About a month ago, CMS released data for 2024 Medicare Part B payments by CPT code. I noted then that billing of 81419 - epilepsy panel - was anomalous as the second-highest of all non proprietary genomic codes. And, along with mitochondrial panel 81440 and inherited conditions 81443, 81419 shot up a "zillion" percent from almost no usage 2-3 years ago. And Medicare usage of 81419, 81440, 81443 was almost zero at major genetic labs (Ambry, GeneDx, etc). And usage was practically exclusive to Novitas and First Coast states.
Hundreds of millions of dollars are involved.
- On October 7, 2025, 360DX (part of the Genomeweb news system) has a deep dive article by Adam Bonislawski.
- Find it here (subscription).
The spending on these codes resembles the spending on a similar, and almost-adjacent code, 81408, as documented by OIG reports and trade journal articles at Genomeweb and Dark Report. Spending there topped a billion dollars (including adjacent codes 81407, 81406). OIG stated that 81408 was largely unpayable after December 2021, but a few codes away, Novitas payments for 81419 were about to explode.
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Also seeing a doubling in revenue is code 87798, which is "infectious agent, other, amplified probe." This code rose from $225M in 2022 to $446M in 2024, also, hugely focused on the Novitas and First Coast states. (13 of the top 15 billers for 87798 are in Novitas-FCSO states again). 10 of top billing labs are LLCs, which can be set up very quickly in most states. (Many of them had NPI's only a year or two old). Names are often unusual, like "Ace Quality Lab LLC." (See lower part of this blog).
At $446M, 87798 is the second-highest paid genomic code after 81479 (unlisted code, paid almost entirely at MolDx).
A few years ago, MolDx noted that while it did not cover large 20-pathogen respiratory and GI panels, a few labs were avoiding those blocked codes by billing instead, "87798 x 20 units." MolDx developed edits to stop that. At Novitas, top billing labs for 87798 often billed 15-30 uses on each patient. In contrast, when Quest billed 87798, which was uncommon, it was in units of 1.
I don't know how NGS MAC edits these codes, but they have always had very low payments for 81408, 81419, and 87798.
Sounds like if CMS had required Novitas (and FCSO) to join MolDx a few years ago, around two billion dollars would have been saved.
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AI generates a "Lewis Black" take on this here.
