Novitas Defenses Against Tier 2 codes in 2022

This is a side bar to my 2021 Medicare genomics billing article here.

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In 2018-2021, over four calendar years, the Novitas and FCSO MACs paid out many, many hundreds of millions of dollars for Tier 2 codes.   These codes were virtually unpaid in other MACs (NGS MACs, MOLDX).  And by Novitas' own current statements, the codes should have been unpayable.

Here's November 2022 documentation from Novitas on Tier 2 codes.

There active LCDs are here:

https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LCD?type=active

If you search this long webpage for 81408, you get first the cardiology LCD, which says Tier 2 codes are unpayable in Cardiology.  Click on L39082, A58795 (also A58955.)

Continue searching and fast master article  A58917, molecular pathology & genetic testing billing.  This article now has a paragraph that makes Tier 2 virtually unpayable, as it should be.   As far as I can tell from the revision history, this language was added on 11/08/2021.  Honestly, it could have easily been added in August 2019 (the first DOJ fraud press release on Tier 2 codes), saving CMS over $900M in 2021 and 2022.

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58917

Tier 2 molecular pathology procedure codes (81400-81408) are used to report procedures not listed in the Tier 1 molecular pathology codes (81161, 81200-81383). 

These codes represent rare diseases and molecular pathology procedures that are performed in lower volumes than Tier 1 procedures. These codes should rarely, if ever, be used unless instructed by other coding and billing articles.

If billing utilizing the following Tier 2 codes, additional information will be required to identify the specific analyte/gene(s) tested in the narrative of the claim or the claim will be rejected:

• 81403
• 81404
• 81405
• 81406
• 81407
• 81408

 

COVID Mortality, Montreal Hospital, 1H2020

It's easy to forget how grim early COVID results were.

Here's a paper on mortality in a Montreal hospital cohort in March-August 2020.  Overall mortality was 30%.    The paper studies obesity; every 10 units of BMI more than doubled mortality.

https://www.nature.com/articles/s41366-021-00938-8

Methods

We conducted a retrospective cohort study in a tertiary academic center located in Montréal between March and August 2020. We included all consecutive adult patients admitted to the ICU for COVID-19-confirmed respiratory disease. Our main outcome was hospital mortality. We estimated the association between obesity, using the body mass index as a continuous variable, and hospital survival by fitting a multivariable Cox proportional hazards model.

Results

We included 94 patients. Median [q1, q3] body mass index (BMI) was 29 [26–32] kg/m2 and 37% of patients were obese (defined as BMI > 30 kg/m2). Hospital mortality for the entire cohort was 33%. BMI was significantly associated with hospital mortality (hazard ratio [HR] = 2.49 per 10 units BMI; 95% CI, from 1.69 to 3.70; p < 0.001) even after adjustment for sex, age and obesity-related comorbidities (adjusted HR = 3.50; 95% CI from 2.03 to 6.02; p < 0.001).

• Article
• Published: 25 August 2021

Epidemiology and Population Health

Association between obesity and hospital mortality in critical COVID-19: a retrospective cohort study

• Guillaume Plourde, 
• Emanuel Fournier-Ross, 
• Hubert Tessier-Grenier, 
• Louis-Antoine Mullie, 
• Michaël Chassé & 
• François Martin Carrier 

International Journal of Obesity volume 45, pages2617–2622 (2021)Cite this article

Foundation Medicine 2020 Demographics from Medicare

There is a website that gives patient demographics by provider (physician or lab), most recently for CY2020.

https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-provider/data

I filtered for provider or organization name starts with Foundation Medicine.

This gave two rows.  FMI has two NPI's, the first, '091, in Cambridge MA and the second, '922, in Morrisville NC.

MA served 18,198 benes and NC served 11,969 benes.  But allowed payments were more disproportionate, with $63M allowed payments in MA and $16M in NC.

Patient age demographics were <65, 8%, 65-74 51%, 75-84 33% and >84 8%.   Females were 15,989 and males 14,178, about the ratio you'd expect in the elderly.  15% were dual benes (Medicare/Medicaid).

While CMS race demographics may be inaccurate, the data gives 84% white, 6% Black, and thus 10% other.  CMS shows 9% of beneficiaries in this cohort as having Alzheimer's disease and 265 depression and 21% CHF.

Cloud excel here:

https://docs.google.com/spreadsheets/d/1eTe4kpon3QWrCy0v-5Nb25Y75byzw3aQ/edit?usp=sharing&ouid=110053226805181888143&rtpof=true&sd=true

REG INFO DASHBOARD (Home Page)

 

https://www.reginfo.gov/public/jsp/Utilities/index.myjsp