wheelchairs, well, it could be true.    But if a MAC gets 100 claims in a row, or 10,000, for 80 year olds, all of whom need $9000 worth of 16 different rare genetic tests, that's impossible, it's a different kind of detection issue.  

All billing for Tier 2 codes was $594M.   A bit of this is legitimate (occassional uses of 81401 or 81402 in uncommon patients.)  

See an adjacent blog to download, in Excel, my extract of CMS 2021 genomics data.