Saturday, November 25, 2023

MolDxOlogy: In 2022, MolDx Captured 98% of 81479 Payments

Header.  Genomic test spending under miscellaneous code 81479 was a third of 2022 Part B spending for Tier 1 lab codes at $470M.   98% was via MOLDX MACs.


Back in October 2023, CMS released data for CY2022 Part B payments by CPT code.   (Payments by doctor or lab will be released in summer 2024).  See October blog here.  Molecular spending was about $1.5B for Tier 1 codes, another $340M for PLA codes.   In either code set, the top few codes garnered most of the spending.

I noted that about a third of Category I spending was Unlisted Code 81479.  For a client project, I've gone back to that data and analyzed 81479 spending in CY2022 by MAC.

I analyzed all the states with 81479 over $100K (I had 99.96% of 81479 payments.)  98.3% was in MolDx states, or about $462M of $470M.  More was spent on 81479 than all PLA codes together.  

Also for 81479, $7.5M was in Novitas (PA), and just $500K in NGS MAC states (specifically, Illinois).

70% of 81479 spending was in California (61% northern, 9% southern) and 13% was in Arizona.  

About 90% of 81479 spending was via the Noridian MAC.  

The table below can be clicked to view.

click to view

81479 spending at MOLDX was paired with "Z codes," allowing granularity in claims processing. 

However, large amounts of molecular spending fall outside of PAMA and fall outside of public code data that can be used for academic and public health purposes.   For example, one cannot tally up how many Medicare patients had BRCA testing in 2022, if it is recoded as "81479."  (In contrast, you CAN tally up how many FFS patients had prostatectomies, colonoscopies, and so on).