Sunday, November 26, 2023

MolDxOlogy - Payments for 2022 Category 1 Genomic Codes, by MAC

Header:  Of Category I genomic CPT codes, about 65% MolDx payments, 20% NGS MAC, 15% Novitas.  But, most NGS MAC payments represented Cologuard, an NCD-driven code.  Otherwise, NGS MAC had 4% of payments.


In October, I posted some data on national CY2022 spending by CPT code (here).  

This week, in prior blogs, I broke out spending by MAC, first by 81479 miscellaneous code (here) and then by PLA code (here).

In this third and final blog for today, I show Category I CPT code spending by MAC (or MolDx).  I pulled cloud data for all 2022 payments on codes starting with (811, 812, 813, 814, 815).  

I then used an Excel pivot table to sum spending by "carrier" (usually "state") and rolled the results up by MAC and MAC system. The MAC policy systems are MolDx, Novitas/FCSO, and NGS MAC.


Of $1.5B in genomic spending in this code set, 63% was via MolDx, 22% via NGS MAC, and 15% from Novitas/FCSO MACs.

However, I would rush to point out, nearly all the NGS MAC spending in this code set was driven by a single national decision (not local MAC LCDs).  It's the NCD for Exact Sciences Cologuard (state Wisconsin, payments $268M under NCD, code 81528).  Minus that, NGS MAC in all other states and codes altogether paid $64M for Category I codes (811xx etc) in 2022, or 4% of payments of $1.5B.

Click to enlarge.

Summary of 3 Posts

For the following data, I simplified each data set (e.g. dropping lines <$100K), so the numbers vary a tiny bit from exact nationwide numbers.

For Category I codes (811nn-815nn), payments were $1.4B, of which 63% MolDx, 22% NGS MAC, 15% Novitas MAC.   Excluding the NCD for Cologuard, which is close to $300M, NGS MAC payments fell to 4%.

For PLA codes, payments were about $330M of which 81% MolDx, and about 10% each to Novitas/FCSO and NGS MACs.  However, most of the 10% to NGS MACs can be accounted for by FMI payments driven by NCD 90.2 for FDA PMA NGS tests.

For 81479 miscellanous codes, payments were about $470M, of which 98% was paid by MolDx MACs.  90% of that, was via Noridian MAC.  81479 was the national highest-paid genomic CPT code.


This fall, I used the Medicare coverage database to tally MAC Articles about genomic codes (811nn to 815nn).   There were 82 MolDx articles, 8 Novitas articles, and 4 NGS MAC articles.