Thursday, June 20, 2024

Brief Blog: CMS Releases Part B Cloud Database for CY2022 by Physician & CPT Code

For a decade now, CMS has been released Part B calendar-year data by physician (or lab) and CPT code. The data comes out about 18 months after the end of a calendar year - June 2024 for CY2022.

On June 4, 2024, CMS released this database for Part B CY2022.  Find it here:


The data has 10M rows, so filtering it in the cloud is key.

For example, if you want all Genomic Sequencing Procedure codes, you can filter for codes that start with 814.   (Click Filter, click "basic filtering = " HCPCS-Cd, and "starts with" 814.  Push "apply filters."  You get 468 rows of data, which you can 'export' in a downloadable spreadsheet for Excel.

Or if you want PLA codes, click Filter, "basic filtering=" HCPCS-Cd again, but now filter for "ends with" and "U".   (You get 2737 rows, most are for for pathogen panels).  

Screen Shot: PLA Codes

For PLA codes, the top 10 lines out of 2737 lines, have 75% of all PLA code payments.  A Guardant test (0242U) and a Foundation Medicine test (0037U) have 25% and 19% of PLA payments, respectively. (Below, click to enlarge). (Top 10, $254M of $327M).

click to enlarge

Screen Shot: The Death of 81408

I began reporting several years ago that in Novitas/FCSO states, the $2000 genomic code 81408 was treated like a magic ATM machine, rapidly skyrocketing to the largest or near-largest codes in genomics.   It was literally a billion dollars, and many labs that billed this code, billed it always in multiples of 2 and always in full panels of all the rare gene codes (81401-81408). 

That's gone.   Only a few dozen payments for 81408 in Medicare in 2022, and only 3 data lines.

81408 2022

See the June 2023 OIG report on 81408 fraud here.   
See my 2021 blog on the severity of the situation, when 2019 data was released - I coined the term, "fraudomatic."  
See my June 2023 update.

So 81408 rose out of nowhere (in 2017) to be a super high paying code in 2019, 2020, and 2021.  By 2022 it was nowhere to be found, like it started.


Screen Shot:  Usage of 81479 "Other Genomic Test"

This code totaled $470M of usage, nearly all of it in MolDx states.  The top 3 billers had 61% of 81479 payments, and the top 10 had 90% of 81479 payments.  Click to enlarge.

81479 click to enlarge


Timeline for This Database

The data for CY2022 was released in June 2024.  I believe CMS allows 12 months for the claims to come in (last date of service 12/31/2022, so last claim deadline 12/31/2023).   After that "12 months to file' date passes, the data is released 5-6 months later.  Much briefer national summary data for CY2022 was released in simple excel spreadsheets around 11/2023.