New CMS code for Undersea and Hyperbaric Medicine in 2019: D4

Undersea and Hyperbaric Medicine practitioners, you have a new CMS code next year: D4.

Through the joint efforts of several individuals in the Undersea and Hyperbaric Medical Society and the American College of Hyperbaric Medicine, physicians who specialize in Undersea and Hyperbaric Medicine have been assigned a unique specialty code by the Centers for Medicare and Medicaid Services. That specialty code is D4. The code goes into effect on January 1, 2019.

Current CMS regulations state that if a patient has been seen by another provider in the same specialty within the past 36 months, you may NOT bill an E/M for a new patient evaluation, but, must use a follow-up evaluation and management CPT code (e.g., if you are a surgeon practicing hyperbaric oxygen therapy, and another surgeon refers a patient with necrotizing fasciitis to you, you cannot bill for a new patient evaluation if that surgeon has seen the patient in the past 36 months. This rule prevents you from obtaining reimbursement for a lengthy new patient evaluation. Similarly, if you are an emergency physician and are referred a diver or CO poisoning patient from the ER, you cannot bill for a new patient evaluation.)

The new code will eliminate that restriction.

This may also affect physicians under the Merit-Based Incentive Payment System. Since cost will be factored into the MIPS score from now on, calculations that reflect cost attribution may be linked to specialty codes. For example, Family Practice physicians who designate as FP will be compared to other FPs. If those same physicians practice hyperbaric medicine and wound care and designate themselves D4, they should be compared to other D4s regardless of primary specialty. Since so many of the products and services provided by hyperbaric and wound care physicians are costly, comparison to non-HBO2/WC physicians would be unfair. Hopefully, this new specialty code will allow a more equitable comparison of cost as we move away from a fee-for-service model.

Those who would most benefit from this change are physicians who solely practice UHM. If you are a physician who practices part-time, you may or may not want to change your specialty code. Since Medicare specialty codes are self-designated, this will have no effect on Medicare fee schedules, only on the ability to bill for a new patient exam as described above.

Existing enrolled providers who want to update their specialty to reflect the new specialty code must submit a change of information application to their Medicare Administrative Contractor (MAC). Providers may submit within 60 days of the implementation of the new specialty code, which goes into effect on January 1, 2019. Physicians who are newly enrolling should submit a Medicare enrollment application (CMS-8551 or CMS-8550) form.

5 comments

  1. I’m board certified Family Medicine and Undersea and hyperbaric as well and mainly do Hbot with minimal family practice. What would be my best way to proceed for 2019

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    1. The reality is, no one knows. You will be compared to your HBO2 colleagues, but you have to do MIPS to maximize your return. Since your facility is freestanding, yourr facility reimbursement will be tied to your MIPS score.

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  2. For an example, cost was not counted in the MIPS score this year, so getting a score of 3 out of a possible 10 on a quality measure that CMS created FOR the client didn’t hurt this year, but it will start to hurt when cost is worth 30% of your final score.

    Dr. Fife provided this info from her MIPS scorecard. She’s a family practice doctor and so her Medicare spending per beneficiary was compared to other family practice doctors. As a result, it appears that she overspends and therefore she received a low decile ranking for this measure.

    Presumably when the Hyperbaric specialty code is available, the cost benchmark ratings will change because all hyperbaric practitioners will be compared with each other, decreasing the likelihood that a physician will be disadvantaged by appearing to spend more than other physicians in their primary (non-hyperbaric) specialty.

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