CMS Part B Data: Profiling Code 81479 Billing in CY2018

Summary:  This article briefly highlights use of unlisted molecular pathology code 81479 in 2018 versus 2019, with a deep dive into recently-released granular data for 2018.  CMS data is easy to find and review; this blog took less than an hour "A to Z" including finding the cloud data, arranging it in small Excel tables, and writing.  

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National Data for 81479

From data released nationally by CMS in Excel spreadsheets (here), we know that CY2017 use of code 81479 (unlisted molecular test) was $116M, CY2018 use was $135M and CY2019 use was $202M.   The growth rate more than doubled from +16% to +50%, and the two-year growth in 81479 was +75%.

• In CY2019, 81479 the third-highest MoPath code (behind 81408, #1 at $290M, and 81528 Cologuard, #2 at $245M).   
• 81479 is an "unlisted" code that falls outside of PAMA pricing rules, both regarding data collection and regarding price setting.

By going through state-by-state Excel spreadsheets for CY2019, I ascertained that nearly all CY2019 use of 81479 was in MolDx states, with a few percent of use by Novitas in Pennsylvania.   For example, from 2018 to 2019, MolDx shifted its coding instructions for about 7000 cases of 81455 to 81479, adding to the 2019 growth in 81479 (see article on 81455 here). 

Here, I focus on detailed and easily-manipulated cloud databases released by CMS for CY2018 (here). This data is older than 2019 data, but far easier to use, since it's in cloud databases.

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State Level Data for 81479 for 2018

CMS's state level data for CY2018 has 260,000 rows (each use of a CPT code in each state can be a row), but filtering for 81479, only 22 rows are left.  That is, 81479 was used in only 22 states.  

58% of the dollarized use was in California, 28% in Ohio (for Myriad Assurex Health, Genesight).  That's 86% of the 81479 use in 2 states out of our 50 states.  See table below (click to enlarge).

Nearly all 81479 billing in 2018 was in MolDx states - easily discovered in the CMS cloud database for 2018.   This is the same result I got by manually going through each one of the newer 2019 state level Excel files one by one for code 81479.  

Lab Level Data for 81479 for 2018

CMS's provider (lab) level data has a robust 10M lines of cloud data.  Filtering for 81479 gives only 58 rows, e.g. 58 labs billed at least 10 uses of 81479. (FN1)

• The top payee for 81479 in CY2018 was Assurex Health, Ohio, 17,341 services, $38M (average allowed, $2,178).  
• The next highest was CareDx, California, 7,571 services at $2841 for $22M.  
• The third highest was Genomic Health, California, 5,184 services at $3121 for 416M.  
• These three of the 58 lines total 56% of the 81479 payments.  

Below, I chart all of the labs paid at least $100,000 in CY2018 in this Part B data.  Like in the prior table, the few labs outside MolDx states are shown in red.  Click to enlarge.

Note that in "state" data for Ohio, there were 17,529 uses of 81479 among 5 providers.  While in "Assurex" data for Ohio, there are 17,341 uses of 81479. at $2178.  Some other 4 providers apparently divided 188 other uses of 81479 in Ohio.  Further down in the lab-level table, we find that Labcorp was paid for 178 uses of 81479 for $321 via its Dublin, OH location.  

Dublin wasn't the only place where Labcorp billed 81479.  Labcorp has two Research Triangle Park entries for 81479, under two different NPIs ('6001 and '8700), getting 3,563 81479 services at one, and 223 81479 services at the other.

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The original spreadsheet data I used is in the cloud here. (FN2)

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Caris - Mix of Molecular and Pathology Codes in 2018

Caris, which raised $310M in growth capital in fall 2020 (here) and ranked highly in recent data I studied for CY2018 use of CGP (tumor profiling) code 81455 (here).  

By pulling Caris lab data for CY2018 from the cloud, we find that 81455 (tumor, 51 or more genes) constituted 71% of its CY2018 payments from CMS; total CMS dollars allowed were $28M in 2018.  

Note that a significant percentage of Caris's CMS payments were 88-series codes, or tissue pathology codes rather than 81-series codes for genomics.

81479 Charge/Payment Ratios

Charge to payment ratios are pretty meaningless in Medicare, but sometimes fun to look at.  I sorted for the labs with Charge/Payment ratios at 5 or over (range, 5-12).  Most had less than $10,000 in Medicare payments.  The average payment was  $177.  All were in non-MolDx states.  (E.g., use of 81479 in non-MolDx states is rare, and pays poorly.)   

Though not a high-ratio case, Labcorp in NC was paid for 3,563 cases of 81479 for $1.2M, but that's only $327 a case.

   

Tennessee  switched from the Cahaba MAC to Palmetto MAC in 2018, but I don't believe MolDx rules were applied until mid-year or later.

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FN1

109 providers billing 81479 are shown in the state data, but only 58 in the national data of labs.  The difference is that providers must be paid for 10 or more uses to show in the national data, providers paid for 9 or less uses are not shown.   Apparently, 51 providers were paid for 9 or less uses of 81479, and 58 were paid for 10 or more uses of 81479.

FN2

This week, Google Drive appears to convert uploaded Excel workbooks into Google Sheets automatically, although my settings tell it not to do that.  (?!)  I believe that if you click Download it will give the option of back-converting to Excel.