Technical Instruction History
| Date | Description of Change |
|---|---|
| 05/19/2020 | Original technical instructions issued |
| 06/24/2022 |
Technical instructions updated in correspondence with the V3.0.0 data dictionary update:
|
Brief Issue Description
The accuracy and completeness of provider specialization information will be added as a T-MSIS priority issue in the spring of 2020. The ability to identify provider specialization in T-MSIS is vital for investigating a number of different research questions. For example, research on the geographic distribution of specialists is dependent on accurate and reliable provider specialty information. There is currently a lack of clarity with respect to which provider specialization identifiers should be used and how those identifiers should be reported. As a result, T-MSIS data on provider specialization is reported inconsistently across states. This technical instruction document provides clarification in this area.
Background Discussion
The PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment captures information specific to provider specialization and authorization. In that file segment, the value in the PROV-CLASSIFICATION-TYPE (PRV088) data element indicates which of four classification types the value in the PROV-CLASSIFICATION-CODE (PRV089) data element represents. The four PROV-CLASSIFICATION-TYPE (PRV088) code values are presented in Table 1.
| Code | Description |
|---|---|
| 1 | Taxonomy code |
| 2 | Provider specialty code |
| 3 | Provider type code |
| 4 | Authorized category of service code |
All PROV-CLASSIFICATION-CODE values provided when PROV-CLASSIFICATION-TYPE is set to 1 (Taxonomy code) must come from the Health Care Provider Taxonomy Code Set (includes external code lists maintained by X12 and external code lists maintained by others and distributed by WPC). All PROV-CLASSIFICATION-CODE values provided when PROV-CLASSIFICATION-TYPE is set to 2 (provider specialty), 3 (provider type), or 4 (authorized category of service) must correspond to values found in the T-MSIS Data Dictionary Appendix A.
When provider taxonomy, provider specialty, and provider type values are present in claims file segment data elements, there should be corresponding PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segments with matching values in the PROV-CLASSIFICATION-CODE (PRV089) data element.
The technical instructions below addresses which classification types should be supplied for a given provider, and whether states are permitted to use state-specific codes or if all PROV-CLASSIFICATION-CODE values should match standardized code sets. These topics are covered in detail below.
Challenges
States have struggled to provide all four provider classification types for every provider. To help states with this challenge, CMS will only require taxonomy codes (PROV-CLASSIFICATION-TYPE=1) for providers that have NPIs and Authorized Category of Service (PROV-CLASSIFICATION-TYPE=4) for providers that do not have NPIs.
Additionally, to clarify the alignment between values provided in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment and values provided in the claims data, this technical instruction document will provide mappings between PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment and data elements in the claims file segments.
Finally, several states are using state-specific code sets for reporting provider specialization. Though states can continue to do this internally, the codes reported in T-MSIS must correspond to values provided by the National Uniform Claim Commission (NUCC) or the T-MSIS Data Dictionary Appendix A. Consistency across states in this area is vital for any type of analysis using provider specialization.
Previously issued related technical instruction
The previously issued technical instructions instructed states that every provider was required to have at least one record segment in PROV-TAXONOMY-CLASSIFICATION (PRV00006) for every provider classification type, and to use the value “88” for the PROV-CLASSIFICATION-CODE when a given PROV-CLASSIFICATION-TYPE is not applicable. The technical instructions provided here modifies that requirement and only require one classification type for any given provider. Additionally, values of “88” should not be used unless it is part of the PROV-CLASSIFICATION-TYPE 1 – 4 code sets listed in T-MSIS Data Dictionary Appendix A.Technical Instruction
PROV-TAXONOMY-CLASSIFICATION (PRV00006)
All providers in the PROV-ATTRIBUTES-MAIN (PRV00002) file segment are expected to have at least one code in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment. When necessary, a single provider can be assigned multiple codes for the same classification category. For example, a hand surgeon may be sub-classified under both orthopedics and plastic surgery, in which case they may have more than one provider taxonomy or specialty.
CMS has identified provider taxonomy (PROV-CLASSIFICATION-TYPE=1) as the preferred method of reporting provider specialization in T-MSIS. Within the context of T-MSIS, the term provider taxonomy refers to the Health Care Provider Taxonomy Code Set maintained by the NUCC. Using provider taxonomy to identify provider specialization has several advantages over the other provider classification codes sets:
- The Health Care Provider Taxonomy Code Set is nationally standardized and actively maintained by the NUCC. This means that the available provider taxonomy codes and their definitions should be consistent across states, and new taxonomy codes will be added as new provider specializations are introduced.
- The NUCC provider taxonomy codes can be very detailed and will provide enough granularity for most research purposes.
- Providers must supply a valid NUCC taxonomy code when they apply for a National Provider Identifier (NPI). As such, all providers with NPIs will have self-identified with at least one provider taxonomy code[1].
Although all states are encouraged to adopt the NUCC provider taxonomy as a method to identify provider specialization, states that are not able to do so will not be penalized. Not all states use the NUCC provider taxonomy in their provider credentialing process, so the relationship between a provider and their taxonomy(s) will not always be available in some state Medicaid Management Information Systems. States that provide documentation indicating their provider credentialing system does not use taxonomy codes will be permitted to use provider specialty (PROV-CLASSIFICATION-TYPE = 2) and provider type (PROV-CLASSIFICATION-TYPE = 3) codes instead of provider taxonomy. If a state cannot provide a taxonomy code for a provider that has an NPI, and the provider specialty and provider type code lists do not contain a valid value for the provider (as is the case for dentists), states should use the authorized category of service code for the provider (PROV-CLASSIFICATION-TYPE = 4).
Atypical providers that do not have NPIs, such as those that provide transportation or some home health services, may not have specializations that easily map to the taxonomy, specialty or provider type codes (PROV-CLASSIFICATION-TYPE = 1, 2, or 3). For these providers, states should provide authorized category of service codes (PROV-CLASSIFICATION-TYPE = 4).
Though only one PROV-CLASSIFICATION-CODE (PRV089) is required for each provider, states are encouraged to provide all available data. Providers that have more than one value for a given classification type (e.g., more than one taxonomy) and/or more than one classification type (e.g., a taxonomy and a specialty), will have multiple simultaneously active PROV‐TAXONOMY‐CLASSIFICATION‐PRV00006 record segments.
If a given provider’s specialization changes over time, retired entries should be end dated and new entries should be given appropriate start dates so that dates in the PROV-TAXONOMY-CLASSIFICATION file segment align with dates found in the claims data.
State-Specific Codes
Any type of provider specialization analysis requires the availability of standardized specialization code sets that are consistent from one state to another. Therefore, all PROV-CLASSIFICATION-CODE (PRV089) values in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment must come from values provided on the X12 website, now hosting content from Washington Publishing Company (for taxonomy codes) or from values provided in the T-MSIS Data Dictionary Appendix A in tables specific to PROV-CLASSIFICATION-TYPE 2, 3, or 4. State-specific provider specialization codes should not be used in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment or in the claims data.
Claims
The codes provided in the claims data elements must have corresponding values in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment. Since there is no column to report authorized category of service code in any of the claims file segments, claims submitted by atypical providers are not expected to have taxonomy, specialty, or provider type values (though they can be reported if they are available).
The values provided in the claim file segments should come directly from the claims when they are submitted, values provided by managed care organizations, or values derived from NUCC taxonomy codes that came in on the claims. States should not populate missing data elements on the claims file segments by mapping values from the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment to the claims file segments. This is to avoid complications that may arise in situations when a provider has more than one value for a given PROV-CLASSIFICATION-TYPE code in the PROV-TAXONOMY-CLASSIFICATION (PRV00006) file segment. For example, if a paid claim was missing the taxonomy for the rendering provider and the rendering provider has more than one taxonomy in PROV-TAXONOMY-CLASSIFICATION (PRV00006) (e.g., a hand surgeon that sub-classifies under plastic surgery), it is not immediately obvious which taxonomy code should be populated on the claim.
The relationship between the codes provided in the PROV-TAXONOMY-CLASSIFICATION file segment and the claims file segments are outlined in Table 2.
| Provider Classification Data Elements in the Claims files | Claim file type | PROV-CLASSIFICATION-TYPE (PRV088) in the Provider file |
|---|---|---|
| ADMITTING-PROV-TAXONOMY | LT, IP | 1 |
| ADMITTING-PROV-SPECIALTY | LT, IP | 2 |
| ADMITTING-PROV-TYPE | LT, IP | 3 |
| BILLING-PROV-TAXONOMY | LT, IP, OT, RX | 1 |
| BILLING-PROV-SPECIALTY | LT, IP, OT, RX | 2 |
| BILLING-PROV-TYPE | LT, IP, OT, RX | 3 |
| OPERATING-PROV-TAXONOMY | IP | 1 |
| DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY[a] | RX | 1 |
| PRESCRIBING-PROV-TAXONOMY[a] | RX | 1 |
| PRESCRIBING-PROV-SPECIALTY[a] | RX | 2 |
| PRESCRIBING-PROV-TYPE[a] | RX | 3 |
| REFERRING-PROV-TAXONOMY[a] | LT, IP, OT | 1 |
| REFERRING-PROV-SPECIALTY[a] | LT, IP, OT | 2 |
| REFERRING-PROV-TYPE[a] | LT, IP, OT | 3 |
| SERVICING-PROV-TAXONOMY[b] | LT, IP, OT | 1 |
| SERVICING-PROV-SPECIALTY | LT, IP, OT | 2 |
| SERVICING-PROV-TYPE | LT, IP, OT | 3 |
| UNDER-DIRECTION-OF-PROV-TAXONOMY[a] | LT, IP, OT | 1 |
| UNDER-SUPERVISION-OF-PROV-TAXONOMY[a] | LT, IP, OT | 1 |
[a] This data element has been deprecated as of V3.0.0 of the Data Dictionary.
[b] This data element has been deprecated from the IP and LT files as of V3.0.0 of the Data Dictionary.
As noted previously, non-missing values reported in the claims file segments must have corresponding entries in the PROV-TAXONOMY-CLASSIFICATION file segment. Instances in which values do not match between file segments are an indication of incomplete or incorrect data. Future data quality evaluations may include checks that will flag such data inconsistencies.
[1] Though the list of NPIs and affiliated taxonomies is available for download from the National Plan and Provider Enumeration System (NPPES), NPPES does not verify the accuracy of these codes and does not monitor changes in a given provider’s specialization over time. Any changes to the taxonomy listed in the NPPES data must be made by the provider themselves.