Hyperbaric Medicine’s New Specialty Coding

You may have heard a few firecrackers on New Year’s Eve, but the biggest fireworks in our industry went off Jan. 7. That’s because the Centers for Medicare & Medicaid Services (CMS) has established a new physician specialty code for Undersea and Hyperbaric Medicine – “D4”. (The policy is effective Jan. 1, with an implementation date of Jan. 7.) When physicians enroll in Medicare, they “self-designate” their specialty on the enrollment application (Form CMS-855I or Form CMS-855O) or the internet-based Provider Enrollment, Chain, and Ownership System (PECOS). You do not have to be board-certified in the specialty that you self-designate. For example, for most of the 23 years that I was on the faculty at the University of Texas Health Science Center in Houston, I was in the department of anesthesiology. As a result, my department designated me as an anesthesiologist on my PECOS form, even though I am board-certified in family practice. When I later moved to the cardiology division of internal medicine, the university changed my specialty designation to cardiology! When I left the university and went into private practice, I changed my self-designation to family practice even though I was practicing wound care and hyperbaric medicine. Why? Because even though I am actually subspecialty board-certified in undersea and hyperbaric medicine via preventive medicine, there was no way to designate that on the PECOS form. 

Specialty codes are used by CMS for programmatic and claims-processing purposes. Why does this matter? By using the “D4” designation, practitioners can “explain” to CMS the nature of their particular practice. I will give you an example from my 2017 Merit-Based Incentive Payment System (MIPS) report: In 2017, Medicare did not include “cost” in the calculation of the MIPS score, but it reported data about cost for each participating physician to see. My 2017 cost data were very interesting. In 2017, CMS calculated my total per capita cost at $24,306 and my per-episode cost at about $58,000. This was CMS’ analysis of how much money was spent on my patients (at least, on the patients living with conditions that CMS cares about, such as heart failure and diabetes with complications). After calculating these costs, CMS then compared my cost data with those of other family practice physicians because I self-designated as a family practice physician. Not surprisingly, compared to my colleagues in family practice, I had a much higher per-patient cost. As a result, CMS assigned me to the third decile (which is actually as bad as you can get). In other words, CMS told me that I spend too much money per patient compared to other family practice doctors and way too much money at all. Well, of course I do, given that my patients have an average of 10 serious comorbid conditions and take an average of 12 medications! In 2017, why didn’t CMS compare my data to other hyperbaric practitioners? Because there was no specialty designation code to enable CMS to know who the other hyperbaric practitioners actually were. 

In other words, unless you are a critical care physician or transplant surgeon, your typical hyperbaric patients are likely to be more complicated than the average patient cared for by colleagues in your same specialty. This could result in your receiving a low-decile ranking in the cost category of MIPS, a category that is taking on more importance each year. However, if you change your designation to “D4” to reflect the fact that you are a hyperbaric medicine practitioner, CMS will compare your spending with your peers in hyperbaric medicine. Changing your designation to “D4” will decrease the chances you will lose Medicare money because of a poor MIPS cost score. It also allows us to collect accurate data on total per capita charges among hyperbaric patients. The CMS-855I and CMS-855O paper applications will be updated to reflect the new physician specialty, but, in the interim, providers should select the “undefined physician type” option on the enrollment application and specify “undersea and hyperbaric medicine” in the space provided. This is important — existing enrolled providers who want to update their specialty to reflect the new specialty must submit a change-of-information application to their Medicare Administrative Contractor within 60 days of the Jan. 7 implementation date. More information is provided online.^1-3  

1. New physician specialty code for undersea and hyperbaric Medicine. CMS. 2018. Accessed online: www.cms.gov/outreach-and-education/ medicare-learning-network-mln/mlnmattersarticles/downloads/mm10666.pdf 

2. Pub 100-06 medicare financial management. CMS. 2018. Accessed online: www. cms.gov/regulations-and-guidance/guidance/ transmittals/2018downloads/r309fm.pdf 

3. Pub 100-04 medicare claims processing. CMS. 2018. Accessed online: www.cms. gov/regulations-and-guidance/guidance/ transmittals/2018downloads/r4184cp.pdf