Brief Blog: 2014-2015 Evolution of Part B Payments for BRCA Testing

The Medicare Part B provider database (here) gives us a window into CMS payments for BRCA testing in recent years. I show data for 2014 and 2015; similar public data is online for 2012-2013 but in a less user-friendly format.   Details after the break.

The data table in the cloud here, or click to enlarge the table below.

Coding in 2014-2015 and in 2016-2017
In 2014 and 2015, there were two relevant codes, 81211 (BRCA 1-2 sequencing and common Dup Del) and 81213 (uncommon Dup Del).   Today, there are additional codes for BRCA related panel (81432) and panel Dup Del (81433) and one code for a comprehensive two-gene panel of BRCA 1-2 plus Dup Del (81162).  Data on Medicare's use of 81432, 81433, and 81162 during 2016 will be available in about November 2017 at the state level and May 2018 at the lab level.

Medicare Payments for BRCA Testing 2014-2015

• As "dollars allowed," Medicare payments in 2014 were $43M, 
• with 85.5% or about $37M to the largest provider.   
• Payments in 2015 were $52M, 20% higher, 
• with 72.9% or about $38M to the largest provider.

Most providers performed about a 1:1 ratio of 81211 and 81213, but some small providers billed only 81211.  There is a CMS CCI edit against use of 81211+81213 together, but it can be overcome by use of the -59 modifier (see below).

The biggest gain year-on-year in market share was GeneDx, doubling from 8% to 16% of the Medicare Part B market.  Labcorp changed its billing laboratory from Dublin, Ohio, in 2014, to Raritan, NJ, in 2015.
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As part of the code research, I looked through Correct Coding edits, using the April 2017 version on the CMS website.   There's an edit that I don't understand, and it is listed as being in place since April 2013.  It seems to block use of 81213 when 81211 is used "as mutually exclusive procedures."

I've included a screen shot below, since even as a Medicare expert, I find the edit puzzling -- and moreover,  it doesn't seem to be applied in practice by MACs, since they pay huge numbers of claims that list 81211 & 81213 together:

After January 1, 2015, arguably, simultaneous use of 81211+81213 might be replaced by better coding with single use of 81162.  But I'm unsure why an edit against use of 81211+81213 was put in place in 2013,and if it is there, why it doesn't affect the two codes billing and paying together.

For a later update on the CCI topic, here.