CMS Pub. 100-04, ch. 26, § 10.8

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.

10.8.1 - Assigning Specialty Codes by A/B MACs (B) and DME MACs

Physicians are allowed to choose a primary and a secondary specialty code. If the A/B

MAC (B) and DME MAC provider file can accommodate only one specialty code, the

A/B MAC (B) or DME MAC assigns the code that corresponds to the greater amount of

allowed charges. For example, if the practice is 50 percent ophthalmology and 50

percent otolaryngology, the A/B MAC (B)/DME MAC compares the total allowed

charges for the previous year for ophthalmology and otolaryngology services. They

assign the code that corresponds to the greater amount of the allowed charges.