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NPI 1720688054 · Boston, MA · Clinical Medical Laboratory
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Foundation Medicine, Inc. is a clinical medical laboratory provider located in Boston, Massachusetts. This profile covers 4 Medicare and 6 Medicaid CPT/HCPCS procedure codes, with claims volume, average reimbursement, and total revenue by code, benchmarked against other providers billing the same services.
Provider details (source: NPPES NPI Registry)
| Field | Value |
|---|---|
| Entity Type | Organization |
| Organization | Foundation Medicine, Inc. |
| Address | 400 Summer St |
| City | Boston |
| State | MA |
| ZIP | 02210 |
| Taxonomy | Clinical Medical Laboratory |
| NPI Enumerated | October 27, 2020 |
Lifetime revenue by payer source (source: CMS Medicare & Medicaid claims data)
| Payer Source | Total Paid |
|---|---|
| Medicare | $79.7M |
| Medicaid | $11.5M |
Foundation Medicine, Inc. operates as a specialized genomic oncology laboratory: its two proprietary PLA codes, 0037U (FoundationOne CDx™) and 0239U (FoundationOne® Liquid CDx), dominate the clinical profile and indicate a product mix built around tissue-based companion diagnostics and cfDNA next‑generation sequencing liquid biopsy panels. The code descriptions and high average paid/claim values for these PLA tests are consistent with a company offering proprietary, manufacturer‑specific oncology genomic assays rather than general clinical lab panels.
Medicare revenue is highly concentrated in a very small set of high‑value tests: the precomputed top 3 Medicare codes account for 99.3% of this provider’s total Medicare revenue, with 0037U at 66.7%, 0239U at 30.9%, and 81479 at 1.7% of Medicare dollars, against a lifetime Medicare revenue of $79.7M. This concentration means the provider’s Medicare performance is driven almost entirely by these proprietary and high‑complexity molecular tests.
Medicaid revenue shows the same concentrated pattern at smaller scale: the top 3 Medicaid codes account for 98.1% of the provider’s total Medicaid revenue, led by 0037U at 75.0%, 0239U at 19.7%, and 81455 at 3.4% of Medicaid dollars, on $11.5M in total Medicaid revenue. This indicates that Medicaid billing is likewise dominated by the same pair of proprietary oncology assays with a smaller footprint for broader genomic panels.
The provider’s payer mix is heavily Medicare‑weighted: lifetime Medicare revenue is $79.7M versus $11.5M in Medicaid revenue, making Medicare the dominant revenue source by scale. Payer rate differences are stark for the PLA codes—Medicare average paid/claim for 0037U and 0239U are $3421 and $3424 respectively, while Medicaid averages for the same codes are $823 and $659—highlighting material reimbursement variation between payers for identical proprietary tests.
Competitive standing for the PLA tests is notable but must be interpreted with the available peer context: 0037U and 0239U each rank #1 of 1 providers nationally on Medicare, but the notes indicate "no national peer volume comparison available," which suggests these PLA claims are concentrated under this billing entity’s NPI rather than directly comparable national volumes. In-state, 0037U and 0239U rank #1 of 2 providers in Massachusetts (100th percentile), indicating this NPI is a leading in‑state reporter for those proprietary assays.
Certain ancillary pathology codes show outsized volume relative to peers: 88360 is labeled an "extreme outlier" — on Medicare it has 8.2K claims and ranks #4 of 5330 providers nationally (100th percentile), and on Medicaid it has 6.2K claims and ranks #1 of 17 providers in-state (100th percentile). This pattern suggests unusually high immunohistochemistry/stain activity relative to peers and may reflect internal pathology workflows or high case throughput that accompanies its genomic testing business.
Other molecular codes show a more typical competitive footprint: Medicare 81479 (molecular pathology, unlisted) yields $1.4M and ranks #30 of 80 providers nationally (63th percentile), described as "typical, unremarkable volume," while Medicaid 81455 (large genomic panels) produces $395.7K and ranks #1 of 2 in-state (100th percentile typical). These data points indicate that outside the two dominant PLA assays, the provider’s participation in broader genomic panel billing is present but not the primary revenue driver.
The NPI tenure is relatively recent: the provider was enumerated on 2020-10-27 (~6 years ago). Despite this recent enrollment, the lifetime totals of $79.7M Medicare and $11.5M Medicaid revenue demonstrate rapid scale‑up concentrated in a narrow set of proprietary oncology tests, which concentrates operational and reimbursement exposure on those specific assays.
Medicare revenue breakdown by CPT/HCPCS procedure code.
View: Bar Chart1 / 2
The CPT/HCPCS codes generating the most Medicare revenue for this provider.
4 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| 0037U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code describes only one unique lab test made by a specific manufacturer or performed by a specific lab. Code 0037U describes the… | 15,550 | $3,420 | $53.2M |
| 0239U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code applies to only one unique lab test made by a specific manufacturer or performed by a specific lab. Report 0239U for… | 7,190 | $3,420 | $24.6M |
| 81479 | Use 81479 to report a molecular pathology procedure that does not have a specific code. | 480 | $2,860 | $1.4M |
| 88360 | The lab analyst applies a single antibody stain on a slide or slides prepared from a single patient specimen, such as tumor tissue. Then a qualified provider, typically a pathologist, evaluates the… | 8,210 | $70 | $550.3K |
How this provider's Medicare billing volume and revenue compare to other providers nationally and within its state, across 4 CPT/HCPCS codes.
Medicaid revenue breakdown by year and by CPT/HCPCS procedure code, including monthly billing trends and the top codes driving revenue.
View: By Year1 / 3
Every CPT/HCPCS code this provider has billed to Medicaid, with claims volume, average payment, and total revenue.
6 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| 0037U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code describes only one unique lab test made by a specific manufacturer or performed by a specific lab. Code 0037U describes the… | 10,500 | $820 | $8.6M |
| 0239U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code applies to only one unique lab test made by a specific manufacturer or performed by a specific lab. Report 0239U for… | 3,440 | $660 | $2.3M |
| 81455 | The lab analyst performs a genomic sequence analysis panel to evaluate the patient specimen, such as tumor tissue or bone marrow, for DNA and possibly RNA alterations in 51 or more genes known to… | 960 | $410 | $395.7K |
| 88360 | The lab analyst applies a single antibody stain on a slide or slides prepared from a single patient specimen, such as tumor tissue. Then a qualified provider, typically a pathologist, evaluates the… | 6,150 | $30 | $172.3K |
| 88381 | A clinician, typically a pathologist, performs a manual microdissection of a patient’s specimen, such as a biopsy or tissue preserved from a previous case. | 610 | $60 | $36.9K |
| 81456 | The lab analyst performs a genomic sequence analysis panel to evaluate the patient specimen, such as tumor tissue or bone marrow, for RNA alterations in 51 or more genes known to relate to solid… | 60 | $250 | $14.6K |
How this provider's Medicaid billing volume and revenue compare to other Massachusetts providers billing the same CPT/HCPCS codes.
Full comparison — all codes billed, vs. Massachusetts median
6 rows
| CPT/HCPCS Code | Description | Rank | Provider Count | Median Claims | Avg Paid | Average Revenue |
|---|---|---|---|---|---|---|
| 0037U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code describes only one unique lab test made by a specific manufacturer or performed by a specific lab. Code 0037U describes the… | 1 | 10 | 7,600 | $710 | $5.4M |
| 0239U | This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code applies to only one unique lab test made by a specific manufacturer or performed by a specific lab. Report 0239U for… | 1 | 10 | 1,860 | $660 | $1.2M |
| 81455 | The lab analyst performs a genomic sequence analysis panel to evaluate the patient specimen, such as tumor tissue or bone marrow, for DNA and possibly RNA alterations in 51 or more genes known to… | 1 | 10 | 490 | $410 | $201.6K |
| 88360 | The lab analyst applies a single antibody stain on a slide or slides prepared from a single patient specimen, such as tumor tissue. Then a qualified provider, typically a pathologist, evaluates the… | 1 | 20 | 40 | $40 | $24.8K |
| 81456 | The lab analyst performs a genomic sequence analysis panel to evaluate the patient specimen, such as tumor tissue or bone marrow, for RNA alterations in 51 or more genes known to relate to solid… | 1 | 10 | 60 | $250 | $14.6K |
| 88381 | A clinician, typically a pathologist, performs a manual microdissection of a patient’s specimen, such as a biopsy or tissue preserved from a previous case. | 1 | 10 | 60 | $50 | $9K |
Other providers in the same ZIP code as Foundation Medicine, Inc., ranked by combined Medicare and Medicaid revenue.
| Provider | State | Taxonomy | Medicare Revenue | Medicaid Revenue |
|---|---|---|---|---|
| Ma Department Of Youth Services | MA | Public Health or Welfare Agency | $0 | $72.5M |
| Angel Baricelli | MA | Specialist | $262.9K | $0 |
| David Sola-del Valle | MA | Ophthalmology Physician | $178.5K | $0 |
| David Bowen | MA | Sports Medicine (Physical Medicine & Rehabilitation) Physician | $90.9K | $0 |
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