If you love CMS Part B data, Christmas comes every May or June, when CMS releases extensive cloud data for all labs and all physician providers of every CPT code.
CMS classes this as;
Data.cms.gov
>> Provider Summary by Type of Service
>> Medicare Physician and Other Practitioners [incl labs]
Find it here:
https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-provider-and-service
The 2024 data set was released on May 21, 2026. The same source has year-by-year back files to 2013. the 2024 data has 9,781,673 rows. You use it by filtering - for example, every lab that got paid $1 or more for code 81479 (filter on HCPCS = 81479).
##
I filtered for codes ending in M or U, plus 811, 812, 813, 814, 815. This misses the molecular microbiology codes, which are in different ranges up in the 87000-87999 range.
The codes I did filter - without 877 microbiology - were paid $2,813,342,286, meaning, amost 3 billion dollars.
This produces lines as "lab x code" so, for example, 81479 is split over many lines, many labs.
The top code was 81528, Exact Sciences, $306M, or 11% of all molecular payments. Next ccame Natera, CareDx, and Caris, all for code 81479, respectively for $104M, $102M, $100M.
The top 10 codes were paid $1.2B or 41% of all molecular payments. About 30% of the top 20 lines were 81479 payments. 81479 providers were paid $572M, 95% to the top 12 billers of 81479. 81479 used only in MolDx states. Below: Click to enlarge.
 |
| click to enlarge |
##
I've heard there was a recent boom in uncontrolled (no LCD) payments for 81419, epilepsy panel. I used Ctl-Alt-L to turn the highlighted "CODES" column into a drop-down-box selection column and checked only 81419. Let's remember, just because codes like 81419 epilepsy, 81443 expanded carrier panel (e.g. cystic fibrosis), or 81440 mitochondrial genes, rapidly rose greatly in utilization and primarily in TX and FL, where Novitas did not have controlling edits, does NOT mean that anything inappropriate was occurring.
Top payments for 81419 epilepsy panel were $73M with with half of national payments going to the top 6 epilepsy panel labs.
Note the states; TX, FL, NJ, PA, TX, FL, FX, FL.
Nearly all labs getting paid for Epilepsy Gene Panel 81419 in Medicare, were under the Novitas and FCSO MACs, which had in recent years paid around a billion dollars for 81408 (Tier 2 code) and adjacent codes. That's a code not covered by any other MACs, and one whose payments were apparently finally stopped by OIG.
While payments stopped for 81408 around 2023, by 2024 labs provided market access for genetics to patients under a different uncontrolled code [no LCD], 81419, literally just ten digits away in the code book.
 |
| click to enlarge |
I took the top 4 labs for 81419 (as above - FL, FL, PA, TX) and pulled all of the billing for these four NPI's for 2024. The four labs were paid $27M for 81419 and $118M for all genetic codes. Other leading codes from these four labs were 81440 (mitochondrial genes), 81443 (inherited conditions aka expanded carrier panel, CF etc), 81162 (BRCA).
At a glance, these genes seem medically unrelated. One lab billed the same number of patients for 81443 and 81448, and the same number for 81181, 81183, 81343.
###
AI CORNER
###
I gave the data to both Claude Opus and Chat GPT. Claude noted that many of the labs - about a dozen out of 48 nominally independent labs - billed the exact same charge, to the penny for 81419. That's a clever observation and one I never have looked for. Of course, that could happen for many reasons and I do not view it as suspicious. Claude also wrote, "A single elderly Medicare beneficiary rwho medically requires an epilepsy panel + a 100-gene mitochondrial-disease panel + a prenatal-style carrier screen is not a workup that exists in nature." Claude also asserted that many of the single-gene codes were already inside 81443, something that CMS edits should have known. (I have not manually checked that.)
Of the four labs we checked based on high 81419 billing, one billed only 3 CPT codes, one billed 18, and the other two (both in the same city) billed about 65 codes each.
Chat GPT studied the Excel's and opined, "The data do not look like an organic epilepsy-testing market. They look like a rapid, concentrated exploitation pattern around a high-paying, apparently weakly edited genetic CPT code, with the strongest signals in Florida/Texas, and especially around a small number of labs whose broader code portfolios show high-volume use of many unrelated genetic codes, not a coherent epilepsy-testing service line." It tallied 7 of 48 labs billing 81419, as all being in Deerfield Beach FL. Labs billing the same charge were as little as 1000 feet apart.
