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Medical Coding News Archives

Specialty Code Requirements Revised

May 26, 2009:

The Centers for Medicare and Medicaid Services is revising its criteria for approving or denying a request for a new physician specialty code. 
To request that CMS create a new specialty code, a physician specialty association will submit a request to the director, Division of Practitioner Services, Center for Medicare Management, Centers for Medicare & Medicaid Services, Mail Stop C4-01-26, 7500 Security Blvd., Baltimore, MD 21244.

When evaluating a request for expanding the specialty code list for physician and nonphysician practitioners, CMS will consider the following:

  • Whether the requested specialty has the authority to bill Medicare independently
  • The requester’s stated reason or purpose for the code
  • Evidence that the practice pattern of the specialty is markedly different from that of the dominant parent specialty
  • Evidence of any specialized training and/or certification required
  • Whether the specialty treats a significant volume of the Medicare population
  • Whether the specialty is recognized by another organization, such as the American Board of Medical Specialties
  • Whether the specialty has a corresponding health care provider taxonomy code

Physicians may not have a specialty code of 70 (single or multispecialty clinic or group practice). Medicare contractors must contact physicians whose records indicate specialty code 70 and require the physicians to update their enrollment records by submitting a CMS-8551 with a specialty that is valid for a physician.

Additionally, CMS will be adding new specialty code 17 for hospice and palliative care, effective for October 1, 2009.

Physician/nonphysician practitioner specialty codes describe the specific/unique types of medicine that physicians and nonphysician practitioners (and certain other suppliers) practice. CMS uses these codes for programmatic and claims processing purposes. Physicians self-designate their Medicare physician specialty on their enrollment application (CMS-855I) or on the internet-based Provider Enrollment, Chain and Ownership System. Nonphysician practitioners are assigned a Medicare specialty code when they enroll based on their profession.

Deborah C. Hall
Clinical/Technical Editor


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