The Center for Medicare and Medicaid Services (CMS) has established a unique specialty code for Medical Toxicology (C8-PHY) effective October 1, 2017. Existing enrolled Toxicologists who want to update their specialty must submit a change of information application to their Medicare Administrative Contractors (MACs).
Providers may submit an enrollment application to initially enroll or update their specialty code within 60 days of the implementation date (October 1, 2017). Make sure your billing staffs are aware of this change. Medicare physician specialty codes describe the specific/unique type of medicine the physicians practice. CMS uses specialty codes for claims processing and programmatic purposes.
- What is the impact of the new specialty code for Medical Toxicology on enrollment with CMS and credentialing with private insurers?
When the new specialty code becomes available, you will be appropriately recognized as a unique specialty with CMS and also private insurers. If you are in a group practice, this will enhance your ability to bill for services offered to new patients, and also potentially reduces your medical claims denials. The National Uniform Claim Committee (NUCC) maintains a list of 10-digit “health care provider taxonomy codes.” Please note that Medicare does not use the taxonomy code for pricing a provider’s services. Medicare uses the provider’s specialty code to price appropriately. So according to Medicare, the taxonomy codes are used as a HIPAA-accepted code set necessary for compliance with HIPAA standards regarding electronic claims submissions and acquisition of NPI numbers, but not used to identify a provider’s specialty for claims processing purposes.
- What is the impact of the new specialty code for Medical Toxicology on coding and billing?
There will not be impact on your coding of procedures and services offered to your patients. Your billing might be impacted as there will be potentially lesser claims denials (see below):
Group Practice: Physicians in the same group practice who are in the same specialty code must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty code in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.
New Patient: Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service from the physician or physician group practice (same physician specialty code) within the previous 3 years.
- What is the impact of the new specialty code on RVUs and reimbursement rates?
The CMS physician fee schedule is based on Resource-Based Relative Value System (RBRVS). Each CPT and HCPCS code has a weighed RVU as determined by physician work, practice expense, professional liability insurance and geographic status. CMS now has one fee schedule for all physician services based on CPT code - the same reimbursement applies regardless of the physician specialty - only difference is geographic adjustments. As for our specialty, we have few procedures and rely largely on E&M CPT codes e.g. 99205 new patient level 5. Our new specialty code will allow us to potentially negotiate more fairly with private insurers on the percent of Medicare rates associated with our frequently utilized E&M codes.
- What other benefits might be realized from the new specialty code for Medical Toxicology?
Currently we are in the blind spot as far as CMS and other private insurers are concerned. Our impact on our patients is hidden within other specialties like emergency medicine, pediatrics, occupational medicine and others. With the new specialty code, our patients can be properly attributed and our contribution accurately measured. This will also help measure and track quality outcomes meaningful to our patients. In addition, we will be able to better substantiate a burning platform to adequately fund our research agenda.
Thank you to Danyal Ibrahim, MD, FACMT, for this submission.