Provider Types Affected
Physicians and non-physician practitioners submitting claims to Palmetto GBA for services provided to Medicare beneficiaries.

Provider Action Needed
This article is informational only and is based on Change Request (CR) 6303 and alerts providers that the Centers for Medicare & Medicaid Services (CMS) is to revising the Medicare Claims Processing Manual, Chapter 26, Section 10.8 in order to clarify the criteria CMS considers when reviewing Medicare physician/non-physician practitioner specialty code requests.

Background
Medicare physician/non-physician practitioner specialty codes describe the specific/unique types of medicine that physicians and non-physician practitioners (and certain other suppliers) practice. Physicians self-designate their Medicare physician specialty on their Medicare enrollment application (CMS-855I, which is available at www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf (PDF, 1.39 MB) or on the Internet-based Provider Enrollment, Chain and Ownership System. Non-physician practitioners are assigned a Medicare specialty code when they enroll based on their profession. Specialty codes are used by CMS for programmatic and claims processing purposes. Physicians and non-physician practitioners self-designate their Medicare physician/non-physician practitioner specialty on Form CMS-855I when they enroll in the Medicare program. The specialty code becomes associated with the claims submitted by that physician or non-physician practitioner. Medicare physician/non-physician practitioner specialty codes describe the specific/unique types of medicine that physicians and non-physician practitioners (and certain other suppliers) practice. Specialty codes are used by CMS for programmatic and claims processing purposes.

• Your Medicare contractor has been advised of the criteria CMS considers when reviewing Medicare physician/non-physician practitioner specialty code requests
• When considering a request for expanding the specialty code list for physician and /non-physician practitioners, CMS will take into consideration the following:
  • Whether the requested specialty has the authority to bill Medicare independently
  • The requester’s clearly 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 and
  • Whether the specialty has a corresponding Healthcare Provider Taxonomy Code  

Additional Information
The official instruction (CR 6303) issued to Palmetto GBA is available at www.cms.hhs.gov/Transmittals/downloads/R1725CP.pdf (PDF, 110 KB).

If you have questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

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