4. The achievement of “Board Certified” specialty status

The fact that a physician has recently been “Board Certified” in a specialty does not by itself justify the recognition of higher “customary” charges. For example, a physician may have been board eligible and made charges in line with the fees of other specialists in the field for some time, and the carrier’s customary charge screen may reflect these charges. In such a situation, an increase in the customary charge screen to further recognize the physician’s specialty practice would not be warranted.

Except in situations in which the regulations or CMS instructions provide specific exceptions, the amount recorded as a customary charge limit for a service in a carrier’s screen must normally be the median of the charges made by the physician or other person for the service during the full one-year period. However, where a carrier makes an equity adjustment in its customary charge screen under this exception, the carrier records a new fee as a customary charge after the charge has been made by the physician or supplier to patients for at least three months.

Each carrier has the responsibility for determining whether an equity adjustment in a physician’s or supplier’s customary charge profile can be made. In each instance in which an adjustment is made, the carrier documents the situation and its determination, and has such documentation readily available for review by CMS. Normally, equity adjustments are made in customary charge profiles only in a relatively small number of situations.