Release Newsletter

Version 1.88

OCTOBER 2007

Institutional Change Summary

We are pleased to announce the release of PC-ACE Pro32 version 1.88. This upgrade contains several CMS Medicare Mandates and product enhancements effective 10/01/2007, including these highlighted changes:

¨ Present on Admission Indicator – Modifications made to the Institutional claims module to support the “Present On Admission” (POA) Indicator reporting requirements described in CR5499.

¨ Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-9 Annual Update – 145 new diagnosis codes; 39 new procedure codes

ENCLOSED Materials

¨ Pre-built PC-ACE Pro32 1.88 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers

¨ This Newsletter

CMS Medicare Mandates

CR5499 – Present on Admission Indicator

Made several changes to the Institutional claims module in support of the "Present On Admission" (POA) Indicator implementation. PC-ACE Pro32 uses the 8th position of the Principal Diagnosis Code, Other Diagnosis Codes, and External Cause of Injury (E-Code) fields to hold the POA indicators. The specific program changes include:

ª Enhanced the Institutional claim form to clearly display POA indicators in a shaded area to the right of each diagnosis code.

ª Added the new "POA Type" field to the Diagnosis/Procedure tab of the Institutional claim form. This optional qualifier specifies the processing method for the diagnosis code's POA indicators. Leave this field empty to indicate standard POA processing. Valid values are 'Z' (standard processing) and 'X' (special processing).

ª Modified the Institutional Claim Import Module to support import of POA information from an ANSI-837 import file's claim-level "File Information" (K3/2300) segment.

ª Modified the Institutional Claim Import Module to support Present On Admission (POA) indicators when importing UB92 5.0/6.0 EMC files. When this feature is enabled, the 6th position of the Principle Diagnosis Code field (RT 70 ; Field 4), the eight Other Diagnosis Code fields (RT 70 ; Fields 5-12), and the External Cause of Injury Code field (RT 70 ; Field 26) should contain the POA indicator, when applicable. Valid POA indicator values are 'Y', 'N', 'U', 'W' and '1' (same as blank). The 6th position is normally space filled since ICD-9 diagnosis codes never exceed 5 positions. Note: This feature is disabled by default. Contact your software distributor for activation instructions if needed.

CR5454 – Method of Payment for Extended Stay Services Under the Frontier Extended Stay Clinic Demonstration, Authorized by Section 434 of the Medicare Modernization Act

ª Added a new HCPCS code "GXXXX - EXTENDED STAY SVCS <= 4 HRS" (effective 10/1/2007). Also added two new Institutional claim edits restricting the use of Extended Stay HCPCS code GXXXX to Revenue Codes 0510, 0516, 0519 and 0529 and bill types 13x, 71x and 73x. These new edits are effective 10/1/2007.

CR5643 – Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

ª Integrated the annual ICD-9 diagnosis/procedure code file from CMS into the October 2007 release. This update includes 145 new diagnosis codes, 39 new procedure codes, 32 modified diagnosis codes, and 64 modified procedure codes.

CR5545 - Line Item Billing Requirement for Epoetin Alfa (EPO) Submitted on End Stage Renal Disease (ESRD) Claims

ª Terminated several existing Institutional edits, which required Value Code 68 (EPO - DRUG) on all EPO claims (TOB = 72x ; eff. 1/1/2008).

ª Additional changes are forthcoming in the January 2008 release.

ADDITIONAL CMS Mandated CHANGES

CR5635 – Revised HCPCS Codes Relating to Immune Globlin

ª New HCPCS codes effective 7/1/2007:

§ Q4087 - OCTAGAM INJECTION

§ Q4088 - GAMMAGARD LIQUID INJECTION

§ Q4089 - RHOPHYLAC INJECTION

§ Q4090 - HEPAGAM B INJECTION

§ Q4091 - FLEBOGAMMA INJECTION

§ Q4092 - GAMUNEX INJECTION

ª Discontinue HCPCS codes effective 6/30/2007: J1567

CR5714 – October Update to the 2007 Medicare Physician Fee Schedule Database

ª Added a new HCPCS code "G8370 - ASTHMA PT W SURVEY NOT DOCUM" (effective 7/1/2007)

Modifications in Support of ANSI (HIPAA) IG Compliance

UB-04 Manual Updates

Per a review of the current NUBC UB-04 Manual (Version 2.00)

ª Added new Value codes "D4 - CLINICAL TRIAL NUMBER ASSIGNED BY NLM/NIH" (effective 10/1/2007) and "G8 - FACILITY WHERE INPATIENT HOSPICE SERVICE IS DELIVERED" (effective 1/1/2008). Added non-fatal Institutional claim edits prohibiting the use of these new codes prior to their effective dates.

ª Made several changes to the Institutional claim form to reflect a redefinition of Form Locator 15 on the UB-04 claim form. This field was previously named "Source of Referral for Admission or Visit", but is being renamed to "Point of Origin for Admission or Visit" to clarify its purpose. Modified the claim form's fixed lookup list and field edits to reflect the following changes to the valid code list: (1) Deleted codes "3 - HMO referral" and "A - Transfer from rural primary care" from the list of valid codes (effective 10/1/2007) ; (2) Added the new codes "E - Transfer from Ambulatory Surgery Center" and "F - Transfer from Hospice (Under a Hospice POC or Enrolled in Hospice)" (eff 10/1/2007) ; (3) Deleted special Newborn codes "1 - Normal delivery", "2 - Premature delivery", "3 - Sick baby" and "4 - Extramural birth", and replaced them with codes "5 - Born In Hospital" and "6 - Born Outside Hospital" (eff 10/1/2007) ; and (4) Modified the descriptions for several other codes to improve clarity.

ª Added the new Patient Discharge Status code "70 - Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this List" effective 10/1/2007. This new code is a functional replacement for Patient Discharge Status code "05" which has been redefined as "Discharged/transferred to a Designated Cancer Center or Children's Hospital". Modified the fixed lookup lists on this Institutional claim form field to reflect these changes. Modified the field validation edit to allow the new code, and added a non-fatal edit to restrict its use to on or after 10/1/2007.

ª Added the new Revenue Code "0948 - PULMONARY REHAB" (effective 10/1/2007).

Institutional Claim Import Module

ª Modified the Institutional Claim Import Module to support import of Investigational Device Exemption (IDE) Numbers from FL43 on UB-04 print-image files. Version 2.0 of the UB-04 specification allows the IDE number to be printed in the Revenue Code Description (FL43) field for service lines with Revenue Code = 0624 (INVESTIGATIONAL DEVICE). The import routine applies a reasonability check to the FL43 value before importing it as an IDE number. Values that begin with "INV" or "IDE" will be ignored, as will values containing embedded SPACE characters or punctuation other than a hyphen.

Category III Codes – Source: AMA Website

ª Added the following new HCPCS codes (all effective 1/1/2008):

§ 0183T - WOUND ULTRASOUND

§ 0184T - EXC RECTAL TUMOR ENDOSCOPIC

§ 0185T - COMPTR PROBABILITY ANALYSIS

§ 0186T - SUPRACHOROIDAL DRUG DELIVERY

§ 0187T - OPHTHALMIC DX IMAGE ANTERIOR

Category I Codes – Source: AMA Website

ª Added the following new HCPCS codes (all effective 1/1/2008):

§ 90650 - HPV TYP BIVL 3 DOSE IM

§ 90661 - FLU VACC CELL CULT PRSV FREE

§ 90662 - FLU VACC PRSV FREE INC ANTIG

§ 90663 - FLU VACC PANDEMIC

§ 90681 - ROTAVIRUS VACC 2 DOSE ORAL

§ 90696 - DTAP-IPV VACC 4-6 YR IM

HCPCS Update – Source: CMS Website

ª Added the following new HCPCS modifiers (all effective 1/1/2008):

§ EA - ESA, ANEMIA, CHEMO-INDUCED

§ EB - ESA, ANEMIA, RADIO-INDUCED

§ EC - ESA, ANEMIA, NON-CHEM/RADIO

§ ED - HCT>39% OR HGB>13G>=3 CYCLE

§ EE - HCT>39% OR HGB>13<3 CYCLE

Claim Adjustment Reason Code Update

ª Updated the Claim Adjustment Reason Codes reference file with the latest WPC published code set. Codes Added: 7 ; Codes Deleted: 0 ; Codes Modified: 9. The new codes are: "205 - Pharmacy discount card processing fee", "206 - NPI denial - missing", "207 - NPI denial - Invalid format", "208 - NPI denial - not matched", "209 - Per regulatory or other agreement. The provider cannot collect this amount from the patient. ...", " 210 - Payment adjusted because pre-certification/authorization not received in a timely fashion" and " 211 - National Drug Codes (NDC) not eligible for rebate, are not covered.". The modified codes are: 16, 17, 42, 85, 96, 115, 125, 197 and A1.

Claim Status Response Codes Update

ª Updated the Claim Status Response Codes reference file with the latest WPC published code set. Codes Added: Category - 0 , Status - 0 ; Codes Deleted: Category - 1 , Status - 20 ; Codes Modified: Category - 0 , Status - 10. The deleted status category codes are: "RQ - General Questions (Yes/No Responses)" (effective 1/1/2008). The deleted status codes are: "8 - No payment due to contract/plan provisions.", "10 - All originally submitted procedure codes have been combined.", "11 - Some originally submitted procedure codes have been combined.", "13 - All originally submitted procedure codes have been modified.", "14 - Some all originally submitted procedure codes have been modified.", "22 - ... before entering the adjudication system.", "28 - Claim submitted to wrong payer.", "69 - Payment reflects plan provisions.", "70 - Payment reflects contract provisions.", "87 - Denied: Entity not found. (Use code 26 with appropriate Claim Status category Code)", "108 - Coverage has been canceled for this entity. (Use code 27)", "118 - TPO rejected claim/line because payer name is missing. (Use status code 21 and status code 125 with entity code IN)", "119 - TPO rejected claim/line because certification information is missing. (Use status code 21 and status code 252)", "120 - TPO rejected claim/line because claim does not contain enough information. (Use status code 21)", "122 - Missing/invalid data prevents payer from processing claim. (Use CSC Code 21)", "169 - Entity's employer id.", "331 - History and physical. (Use code 316)", "332 - Authorization/certification (include period covered). (Use code 252)", "348 - Chiropractic treatment plan. (Use 345:QL)", and "423 - Prognosis". The modified status codes are: 21, 253, 303, 328, 331, 338, 349, 350, 351, and 585.

Remittance Remark Codes Update – Source: WPC Published Code Set

ª Updated the Remittance Remarks Codes reference file with the latest WPC published code set. Codes Added: 42 ; Codes Deleted: 0 ; Codes Modified: 11. The new codes are: N388, N389, N390, N391, N392, N393, N394, N395, N396, N397, N398, N399, N400, N401, N402, N403, N404, N405, N406, N407, N408, N409, N410, N411, N412, N413, N414, N415, N416, N417, N418, N419, N420, N421, N422, N423, N424, N425, N426, N427, N428 and N429. The modified codes are: M26, M27, M70, MA14, MA59, MA62, N12, N84, N85, N125 and N129.

Provider Taxonomy Code Update

ª Updated the Provider Taxonomy Code reference file with the latest WPC published code set. Code Added: 23 ; Codes Deleted: 0 ; Codes Modified: 2. The new codes are: "102X00000X - Poetry Therapist", "103GC0700X - Clinical Neuropsychologist : Clinical", "103TE1000X - Psychologist : Educational", "103TM1700X - Psychologist : Men & Masculinity", "103TP2700X - Psychologist : Psychotherapy", "103TW0100X - Psychologist : Women", "172V00000X - Community Health Worker", "1835G0000X - Pharmacist : General Practice", "207QB0002X - Family Medicine : Bariatric Medicine", "207RB0002X - Internal Medicine : Bariatric Medicine", "207RT0003X - Internal Medicine : Transplant Hepatology", "207VB0002X - Obstetrics & Gynecology : Bariatric Medicine", "207ZC0006X - Pathology : Clinical Pathology", "2080T0004X - Pediatrics : Pediatric Transplant Hepatology", "2081N0008X - Physical Medicine & Rehabilitation : Neuromuscular Medicine", "2084B0002X - Psychiatry & Neurology : Bariatric Medicine", "2084N0008X - Psychiatry & Neurology : Neuromuscular Medicine", "213EG0000X - Podiatrist : General Practice", "246ZC0007X - Specialist/Technologist, Other : Certified First Assistant", "252Y00000X - Early Intervention Provider Agency", "273100000X - Epilepsy Unit", "2865C1500X – Military Hospital : Community Health", and "333300000X - Emergency Response System Companies". The modified codes are: "176B00000X - Midwife" and "207XX0004X - Orthopaedic Surgery : Foot and Ankle Surgery".

Edits

ª Added several non-fatal Institutional claim edits which require that the Attending, Operating and Other Physician ID Type (i.e., ANSI qualifier) fields not be left empty when the associated identifier is a valid National Provider ID (NPI). These edits will prevent inadvertent entry of NPIs without the corresponding "XX" type/qualifier code.

ª Modified several Institutional claim edits which enforce NUBC requirements for the new UB-04 paper-only "days" Value codes 80, 81, 82 and 83. The edits requiring that the amounts associated with these special Value codes be equal to the corresponding "days" fields on the claim have been change from fatal to non-fatal. In addition, these edits are now bypassed for Medicaid claims. A related edit requiring that the amounts associated with Value Codes 80, 81, 82 and 83 always be integer values (i.e., cents = zero) has also been bypassed for Medicaid claims. It has come to our attention that not all Medicaid plans are adopting these new NUBC code assignments, and have apparently already defined these "reserved for national use" Value Codes for their own state use.

General product enhancements

PC-ACE Pro32 Product Reinstallation Simplification

ª Modified the PC-ACE Pro32 installation program (SETUP.EXE) and PC-ACE Pro32 Client installation program (CLIENT32.EXE) to be more tolerant with respect to previous installations. These programs will now check the existing PC-ACE Pro32 entries in the Windows registry to see if they still refer to a valid product installation. If the registry entries appear to be obsolete, the installation programs will silently clear this information from the registry and proceed normally. Previously, the installation programs would abort with an error if remnants of a previous installation were present in the Windows registry. This change will allow simpler reinstallation when the product has been manually uninstalled by deleting the "winpcace" folder tree. These less restrictive rules will also aid installation on Windows Vista computers where the per-user registry settings for administrators and standard Windows users can create confusion.

Miscellaneous ANSI Transaction Handling Improvements

ª Implemented changes to simplify the default handling/processing procedures for ANSI-271 (Eligibility/Benefit Response), ANSI-277 (Claim Status Response) and ANSI-835 (Electronic Remittance) files. These improvements significantly reduce the number of steps required to access the information in these files once they have been staged to the appropriate folder. These changes are especially beneficial to sites that use the PC-ACE Pro32 Report Manager to pre-stage files that have been downloaded to a standard "mailbox" folder. It is no longer necessary to manually invoke the Report Manager in order to pre-stage these files. PC-ACE Pro32 will now run the Report Manager automatically in a silent (i.e., hidden) "archive only" mode to perform these pre-staging activities. These enhancements will also aid sites that do not use the Report Manager by eliminating the need to manually open the ANSI-271 or ANSI-277 log screens when the intent is only to process/post a response file already present in the respective staging folder. All such activities are now performed behind the scenes at appropriate points in the standard work flow. For example, launching one of the ANSI-835 Remittance Processors from the "ANSI-835 System Selection" form will now silently invoke the Report Manager to pre-stage files from the standard "mailbox" folder to the appropriate ANSI835 staging folder, when applicable. Simply opening the "Eligibility Benefit Request List" form will now invoke the Report Manager silently to pre-stage files from the standard "mailbox" folder, and then automatically process/post the eligibility responses from any ANSI-271 files present in the predefined staging folder. It is no longer necessary to run the Report Manager manually to pre-stage these files. Neither is it necessary to open the "Eligibility Benefit Response Log" form in order to process/post the ANSI-271 response files. These operations are now performed automatically and transparent to the user. Note that the ANSI-270/271 Eligibility/Benefit Request/Response feature, the ANSI-276/277 Claim Status Request/Response feature, and/or the ANSI-835 Electronic Remittance Processor (ETRA) feature may not be available on all PC-ACE Pro32 installations.

PC-ACE Pro32 Report Manager

ª Enhanced the PC-ACE Pro32 Report Manager to perform an automatic cleanup of the standard "mailbox" folder during program startup. All files older than 21 days which aren't recognized by the Report Manager will be deleted from the "mailbox" folder. This maintenance activity will improve performance by preventing a large accumulation of unprocessable files in the mailbox folder. The user may disable this automatic cleanup operation if necessary by unchecking the new "Perform automatic cleanup of old and unprocessable files from standard mailbox folder" preferences option. Note that all users in a networked installation must disable this option in order to prevent the cleanup from occurring. Not all PC-ACE Pro32 installations include the PC-ACE Pro32 Report Manager.

Installing the Upgrade

Perform a full PC-ACE Pro32 database backup before installing the upgrade. To install the upgrade, run the attached PCACEUP.EXE file using Windows Explorer or equivalent, and follow the simple upgrade wizard steps. When prompted, enter the upgrade password provided by your software supplier. For networked instructions, it is recommended (but not required) that the update be run from the server’s console.

IMPORTANT: The recommended database backup is for safety purposes only, and should NOT be restored after successfully installing the update. The update program preserves all existing claims and reference file settings.