This past week, CMS released data on lab test utilization by CPT code for CY2024 and CY2023. I published a rapid blog on this and looked at the distribution of payments by proprietary PLA code.
https://www.discoveriesinhealthpolicy.com/2025/09/cms-releases-part-b-utilization-by-cpt.html
I've gone back and looked at the CPT code series 811nn, 812nn, 813nn, 814nn - these are the non-proprietary genetic CPT codes. Here are the top codes paid in 2024. Click to enlarge
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This category of code was paid $1.4B by CMS Part B in 2024, of which 42% or $584M went to Unlisted Code 81479. Historically, this is paid 90% or more only in MolDx states.
Most of the other top codes are from the roughly dozen codes now assigned to comprehensive genomic profiling (code 81445 forward, CGP codes).
However, it's odd to see Epilepsy Panel 81419 as the second-highest code, paying $74M.
This code grew massively in 2022 and 2023 and 2024, just as notorious code 81408 did in 2018-2021 (reaching about a billion dollars paid.) For 81408, see OIG report $888M lost. Blog 2023 on 2021. Blog 2021 on 2019.
In 2022 there were just 41 payments for 81419, epilepsy panel, in Part B.
For 2023, where we have data by lab and by state, we see the 2023 payments were entirely in Novitas MAC states and FCSO (Florida). This is about the same pattern seen earlier in 2018-2020 for 81408.
About 57% of national Medicare payments for epilepsy panel went to just 4 Novitas-FCSO labs (in FL, NJ, TX).
Conclusion
The program vulnerability at Novitas-FCSO was unchanged from 2018 to 2024, allowing rare genes to explosively rise to the top of the payment cycle with no intervention. The same behavior was never allowed at any other MACS - not MolDX MACs or NGS MAC. Despite repeated statements (up to today) from CMS about interventions with super duper AI against fraud, the situation with 81408 and similar codes can be picked up by a nine year old with an Excel spreadsheet.
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In labs billing 81419, I didn't see major brands like Ambry and Quest. I asked Chat GPT to read a couple dozen lab names that were billing 81419.
- Prestige or Elite Branding
- Use of terms like "Landmark" or "Fidelity"
- Science-y
- Gene Express, Thesis Genetics
- Obscure
- Pro Exonics LLC
- Genomic Pathology UltraSeq LLC
- Odd Shell Names
- ExelproDx Labs LLC
- None of the 81419 labs mention a state or locality. Formulaic names were reused (Exon Express Genetics). LLC name was common.
