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