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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| click to enlarge, top codes in series 811 812 813 814 |
The Top Code is 81479
What The F*** With 81419, 81440, 81443???
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.
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| See column of States at left = Novitas & FCSO MACs |
Billing 81419 was Concentrated
About 57% of national Medicare payments for epilepsy panel in 2023 went to just 4 Novitas-FCSO labs (in FL, NJ, TX).
Labs Billing 81419 Were Atypically of LLC Type
Of 27 labs that billed 81419 in 2023, 16/27 or 60% were "LLC." (Of all labs billing popular code TSH 81443, 27% were LLC (301/1104). See AI comments about the actual lab names below.
Labs Billing 81419 Often Co-Billed 81440, 81443
In 2023, of labs billing any of these unexpected genetic codes (81419, 81440, 81443), 10 billed all three codes (10/27, 37%).
This group of codes (81419, 81440, 81443) was also paid by Medicare [essentially] in only Novitas and FCSO jurisdictions. 81440 is mitochondrial panel >100 genes, $3224, 81443 is inherited severe conditions like Ashkenazi panels, $2449. The total damage? Almost $200M. Click to enlarge
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| click to enlarge |
99% of Payments "NOT" to GeneDx, Ambry, Quest, Labcorp, etc.
In 2023, there were $27M in payments for (81419, 81440, 81443), for 10,832 Medicare patients, of which 123 cases were for familiar labs GeneDx and Labcorp (1.1%).
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 not 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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AI CORNER
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In labs billing 81419, I didn't see major brands like Ambry and Quest. I asked Chat GPT to read and discuss a couple dozen lab names that were billing 81419 in 2023.
- 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.
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(For more on odd lab names here).
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Chat GPT Recognizes Anomalous Names
I gave 3 paired short lists of lab names to ChatGPT 5 and asked whether, in each pair, it could pick the list of anomalous or unusual labs. It was correct 100% of the time.
NPIs Often Brand New
I spot checked a few NPIs and they were all from 2022 or 2023 (for labs paid millions in 2023), and some were out of business by 2025.
Multi-Code Billing Per CMS Patient
Another flag was, if ABC Lab had 1,206 Medicare cases of 81419 Epilepsy gene panel, it also happened to have 1,206 Medicare cases of 81440 (Ashkenazi panel) and 1,206 Medicare cases of 81443 (mitochondrial gene panel). This parity among the 3 codes was never seen at Ambry, Quest, GeneDx, or LabCorp. It reminds of the 81408 situation of 2020, where a lab would bill for 1,206 cases of rare gene 81408, also for exactly 1,206 cases of rare gene 81407, of 81406, of 81405.
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AI-Generated Monolog
See an AI generated complaint in the voice of comedian Lewis Black about the Medicare payments - here.
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Novitas Controls?
Novitas and FCSO have a generic article that lists hundreds of gene code and makes a generic statement that services must be reasonable and necessary - A58918.
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FFS vs Medicare Advantage??
Another quick scan for CMS detection of "anomalous claims," would be pull up labs that ONLY bill genetics to FFS Medicare patients, and never to the majority of Medicare patients who are in Medicare Advantage. I can't run that query.
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These Lab Over At MolDX DEX Registry
Of 27 labs paid for 81419 in 2023, aside from GTI AZ and GENEDX MD, 2 labs were listed and had genes on offer but none showed approved or payable from MolDx. 3 others were listed in DEX registryby lab name only but no tests had been submitted.
