Sunday, October 4, 2020

MolDx Genomic Payments 87% of CY2017 Payments (Excepting Cologuard)

 This is summary data on CY2017 Part B payments for genomics.  To run this data, I searched the 2017 physician/lab payment database for all 28 MolDx states, and all states in total.  I used CPT codes 812xx, 813xx, 814xx, 815xx.   (Other codes, such as PLA codes, were negligible in CY2017).   

Since a large part of MolDx payments was one test, Exact Sciences Cologuard, I ran data without that test as an alternate analysis.  Cologuard payments are covered nationally by an NCD and paid at a national rate, so the MAC has no hand in the payment volume for this test.

In brief:

In CY2017, about 41%, or $244M/$588M, of the payments were in California.  About $408M/$588M, or 69%, were in MolDx states.  Only $180M/$588M were in non-MolDx states.

The main driver of the non-MolDx payments is one single provider, Exact Sciences, which billed $118M in CY2017 in Wisconsin, a non-MolDx state.  Of the $180M of non-MolDx payments, $118M/180M (65%) were due to one test, Cologuard.  Said differently, only $62M of $588M (10%) were regular non-MolDx MAC payments, that is, neither Cologuard nor a MolDx payment.  

Alternate Analysis.  If we ignore the $118M in payments for the single test Cologuard, MolDx handled 87% of the remaining Medicare molecular pathology payments.



Cologuard (81528) dollars paid in Part B were $116M in 2017, $168M in 2018, and $241M in 2019.   The above data may use dollars allowed which are slightly higher than dollars paid by CMS.

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