Requirements for Specialty Codes

10.8 - Requirements for Specialty Codes (Rev. 1725, Issued: 05-01-09, Effective: 07-01-09, Implementation: 07-06-09) 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) 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. A. A physician specialty association will submit a specialty code 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. Medicare contractors shall not add any specialty codes to the list. They must send all requests for expansion of the specialty code list to the Director, Division of Practitioner Services, at the address above. B. 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 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. Physicians may not have a specialty code of 70 (single or multi-specialty Clinic or Group Practice.) 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.