Medicare Part B: Miniscule Use of Tumor Genomic Profiling Code 81455

It's been nearly ten years since the AMA CPT creating a code for tumor genomic profiling - 81455, currently priced by CMS at $2916.   Let's put two facts together and see what happens.

• AMA is holding a multiple-month workshop series on updating the coding system for tumor genomics.
• See the August 18 invitation here (archive here).
• CMS recently released data, by lab, on CPT utilization in CY2020 - here.

Here's the answer.   The CY2020 payments, in Part B, for CPT code 81455 were minuscule.  

There were just 933 uses of code 81455, to 9 different labs, paying $2.67M.

And with 2/3 of those payments going to an Alabama lab, Circulogene Theranostics (at 658 cases for $1.9M).

See table here:

click to enlarge

Interestingly, Johns Hopkins billed less than the fee schedule (only $2250) and the highest charge was from Siparadigm in NJ, at $14,595 per test (CMS pays $2917).  

Of course, a lot more cases went through the Foundation Medicine code, the FDA approved test under PLA code 0037U with 22,147 cases and $77.5M dollars.   

Are More Uses of 81455 Hiding?

Or we should say, are more cases of large-panel comprehensive tumor profiling hiding.  Well, yes, and no.  

Are they submitted as PLA codes (other than 0037U)?   Well, I haven't gone through every possible PLA code, but I already know: the top 10 PLA codes are 95% of PLA billing, and none of them (except FMI) is a tumor panel.  (Data view here).  

So if there are PLA codes, for CGP, in CY2020, they're a few hundred thousand dollars or less.  

And MOLDX doesn't use code 81455.  Any large gene panels for tumors at MolDx will come in under code 81479.  

Now, that's in total about $250M a year (almost no MACs except MolDx ever use 81479). But, a lot of that $250M goes to labs like Myriad and CareDx and goes for things other than CGP.   

Within MolDx CGP, Caris got $41M for about 14,000 cases of 81479, most or all of which I assume is CGP and with an ASP of $2916, the same price as 81455.  Said differently, Caris is not all that far behind Foundation Medicine.

Conclusion?  Public Health Data Can't Just Track 81455

One conclusion is that if someone in the public health sphere tries to use 81455 to track Medicare payments for large tumor panels, they'll be far off.  They'll find only 933 cases of CGP, when the actual CGP volume was over 35,000 cases, by adding just FMI (0037U) and Caris (81479) alone.  They billed with 0037U and 81479, not 81455.

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Note.  Alabama is a MolDx state, and Circulogene was paid for 81455, which MolDx management says, it doesn't use as an active code.   Possibly Circulogene was paid from somewhere else (e.g. with a TIN or NPI in a different state).  Circulogene is in the DEX registry, with some tests "covered" and some "not covered;" I didn't see an obvious CGP test that was "covered."