Sunday, November 26, 2023

MolDxOlogy - Payments for 2022 PLA Codes, by MAC

Header: 80% of PLA codes were paid via MolDx.  About 10% each for Novitas and NGS MAC, but the NGS MAC PLA payments were mostly NCD-driven payments for Foundation Medicine.


In the previous blog, I looked at payments for Genomic Miscellaneous Code, 81479, by MAC - here.  I used the CMS cloud data archive for 2022 Part B payments - here.

In this blog, I pulled the CPT codes ending in "U" - the PLA codes - and sorted them in Excel for "Carrier" (usually a state), and sorted those into  the three  MACs for policies - the MolDx MACs, the NGS MACs, and the Novitas/FCSO MACs.

To save manual work, I deleted rows less than $100,000, leaving $330M of PLA payments (97% of the total).   Of this $330M, about $18M were paid out to diverse MACs (such as for a Cepheid IVD, 0241U), which I didn't try to parse by MAC.  

Of the $312M paid to specific MACs for PLA codes, I tallied $252M or 81% to MolDx MACs, and roughly $30M each to Novitas MACs and NGS MACs (about 9-10% each.)

Note, however, that much of the NGS MAC payments come from  PLA codes 0037U and 0239U, Foundation Medicine FDA CDx codes (FFPE and LBX, respectively) - these are controlled by an NCD, NCD 90.2, and are not discretionary payments under the judgment of the NGS MAC.   If you tallied NGS MAC payments NOT controlled by NCD 90.2, it would be very low.

Click to enlarge.

click to enlarge

I previously posted, in October, that national payments for PLA codes were highly concentrated, with the highest-paid codes mostly being FDA approved.  Just 3 of 500 PLA codes, had half the PLA payments.