Medicare Denials

Look into Physician Specialty codes to help with what they're looking for; this will be a 2-digit alphanumeric different from CPT's.

You are correct.  I was just looking at a Certificate of Waiver for one of our locations and there are no specialties/types of testing listed.  There doesn't even appear to be a place to put it. 

Thought maybe there was a waived and a non-waived CPT for PT, but there is not - there is only 85610, which you are using.  Maybe they don't think PT can be a waived test?

This is the website that Medicare is sending us to refer to regarding denials.  It is The Joint Commission library.  The changes are for Joint Commissioned Accredited laboratories.
https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000001464

This note appears on the site:

Note: This FAQ does not apply to CLIA Certificates of Waiver or Provider Performed Microscopy Procedures (PPMP). The laboratory is not required to declare specialties or sub-specialties on these types of certificates. Specialties and sub-specialties are also not listed on the certificate issued to a new laboratory before it is inspected, which is identified as a CLIA Certificate of Registration.

That seems to be a counterproductive response you're receiving. The CMS Specialty Code in question is not the CLIA Subspecialties listing, try looking into this link for more information regarding this rejection:  Find Your Taxonomy Code | CMS  

This code somewhat identifies what type of service is being provided and is required for CMS reimbursement in addition to the proper CPT's and modifiers like QW.

You may want to address questions directly to this email: providerenrollment@cms.hhs.gov 

Medicare indicated that the change that required CLIA sub-specialties occured on 10/1/2025.  I am trying to find what actually changed.  Is this somewhere on the CMS website?

This is from a message I received from our revenue cycle people after they called Medicare:  Amanda advised that there was a CLIA edit implemented on 10/01/2025 and advised that the lab sub-specialty wasn't tied to the CLIA certification record, and we would need to have sub-specialty updated in order for the claim to be processed correctly.

Since the CLIA certificate is for waived testing there are no sub-specialties listed.

Is your CLIA certificate number still appearing on the lab report. Maybe there was a change to the report in the EMR/HMS.