In summer rulemaking, CMS proposed surgical biopsy billion-dollar-code 88305 as a mispriced code. Blog #1 here. I also had Chat GPT research the policy history of the odd surg path coding system (it took 26 minutes!). Blog #2 here.
In this third blog, I looked at provider-by-provider Medicare Part B data for 88305. Find it here. CY2024.
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17,430 different providers paid for 88305. $931M.
576 were Clinical Laboratories, paid $226M or about 20% of all dollars. All the other dollars went to entities enrolled as providers (pathologists, dermatologists, etc.)
13,680 rows were pathologists. 1719 were dermatologists. 904 were gastroenterologists. Just 33 were urologists (Medicare pays for prostate biopsies as a blanket lab fee, not per core).
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Average services per bene were 2.0. For gastroenterologists, 2.6. About 30 of 900 gastroenterologists billed 5-10 services per patient.
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CLINICAL LAB DEMOGRAPHICS
The top 15 of 576 clinical labs received 34% of clin lab payments and performed 1.2M services. At 0.3 hr per service (20 minutes), that is 400,000 hours of pathologist time or about 200 man-years of at-the-microscope pathologist diagnosis time. That's $379,812 of income ($77M) per pathologist man-years. (But that money-per-pathologist must also pay techs, overhead, etc). The top 15 labs logged 9 to 23 pathologist man-years per entity and billed 50,000 to 120,000 of 88305 services (in total 1.2M) to CMS.
'PHYSICIAN" DEMOGRAPHICS
The top 15 of 16853 providers were paid $32M, or 4.5% of the total. They performed 537,000 services. At 0.3 hr per service, that is 177,000 microscope hours or about 90 pathologist-years. It's $362,676 of income per fictional (2000 hr) pathologist ($32M for 90 pathologists).
The top 15 entities logged 4 to 10 pathologist-years per entity and billed 24,000 to 58,000 88305 services to CMS. (In total, 537,000 services).
What we show in the "provider" table is entities or NPIs that billed Medicare. I doubt any single pathologist signed out 60,000 services (20,000 hours or 10 man-years or 2.5 actual years 24/7). What may have been an underlying group practice of some kind may appear to be "a pathologist" or "a dermatologist" in the Medicare public display files.
Data below. Click to enlarge. 8 of the top 15 pathologists were in Florida, 1 in Texas. 4 of the top labs were in Florida, 4 in Texas.
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| Labs click to enlarge |
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| Providers click to enlarge |
