Example of Proactive Payer Non Coverage: Aetna & Cardiac & Cancer Biomarkers Non Covered

Example of Pro-active NON COVERAGE policy, listed 100+ tests as non covered.

http://www.aetna.com/cpb/medical/data/300_399/0381.html

Aetna considers any of the following tests for assessing CHD risk experimental and investigational because their clinical value has not been established:

A.                  Activated factor VII

B.      Adiponectin

C.       Angiotensin gene (CardiaRisk AGT)

D.      Anti-thrombin III

E.       Apelin

F.       Apolipoprotein A-I (apo AI) (Boston Heart HDL Map panel)

G.      Apolipoprotein E (apo E)

H.      Apolipopritein E genotyping

I.         ASCVD risk testing (individual or panel) (eg, c-peptide, islet cell antibodies, nonesterified fatty acids (free fatty acids), proinsulin and total insulin)

J.        B-type natriuretic peptides (see CPB 0618 - Brain Natriuretic Peptide Testing)

K.       Carotid ultrasound screening of asymptomatic persons for carotid artery stenosis

L.       Cathepsin S

M.    Chromosome 9 polymorphism 9p21

N.      Circulating microRNAs (e.g., miR-1, miR-16, miR-26a, miR-27a, and miR-29a, miR-133a, and miR-199a-5p; not an all-inclusive list)

O.      Coenzyme Q10 (CoQ10)

P.       Coronary artery reactivity test

Q.      Cystatin-C

R.      Factor II (thrombin) (F2 gene)

S.       Factor V Leiden (F5 gene)

T.       Fibrinogen

U.      4q25 genotype testing (eg, 4q25-AF Risk Genotype Test, Cardio IQ 4q25-AF Risk Genotype Test)

V.      Galectin-3

W.    Genetic testing  (for genetic testing for familial hypercholesterolemia, see CPB 140 - Genetic Testing)

X.       Growth stimulation expressed gene 2 (ST2)

Y.       HDL subspecies (LpAI, LpAI/AII and/or HDL3 and HDL2)

Z.       Homocysteine testing

AA.  Interleukin 6 (IL-6)

BB.  Interleukin 6 -174 g/c promoter polymorphism

CC.   Interleukin 17 gene polymorphism

DD. Interleukin 18 (IL-18)

EE.   Kinesin-like protein 6 (KLP6)

FF.    LDL gradient gel electrophoresis

GG. LDL subspecies (small and large LDL particles)

HH. Leptin

II.       Lipidomic and metabolomic risk markers

JJ.      Lipoprotein remnants: intermediate density lipoproteins (IDL) and small density lipoproteins

KK.   Lipoprotein(a) (Lp(a)) enzyme immunoassay

LL.    Lipoprotein-associated phospholipase A2 (Lp-PLA2) (PLAC)

MM.            Long chain omega-3 fatty acids composition in red blood cell

NN. LPA Intron-25 genotype testing (eg, Cardio IQ Intron-25 Genotype Test, LPA Intron-25 Genotype Test)

OO. MaxPulse testing

PP.   Measurement of free fatty acids

QQ. Mid-regional pro-atrial natriuretic peptide

RR.   MIRISK VP test

SS.    Myeloperoxidase (MPO)

TT.   NMR Lipoprofile

UU. Osteoprotegerin

VV.  Oxidized phospholipids

WW.           Peroxisome proliferator-activated receptor

XX.   Plasminogen activator inhibitor (PAI–1)

YY.   Pregnancy-associated plasma protein-A (PAPP-A)

ZZ.    Protein C

AAA.            Prothrombin gene mutation testing

BBB.            Receptor for advanced glycosylation end products (RAGE) gene Gly82Ser polymorphism testing

CCC.             Resistin

DDD.           Retinol binding protein 4 (RBP4)

EEE.              Serum sterols (eg, Boston Heart Cholesterol Balance Test)

FFF.Singulex SMC testing for risk of cardiac dysfunction and vascular inflammation (eg, SMC Endothelin, SMC IL-6, SMC IL 17A, SMC c TnI and SMC TNF-α)

GGG.           Skin cholesterol (eg, PREVU)

HHH.           SNP-based testing (eg, Cardiac Healthy Weight DNA Insight, Healthy Woman DNA Insight Test, Heart Health Genetic Test)

III.     Soluble cell adhesion molecules (e.g., intercellular adhesion molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1], E-selectin, and P-selectin)

JJJ.   Thromboxane metabolite(s) testing

KKK.             Tissue plasminogen activator (tPA)

LLL. Toll-like receptor 4 (TLR4) Asp299Gly (rs4986790) polymorphism

MMM.      Transforming growth factor beta

NNN.          Troponin I (eg, PATHFAST cTnI-II)

OOO.          Tumor necrosis factor alpha (TNF-a)

PPP.             Total cholesterol content in red blood cell membranes

QQQ.          Vertical Auto Profile (VAP) with or without vertical lipoprotein particle (VLP) technology

RRR.             Visfatin

SSS.von Willebrand factor antigen level.

http://www.aetna.com/cpb/medical/data/300_399/0352.html

Aetna considers each of the following experimental and investigational.  The peer reviewed medical literature does not support these tests as having sufficient sensitivity or specificity necessary to define their clinical role:

1.      CEA used for all other indications including any of the following:

a.                  As a screening test for colorectal cancer; or 

b.      As a sole determinant to treat a colorectal cancer member with adjuvant therapy or systemic therapy for presumed metastatic disease; or

c.       For diagnosis of esophageal carcinoma; or

d.      For screening, diagnosis, staging or routine surveillance of gastric cancer.
 

2.      AFP for the diagnosis of trophoblastic tumors and oncologic indications other than those listed above.

3.      Assaying for loss of heterozygosity (LOH) on the long arm of chromosome 18 (18q) or deleted in colon cancer (DCC) protein (18q-LOH/DCC) for colorectal cancer

4.      Biomarker Translation (BT) test for breast cancer and other indications

5.      BioSpeciFx, including Comprehensive Tumor Profiling for any indication

6.      BRAF mutation analysis in lung cancer

7.      Breast Cancer Gene Expression Ratio (HOXB13:IL17BR)

8.      CA 125 for all other indications including use as a screening test for colorectal cancer or ovarian cancer (other than as indicated above) or for differential diagnosis of members with symptoms of colonic disease

9.      CA 19-9 for all other indications including breast, colorectal, esophageal, gastro-esophageal, liver, or uterine cancer; pancreatic pseudocyst; screening persons with primary sclerosing cholangiitis without signs or symptoms of cholangiocarcinoma; or screening persons with primary sclerosing cholangitis for development of cholangiocarcinoma.

10.  Carcinoembryonic antigen cell adhesion molecule 6 (CEACAM6) (e.g., Benign Diagnostics Risk Test) for breast atypical hyperplasia and for predicting the risk of breast cancer.

11.  Carcinoembryonic antigen cellular adhesion molecule-7 (CEACAM-7) expression as a predictive marker for rectal cancer recurrence

12.  Caris Target Now Molecular Profiling Test

13.  CDX2 as a prognostic biomarker for colon cancer

14.  CEA, Cyfra21-1 (a cytokeratin 19 fragment), p53, squamous cell carcinoma antigen (SCC-Ag) and vascular endothelial growth factor C (VEGF-C) for diagnosis of esophageal carcinoma

15.  Circulating cell-free nucleic acids in colorectal cancer

16.  Circulating tumor cell (CTC) assays (e.g., CellSearch assay) for all indications, including, but not limited to metastatic breast, colorectal, melanoma, and prostate cancers

17.  CK5, CK14, p63, and Racemase P504S testing for prostate cancer

18.  c-Met expression for predicting prognosis in persons with advanced NSCLC and colorectal cancer, and other indications

19.  Cofilin (CFL1) as a prognostic and drug resistance marker in non-small cell lung cancer

20.  ColonSentry test for screening of colorectal cancer

21.  ColoPrint, CIMP, LINE-1 hypomethylation, and Immune cells for colon cancer

22.  Colorectal Cancer DSA (Almac Diagnostics, Craigavon, UK)

23.  ConfirmMDx for prostate cancer

24.  CxBladder test for bladder cancer

25.  Cyclin D1 and FADD (Fas-associated protein with death domain) for head and neck squamous cell carcinoma

26.  Decipher test (a RNA biomarkers assay) for prostate cancer

27.  Decision DX-Melanoma (Castle Biosciences, Phoenix, AZ)

28.  DCIS Recurrence Score

29.  Des-gamma-carboxy prothrombin (DCP) (also known as "prothrombin produced by vitamin K absence or antagonism II" [PIVKA II]) for diagnosing and monitoring hepatocellular carcinoma (HCC) and other indications

30.  EarlyCDT-Lung test

31.  EGFR gene expression analysis for transitional (urothelial) cell cancer

32.  EGFRVIII for glioblastoma multiforme

33.  EML4-ALK as a diagnostic tool for stage IV non-small-cell lung cancer

34.  Estrogen and progesterone receptors when used alone to assign a member with breast cancer to prognostic groupings since they are relatively weak predictors of long-term relapse and breast cancer related mortality rates

35.  Excision repair cross-complementation group 1 protein (ERCC1) for persons with NSCLC, colon or with gastric cancer who are being considered for treatment with platinum-based chemotherapy, and other indications

36.  Fibrin/fibrinogen degradation products (FDP) test (e.g., DR-70 or Onko-Sure) for colorectal cancer

37.  FoundationOne and FoundationOne Heme

38.  Galectin-3 for prostate cancer

39.  Gene hypermethylation for prostate cancer

40.  GeneKey (GeneKey Corp., Boston, MA)

41.  GeneSearch Breast Lymph Node (BLN) assay

42.  Glutathione-S-transferase P1 (GSTP1) for screening, detection and management of prostate cancer

43.  Guanylyl cyclase c (GCC or GUCY2C) (e.g., Previstage GCC Colorectal Cancer State Test) for colorectal cancer

44.  Guardant360

45.  HER2 testing of appendiceal cancer

46.  HERmark testing for breast cancer and other indications

47.  HMGB1 and RAGE in cutaneous malignancy (e.g., basal cell carcinoma, melanoma, and squamous cell carcinoma)

48.  Human epididymis protein 4 (HE4) (e.g., Elecsys HE4 assay) for endometrial cancer, ovarian cancer, or evaluation of pelvic mass, including to assist in the determination of referral for surgery to a gynecologic oncologist or general surgery, and for other indications

49.  IHC4 (e.g., NexCourse IHC4 by AQUA Technology) for breast cancer

50.  Insight DX Breast Cancer Profile

51.  Ki67 for breast cancer

52.  Ki-67 in upper tract urinary carcinoma

53.  4Kscore

54.  Lectin-reactive alpha-fetoprotein (AFP-L3) for liver cancer

55.  Liquid biopsy (e.g., CancerIntercept, GeneStrat, FoundationACT) for any indication, including, but not limited to, breast cancer, colorectal cancer, lung cancer, melanoma, or ovarian cancer. 

56.  Long non-coding RNA in gallbladder cancer

57.  Mammaprint

58.  Mammostrat

59.  Mass spectrometry-based proteomic profiling (e.g., Xpresys Lung) for indeterminate pulmonary nodules

60.  Microarray-based gene expression profile testing using the MyPRS test for multiple myeloma

61.  Micro-RNAs (miRNAs) miRview mets and miRview mets2 (Rosetta Genomics Laboratories, Philadelphia, PA; Rosetta Genomics Ltd., Rehovot, Israel)

62.  MLH1 tumor promoter hypermethylation for endometrial cancer

63.  Molecular Intelligence Services, including MI Profile and MI Profile PLUS (formerly Target Now Molecualr Profiling Test, including Target Now Select and Target Now Comprehensive)

64.  Molecular subtyping profile (e.g., BluePrint) for breast cancer

65.  MUC1 in gastric cancer

66.  Mucin 4 expression as a predictor of survival in colorectal cancer

67.  Mucin 5AC (MUC5AC) as serum marker for biliary tract cancer

68.  My Prognostic Risk Signature (MyPRS) (Signal Genetics LLC, New York, NY)

69.  NRAS mutation for selecting persons with metastatic colorectal cancer who may benefit from anti-VEGF antibody bevacizumab; to predict disease prognosis and select persons with melanoma who may benefit from tyrosine kinase inhibitor therapies, and other indications

70.  OncoVantage

71.  OVA1 test

72.  OvaCheck test

73.  OvaSure

74.  OncInsights (Intervention Insights, Grand Rapids, MI)

75.  p16 protein expression as a prognostic marker in non-oropharyngeal squamous cell carcinoma (cancer of the oral cavity, hypopharynx, or larynx)

76.  Pathwork Tissue of Origin test

77.  Perceptua Bronchial Genomic Classifier

78.  Phosphatidylinositol-4,5-bisphosphonate 3-kinase, catalytic subunit alpha polypeptide gene (PIK3CA) for predicting disease prognosis and selecting individuals with metastatic colorectal cancer who are being considered for treatment with EGFR antagonists cetuximab and panitumumab, and other indications

79.  PreOvar test for the KRAS-variant to determine ovarian cancer risk

80.  Prolaris for prostate cancer

81.  ProOnc TumorSourceDx test (Prometheus Laboratories, San Diego, CA) to identify tissue or origin for metastatic tumor

82.  Prostate core mitotic test

83.  Prostate Px and Post-Op Px for predicting recurence of prostate cancer

84.  Proveri prostate cancer assay (PPCA)

85.  PSA for screening women with breast cancer or for differentiating benign from malignant breast masses

86.  PTEN gene expression for non-small cell lung cancer

87.  Ras oncogenes (except KRAS and BRAF)

88.  ResponseDx Colon

89.  Ribonucleotide reductase subunit M1 (RRM1) for persons with NSCLC who are being considered for treatment with gemcitabine-based chemotherapy, and other indications

90.  ROMA (Risk of Ovarian Malignancy Algorithm) for ovarian cancer

91.  Rotterdam Signature 76-gene panel

92.  Serum amyloid A as a biomarker for endometrial endometrioid carcinoma to monitor disease recurrence and rtargetesponse to therapy

93.  TargetPrint gene expression test for evaluation of estrogen receptor, progesterone receptor, and HER2receptor status in breast cancer

94.  The 41-gene signature assay

95.  Theros CancerType ID (bioTheranostics Inc., San Diego, CA)

96.  Thymidylate synthase

97.  TMPRSS fusion genes for prostate cancer

98.  Topographic genotyping (Pancragen (formerly PathFinderTG))

99.  Total (whole) gene sequencing for cancer

100.                                        TP53 mutation analysis for ovarian cancer

101.                                        UroCor cytology panels (DD23 and P53) for bladder cancer

102.                                        Vascular Endothelial Growth Factor (VEGF)

103.                                        Vascular endothelial growth factor receptor 2 (VEGFR2) expression for identifying persons with colorectal cancer that is likely to respond to VEGF inhibition, and other indications

104.                                        Any of the following circulating tumor markers also is considered experimental and investigational for screening asymptomatic subjects for cancer, diagnosis, staging, routine surveillance of cancer and monitoring the response to treatment:
 

a2-PAG	CA-SCC	MAM-6	TAG12
AMACR	Cathepsin-D, Cathepsin-L	Motility-related protein (MRP)	TAG72
Bcl-2	Cyclin E (fragments or whole length)	Multidrug resistance glycoprotein (Mdr1)	TAG72.3
BCM	DU-PAN-2	Murine double minute 2 (MDM2)	TAG72.5
CA195	Early prostate cancer antigen (EPCA)	NSE	TATI
CA242	Guanylyl cyclase C (Previstage GCC molecular test)	p53 (TP53)	Thrombospondin-1 (THBS-1)
CA50	Hepsin	PCA3 (DD3) / UpM3	Thymosin B15
CA549	Human kallikrein 2 (HK2)	PNA/ELLA	TNF-a
CA72-4	LASA	Prostate stem cell antigen (PSCA)	Topoisomerase II Alpha (TOP2A)
CAM17-1	LPA	SCC	TPA
CAM26	M 26	SLEX	Thymosin B15
CAM29	M 29	SPAN-1	Nuclear Matrix Protein 66 (NMP66)
CAR-3	MSA	SLX	Anti-malignin antibody screen (AMAS) test
CYFRA21-1	MCA	ST-439

B

June 2017 Version of MolDx article M00127 V3: NGS Billing Policies; Code 81479

https://www.palmettogba.com/palmetto/MolDX.nsf/docscat/MolDx%20Website~MolDx~Browse%20By%20Topic~Covered%20Tests~Next%20Generation%20Sequencing%20Coding%20and%20Billing%20Guidelines%20(M00127%20V3)

Next Generation Sequencing Coding and Billing Guidelines (M00127, V3)

June 21, 2017

Next Generation Sequencing (NGS)
NGS allows identification of somatic and/or germline alterations in multiple genes simultaneously. This guideline focuses on Targeted and Comprehensive Genomic Profile testing for somatic variant detection using tumor tissue only-based panels.  Panels involving germline variants, matched tumor-normal, or “liquid biopsies” (including circulating tumor cells (CTCs) or DNA (ctDNA), or cell-free DNA (cfDNA)) will be addressed separately, but should be billed using CPT 81479.

Targeted (aka Hot Spot) Tumor Panels
Targeted NGS panels identify somatic alterations known to occur in certain areas (i.e., 'hotspots') in specific genes of interest. Generally, these NGS panels can detect single nucleotide variants (SNVs or point mutations) and small (typically ≤40 bp) insertions or deletions (indels), but not copy number alterations (CNAs) or structural variants (SVs), such as gene rearrangements, fusions, or translocations. These alterations typically represent genomic targets with corresponding targeted cancer therapies. Identification of a somatic alteration guides use of the corresponding targeted therapy.

To bill for targeted NGS services for somatic variant detection, review CPT codes 81445, 81450 and 81455. Select the appropriate CPT code based on the number of genes in your laboratory’s NGS panel and the test indication for either solid organ or hematolymphoid neoplasms. The units of service (UOS) for an NGS panel is one (UOS=1). 

Effective July 1, 2017, laboratories with 1 to 4 gene(s) on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier (DEX Z-code) to represent this service on their claims.  (Similarly, CPT 81479 should be used to bill for somatic variant detection performed by a targeted NGS panel on a “fluid” sample (e.g., KRAS in pancreatic cyst fluid). Reimbursement is based on the number of reported genes in these small NGS panels. Tier 1 and/or Tier 2 individual biomarker CPT codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.

Comprehensive Genomic Profile (CGP) TestingCGP refers to NGS-based testing that has been optimized to identify all types of molecular alterations (i.e., SNVs, small and large indels, CNAs, and SVs) in cancer-related genes in a single test using complex and often proprietary bioinformatics.  CGP may also include testing for MSI (microsatellite instability) and TMB (tumor mutational burden).

Because CGP includes SNVs, small (≤40 bp) and large (> 40 bp) indels, CNAs, and SVs, CPT codes 81445, 81450, and 81455 do NOT describe a CGP service. Therefore, to report a CGP service, test providers should use CPT code 81479.

February 2016 Version of MOLDX M00130 Guidelines, V2, NGS and T1 T2 Coding

As of summer 2017, MolDX guideline M00130 V2 appears to be taken down from the MolDX website, although some MoLDX documents still guide the reader to look up needed instructions within M00130.

M00130 V2 was still available in June 2017 via GOOGLE CACHE.  As below.

https://webcache.googleusercontent.com/search?q=cache:ASsLgFP_fBYJ:https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/A6LLL81487%3FOpenDocument+&cd=1&hl=en&ct=clnk&gl=us

Next Generation Sequencing (NGS) and Tier 1 and Tier 2 Coding and Billing Guidelines (M00130, V2)

When the AMA developed and published the descriptions for the Tier 1 (T1) and Tier 2 (T2) codes in the Molecular Pathology Procedure Section, the technology for NGS was not fully developed. At that time labs typically used polymerase chain reaction (PCR) and non-NGS sequence analysis to interrogate a single gene or gene component. Therefore, the T1 and T2 codes describe services for a single or occasionally two genes test and subdivide the descriptions by full gene sequence, common variants, duplication/deletion variants, and known familial variants.

NGS platforms have the ability to target and detect multiple specific genes of interest, including common variants, duplication/deletion variants, and known familial variants in one run to create a single report. Therefore, MolDX considers an NGS panel a single test with multiple potential indications. The AMA describes NGS gene panels in the Genomic Sequencing Procedure and Other Molecular Multianalyte Assay (GSP) Section.

To correctly report NGS panels for MolDX claim processing, please review the following guidelines:

• Compare the CPT code descriptions in the GSP Section and select the panel that describes your test. Appropriate GSP codes include the following: 81410, 81412, 81415, 81417, 81420, 81425, 81430, 81432, 81433, 81434, 81435, 81437, 81440, 81442, 81445, 81450, 81455, 81460, 81465, and 81470.
• Do NOT report NGS tests with T1 (codes 81161-81355) and T2 (codes 81400-81408) even if a single gene or multiple genes are selected for testing. MolDX will deny NGS panels reported with T1 and T2 codes as an unbundled service from the primary NGS panel.
• Report codes 81445, 81450 and 81455 for tumor-based targeted (i.e. “hotspot”) panels that test only for SNVs and small indels (10bp)
• Report circulating tumor DNA (ctDNA) and matched tumor-normal testing with 81479
• Report comprehensive NGS panels that perform tumor tissue testing (e.g.SNVs, indels, CNVs and translocations/rearrangements) with 81479.
• Tests reported with CPT code 81479 should be submitted for a teachnical assessment (TA) through DEX after a Z-Code Identifier has been assigned. 

Please suspend claims submission until MolDX has determined coverage and reimbursement for your test. 

Somatic and germline NGS test panel claim submission examples: 

1. One somatic NGS “hotspot” panel split into two tests based on indication and INCORRECTLY submitted with T1/T2 codes and two different Z-Code Identifiers

NGS Test	Investigated Genes	CPT Code	Claim Submission	ID
NGS Colon Cancer Panel 1	BRAF, KRAS, and NRAS	81210, 81275, 81311	Incorrect	Z1234
NGS Lung Cancer Panel 2	EGFR, KRAS, and BRAF	81235, 81275, 81210	Incorrect	Z4567

2. One somatic NGS “hotspot” panel split into two tests based on indication and INCORRECTLY submitted with CPT code 81479 and two different Z-Code Identifiers.

NGS Test	Investigated Genes	CPT Code	Claim Submission	ID
NGS Colon Cancer Panel 1	BRAF, KRAS, and NRAS	81479	Incorrect	Z1234
NGS Lung Cancer Panel 2	EGFR, KRAS, and BRAF	81479	Incorrect	Z4567

3. One somatic NGS “hotspot” panel for two different solid tumor indications and CORRECTLY submitted with CPT code 81445 and one Z-Code Identifier.

NGS Test	Patient Indication	CPT Code	Claim Submission	ID
NGS: targeted genomic sequence analysis panel, solid organ	Colon cancer	81445	Correct	Z4444
NGS: targeted genomic sequence analysis panel, solid organ	Lung cancer	81445	Correct	Z4444

4. One germline test for two patients with different hereditary cancer indications and CORRECTLY submitted with CPT code 81432 and one Z-Code Identifier.

NGS Test	Patient Indication	CPT Code	Claim Submission	ID
NGS: Hereditary breast cancer-related disorders (breast, ovarian, endometrial…)	Breast cancer	81432	Correct	Z5555
NGS: Hereditary breast cancer-related disorders	Endometrial cancer	81432	Correct	Z5555

   *Do not submit code 81432 in addition to T1/T2 testing on the same patient.

February 16, 2016

Quick Guide to Using the Online Medicare Physician Billing Database

Since 2014, CMS has posted annual files of Part B billing data by provider name.  Available files are for CY 2012, CY2013, CY2014, and in June 2017, CY2015.

Originally, you had to download many very large files by alphabet letter of provider's last name, or download a 2 GB database too large for Excel.   Now, you can go to the online web interface and instantly sort for data of interest and download that data quickly into an Excel file that can be easily studied.

For more about the history of this important data file and an example of analyzed data, here.

Some process steps are described below.

Find the home page for the data set here.   The path would be CMS home page > Research and Statistics > Medicare Provider Utilization > Physician and Other Supplier Data 2014 (or 2015).

Click on "Detailed Data: Interactive Dataset: Medicare Physician and Other Supplier PUF CY2014 Interactive Dataset."   Here.   Click yes on a CPT copyright screen.  You now are looking at the tip-to corner of a massive, 2 GB dataset with a couple dozen columns and millions of rows.

What you want to focus on is the FILTER button (above).  Click on this and see a drop down box that includes the button: "+ Add A New Filter Condition." (Below).

Click on "Add A New Filter Condition."  There will be another dropdown - you can choose to filter on NPI, Last Name, City, State, etc.   For example, filter on "HCPCS Code" 95004 to see all data on allergy skin testing.

Instantly, the screen you see in your browser is a far tinier dataset of the 4,114 providers who billed Medicare for "95004" skin allergy testing in CY2014.

You're almost done.  Just click the pale blue EXPORT button and export CSV EXCEL (comma delimited file for Excel).  Save on your hard drive as 2014 95004.csv.  

Open it in Excel, and resave it right away as Excel Workbook.

You have the 900 kb of data you need and are free of the 2 GB scale of the original data.   Now, you can delete unnecessary columns and sort and analyze with ease.

One quirk.  The spreadsheet holds a column for "number of services allowed," and one for "average Medicare allowable price per service."  You probably will want to make an additional column that multiplies these two columns together to get the total dollars allowed for that provider for that service in that year.  E.g. 500 services allowed X $9.00 per service becomes a new column of $4,500.00.

_______________________

I can't give a course in Excel and I'm not an expert with it, but two particularly useful functions are these.

"Sort and Filter" (upper right), click on  Custom Sort, click "Expand Selection" if offered, be sure "My Data Has Headers" is checkmarked, and filter on one or more columns.  For example, you can filter by state, then, by provider type, then, by services allowed in the year.

To quickly see a line plot of data, select an entire column, click Insert, and click "Recommended Charts."  This instantly gives you graphics like this one: