Focus on Molecular Microbiology Code 87798: Impact of Palmetto 2022 LCDs

One of the major policy changes of 2022 in the MAC world has been the introduction of a broad-ranging molecular microbiology LCD by the MolDx states  Generally, only 3-5 concurrent molecular pathogen probes are allowed at once, althogh there are exceptions for unusual conditions like transplant patients.   (In addition, intense use, like in the ICU  sepsis patient, is part of a DRG and not controlled by the LCD).

I've been told that one impact is to control payments of code 87798, other amplified probe ($35).  This has a medical-unlikely edit of 13.   It's been said that past LCDs may have not paid for specific codes (such as "12-18 respiratory pathogens") but the LCDs didn't control use of 87798 x 13 in the same situation.

Here's the growth of 87798 from 2016 to 2021:

Note that the doubling-time began well ahead of the 2020 pandemic.

In other blogs, I've noted that Part B "Tier 2" CPT code payments for rare genes are almost entirely in Novitas/FCSO states (and ranging around $400M a year).   Where do the 87798 payments fall?

They fall mostly in MolDx states.

Using recently released 2021 data, 72% or $149M of the 87798 payments were in MolDx states.  

This left 22% for Novitas (FCSO) states and just 7% for NGS MAC states.

Within the MolDx MACs, payments are dominated by California, with $59M in 2021.  Other MolDx states in the $10-15M range for 87798 include Alabama, Georgia, South Carolina.  

Impact of LCD?

If the LCD drops payments by 90% in MolDx states, that would be about $130M.  The total impact could be higher; data shows that high-billing labs for 87798 bill about $2 in other molecular microbiology codes for every $1 billed as 87798.  (This is outside their Covid billing, which could be half of revenues in 2021).

More Data Views

A Google Sheets spreadsheet is here, with MAC and State level data.  I've clipped a partial table below as a JPEG.   

Interested readers can go to the CMS source for 2021 data here and filter for the code 87798 to see all providers and volumes.  

Average billings of top providers were 18 tests per patient (some in the high 20's or even 30's).  This is  interesting in that the MUE per claim is 13 (for a table of data by top billers, see at bottom).

Across all 87798 billing in 2021, about 75% was from clinical laboratories and about 15% from urologists or urology groups (about $30M).

partial table of MAC x states

click to enlarge