Header: Of Category I genomic CPT codes, about 65% MolDx payments, 20% NGS MAC, 15% Novitas. But, most NGS MAC payments represented Cologuard, an NCD-driven code. Otherwise, NGS MAC had 4% of payments.
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In October, I posted some data on national CY2022 spending by CPT code (here).
This week, in prior blogs, I broke out spending by MAC, first by 81479 miscellaneous code (here) and then by PLA code (here).
In this third and final blog for today, I show Category I CPT code spending by MAC (or MolDx). I pulled cloud data for all 2022 payments on codes starting with (811, 812, 813, 814, 815).
I then used an Excel pivot table to sum spending by "carrier" (usually "state") and rolled the results up by MAC and MAC system. The MAC policy systems are MolDx, Novitas/FCSO, and NGS MAC.
Results
Of $1.5B in genomic spending in this code set, 63% was via MolDx, 22% via NGS MAC, and 15% from Novitas/FCSO MACs.
However, I would rush to point out, nearly all the NGS MAC spending in this code set was driven by a single national decision (not local MAC LCDs). It's the NCD for Exact Sciences Cologuard (state Wisconsin, payments $268M under NCD, code 81528). Minus that, NGS MAC in all other states and codes altogether paid $64M for Category I codes (811xx etc) in 2022, or 4% of payments of $1.5B.
Click to enlarge.
For the following data, I simplified each data set (e.g. dropping lines <$100K), so the numbers vary a tiny bit from exact nationwide numbers.
For Category I codes (811nn-815nn), payments were $1.4B, of which 63% MolDx, 22% NGS MAC, 15% Novitas MAC. Excluding the NCD for Cologuard, which is close to $300M, NGS MAC payments fell to 4%.
For PLA codes, payments were about $330M of which 81% MolDx, and about 10% each to Novitas/FCSO and NGS MACs. However, most of the 10% to NGS MACs can be accounted for by FMI payments driven by NCD 90.2 for FDA PMA NGS tests.
For 81479 miscellanous codes, payments were about $470M, of which 98% was paid by MolDx MACs. 90% of that, was via Noridian MAC. 81479 was the national highest-paid genomic CPT code.
Bonus
This fall, I used the Medicare coverage database to tally MAC Articles about genomic codes (811nn to 815nn). There were 82 MolDx articles, 8 Novitas articles, and 4 NGS MAC articles.
