Release Newsletter

Version 1.90

JANUARY 2008

Institutional Change Summary

We are pleased to announce the release of PC-ACE Pro32 version 1.90. This upgrade contains several CMS Medicare Mandates and product enhancements effective 1/1/2008, 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 and CR5679.

¨ CR5775 – HCPCS Annual Update Reminder – Replaced the HCPCS file with the annual 2008 update applicable to claims with service dates on or after January 1, 2008.

¨ JSM/TDL-08007, 10-01-07 - Mandatory Reporting of the National Provider Identifier (NPI) on all Part A Claims; New Carrier and Part A and Part B Medicare Administrative Contractors (A/B MACs) - Effective January 1, 2008, all Medicare Part A fee-for-service claims must include an NPI in the primary provider fields on the claim (i.e., the billing and pay-to provider fields).

ENCLOSED Materials

¨ Pre-built PC-ACE Pro32 1.90 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers

¨ This Newsletter

CMS Medicare Mandates

CR5679 - Present On Admission Indicator Systems Implementation

The following changes have been made in support of the new "Present On Admission" reporting requirements first implemented per CR5499 (see previous newsletter for details):

ª Added a new "Requires POA Reporting" field to the Institutional Provider reference file. This field should be set to "Y" for providers that are required to submit POA information (e.g., general acute care hospitals). Leave this field empty or set to "N" for providers that are exempt from POA reporting. This new "Requires POA Reporting" field drives various claim edits and other POA-related behaviors.

ª Added a non-fatal Institutional claim edit which prompts for entry of "Present On Admission" (POA) indicators on the Principal and Other Diagnosis Codes. These POA indicators are entered in the 8th position of the Diagnosis Code fields. The edit enforces this POA requirement only on Medicare A inpatient claims (TOB = 11x) with discharge dates on or after 10/1/2007, and only if the "Requires POA Reporting" field is set to "Y" on the billing provider's Institutional Provider reference file record. Refer to the on-line Help topic "The Institutional Claim Form" for a list of valid POA indicators and instructions for entering POA indicators on the claim screen.

ª Added a non-fatal Institutional claim edit which prohibits reporting of "Present On Admission" (POA) indicators on Medicare A inpatient claims (TOB = 11x) with discharge dates prior to 10/1/2007.

ª Added a non-fatal Institutional claim edit which prohibits reporting of "Present On Admission" (POA) indicators on Medicare A claims with TOBs other than 11x.

ª Modified the Institutional Claim Import Module to force unused (not reported) POA indicators to "1" in situations where at least one POA indicator is present in the import file. This feature insures consistency when importing from UB-04 print-image files since the POA indicator is to be left empty to imply unused (not reported).

ª Modified the Institutional Claim Import Module to optionally default POA indicators when such indicators are expected, but aren't available in the import file. This feature will be useful when importing from UB92 print files or UB92 6.0 EMC files since neither format supports POA indicators. These defaults are applied on Medicare A inpatient claims (TOB = 11x) with discharge dates on or after 10/1/2007, and only if the "Requires POA Reporting" field is set to "Y" on the billing provider's Institutional Provider reference file record. This feature is disabled by default. Contact your software distributor if you have a need to enable this feature.

ª Modified the Institutional Claim Import Module to add additional flexibility when importing Present On Admission (POA) information. The import routine will now suppress import of POA information when the POA indicators for all Diagnosis Codes are "1" (Not Used / Unreported) or blank, and reporting of POA information isn't appropriate for the claim. Any of the following criteria will trigger this "not used" POA suppression feature: (a) claims with Service Thru Dates prior to 10/1/2007; (b) claims with a non-acute care bill type (i.e., not 11x); and (c) acute care claims (TOB = 11x) whose billing provider is not required to report POA information (as defined by the "Requires POA Reporting" field on the provider record). This suppression feature is intended primarily as a mechanism for cleaning up POA information that has been indiscriminately reported on UB-04 print-image or ANSI-837 files imported into the product. Numerous claim edit errors, and the subsequent manual cleanup, can be eliminated by simply ignoring the "not used" POA indicators when POA information isn't appropriate for a given claim. This suppression option is enabled by default, but can be disabled if needed.

ª Modified the database update utility to initialize the "Requires POA Reporting" field to "Y" for existing Medicare A (MCA) acute care providers (i.e., Medicare Legacy ID = XX0001 thru XX0999). This initialization will take place during the January 2008 quarterly update.

ª Updated the on-line Help system to describe the Present On Admission (POA) indicators and how to enter them on the Institutional claim form.

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

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

ª Added a non-fatal Institutional claim edit limiting the number of EPO (Q4081) service lines reporting the EM modifier (EMERGENCY RESERVE SUPPLY - ESRD) to a maximum of one per claim.

ª Added a non-fatal Institutional claim edit limiting the number of Aranesp (J0882) service lines reporting the EM modifier (EMERGENCY RESERVE SUPPLY - ESRD) to a maximum of one per claim.

ª Added a non-fatal Institutional claim edit which enforces the medically believable limit of 400,000 units of EPO per month based on the service line units instead of Value Code 68. The total service line units for HCPCS code Q4081 (EPOETIN ALFA, 100 UNITS ESRD) must not exceed 4,000 per claim. Note: This limit was lowered from 500,000 to 400,000 per CR5700 (Transmittal 1307).

CR5700 – Modification to the National Monitoring Policy for Erythropoietic Stimulating Agents (ESAs) for End-Stage Renal Disease (ESRD) Patients Treated in Renal Dialysis Facilities

Added or modified several Institutional claim edits to implement policy changes for billing Erythropoietic Stimulating Agents (ESAs) for End-Stage Renal Disease (ESRD) Patients Treated in Renal Dialysis Facilities.

ª Added an Institutional claim edit prohibiting the hemoglobin (Value Code 48) reading from exceeding 13.0 when HCPCS Q4081 or J0882 is present but modifier ED or EE is not present on at least one of the line items. This edit is bypassed if Condition Code 70 or 76 is present on the claim. (TOB 72x ; eff 1/1/2008)

ª Added an Institutional claim edit prohibiting the hematocrit (Value Code 49) reading from exceeding 39.0 when HCPCS Q4081 or J0882 is present but modifier ED or EE is not present on at least one of the line items. This edit is bypassed if Condition Code 70 or 76 is present on the claim. (TOB 72x ; eff 1/1/2008)

ª Added an Institutional claim edit prohibiting HCPCS modifiers ED and EE from being present on the same claim. This edit is bypassed if Condition Code 70 or 76 is present on the claim. (TOB 72x ; eff 1/1/2008)

ª Modified an existing Institutional claim edit which restricts the total EPO drug units reported in Value Code 68 to a maximum of 500,000 units per ESRD claim such that it terminates effective 1/1/2008. Added a replacement edit, which lowers this limit to 400,000 units. Impacted claims are identified by the presence of Epogen HCPCS code Q4081.

ª Modified an existing Institutional claim edit which restricts the total Aranesp drug Units reported on HCPCS codes Q4054 or J0882 to a maximum of 1500 per ESRD claim such that it terminates effective 1/1/2008. Added a replacement edit, which lowers this limit to 1200 units. Impacted claims are identified by the presence of Aranesp HCPCS code J0882.

CR5803 – Annual DMEPOS Fee Schedule Update

ª Included in annual HCPCS update (CR 5775)

CR5774 - Medicare Physician Fee Schedule Database (MPFSDB) 2008 File

ª Included in annual HCPCS update (CR 5775)

CR5775 – HCPCS Annual Update

ª Replaced the HCPCS file with the annual 2008 update for claims processed on or after January 1, 2008. HCPCS Changes: 267 deleted; 755 added; 263 modified. Modifier Changes: 0 deleted; 18 added; 3 modified.

CR5830 – Update to the Medicare Deductible, Co-insurance, and Premium Rates for CY 2008 - Annual Update

ª Added a new Institutional claim edit to enforce the CY 2008 maximum deductible amount of $1,024.00 per benefit period

ª Added a new Institutional claim edit to enforce the CY 2008 hospital inpatient coinsurance rate of $256.00 per day

ª Added a new Institutional claim edit to enforce the CY 2008 SNF coinsurance rate of $128.00 per day

CR5728 - Medicare FFS NPI Final Implementation

ª The product is designed to comply with NPI requirements based on flexible "rules" configured by the distributor. No action will typically be required by the users other than entering their NPIs in the Provider (mandatory) and Physician (optional) reference files.

ª Refer to JSM/TDL-08007 for additional NPI implementation dates and reporting requirements.

JSM/TDL-08007, 10-01-07 - Mandatory Reporting of the National Provider Identifier (NPI) on all Part A Claims; New Carrier and Part A and Part B Medicare Administrative Contractors (A/B MACs)

This directive states that effective January 1, 2008, all Medicare Part A fee-for-service claims must include an NPI in the primary provider fields on the claim (i.e., the billing and pay-to provider fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI. The secondary provider fields (i.e., attending, operating and other) may continue to include only your legacy number, if you choose. Failure to submit an NPI in the primary provider fields will result in your claim being rejected, beginning January 1, 2008. The following changes have been made in response to this directive (effective 1/1/2008)

ª Fatal Institutional claim and provider file edits will require that NPIs be on file for all primary providers referenced on Medicare Part A claims (effective 1/1/2008). The program will continue to report Medicare Legacy IDs in addition to the NPI if they are available.

ª No changes will be made to the NPI requirements for secondary providers. You may continue to submit only Legacy IDs, NPIs and Legacy IDs, or only NPIs as desired. The program will continue to report all identifiers present on the claim.

ª In anticipation of the announced full Stage 3 NPI implementation date (5/23/2008), the product is configured to begin automatically suppressing Legacy IDs in the ANSI-837 output, effective 5/23/2008. Users will not be required to physically remove these Legacy IDs from the claims or the Institutional Provider records. This transition to full Stage 3 NPI should be transparent to PC-ACE Pro32 users.

ADDITIONAL CMS Mandated CHANGES

CR5567 – Hospice Visits/Services on Hospice Claims

ª Modified an existing Institutional claim edit which allows only 065x Revenue Codes on Hospice (81x/82x) claims such that it expires effective 1/1/2008. Added a replacement edit effective 1/1/2008, which allows Revenue Codes 055x, 056x and 057x in addition to 065x on Hospice claims.

ª Updated the Revenue Code file to require non-zero Units for Revenue Codes 055x, 056x and 057x when billed on Medicare Hospice claims (TOBs 81x/82x).

ª Added a non-fatal Institutional claim edit prohibiting Vxxx diagnosis codes from being reported as the principal diagnosis code on Medicare Hospice claims (TOBs 81x/82x ; effective 1/1/2008).

CR5746 – Billing Instructions for Home Health PPS Case Mix Refinement

ª Added the new HH PPS HIPPS codes in the range 1Axxx thru 5Cxxx per Attachment One to the HCPCS reference file (eff 1/1/2008).

ª Added an Institutional claim edit which restricts billing of the new HHRG codes to Revenue Code 0023 on TOB 32x/33x claims on or after 1/1/2008.

ª Modified an existing Institutional claim edit, which requires an HHRG code on Home Health PPS claims such that it now accepts the new HHRG codes.

ª Added a non-fatal Institutional claim edit which restricts the use of current Home Health PPS HIPPS codes in the range HAEJ1 - HDIM8 to episodes beginning prior to 1/1/2008.

ª Added a non-fatal Institutional claim edit, which allows only one service line containing Revenue Code 0023 on Home Health PPS claims (TOBs 32x/33x ; effective 1/1/2008).

CR5718 - October 2007 Update of the Hospital OPPS: Summary of Payment Policy Changes

ª New HCPCS code effective 10/1/2007:

§ C9236 - INJ, ECULIZUMAB, 10 MG

CR5800 – Remittance Advice Reason Code (RARC) and Claim Adjustment Reason Codes (CARC) Update

ª Updated the Claim Adjustment Reason Codes reference file with the latest WPC published code set. Codes Added: 1; Codes Deleted/Terminated: 5; Codes Modified: 84. The new code is: "212 - Administrative surcharges are not covered". The deleted/terminated codes are: 25, 126, 127, 145 and A4. The modified codes are: 15, 17, 19, 20, 21, 22, 23, 24, 31, 33, 34, 45, 55, 56, 58, 59, 61, 95, 97, 107, 108, 112, 115, 116, 117, 118, 121, 125, 129, 135, 136, 137, 138, 141, 142, 146, 148, 150, 151, 152, 153, 154, 155, 157, 158, 159, 160, 163, 164, 165, 168, 169, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 186, 191, 192, 194, 195, 197, 198, 202, 203, 206, 207, 208, A8, B5, B8, B9, B14, B15, B16, B18, B20 and B23.

ª Updated the Remittance Remarks Codes reference file with the latest WPC published code set. Codes Added: 3 ; Codes Deleted: 2 ; Codes Modified: 11. The new codes are: "N430 - Procedure code is inconsistent with the units billed.|Procedure code is inconsistent with the units billed.", "N431 - Service is not covered with this procedure.|Service is not covered with this procedure." and "N432 - Adjustment based on a Recovery Audit.|Adjustment based on a Recovery Audit." The deleted codes are: N14 and N361. The modified codes are: M25, M26, M75, M112, M113, M114, M115, N70, N367, N377 and N385

CR5734 - NUBC Update on Revenue Codes and Corrected SNF Spell of Illness Chart

ª Modified the Revenue Code reference file to assign a 9/30/2007 termination date for codes 0599, 0709, 0719, 0749, 0759, 0779, 0789, and 0799.

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 Modified several Institutional claim edits added per this change request to reflect the correct demo HCPCS code "G9140 - FRONTIER EXTENDED STAY DEMO". These edits restrict the use of Extended Stay HCPCS code G9140 to Revenue Codes 0510, 0516, 0519 and 0529 and bill types 13x, 71x and 73x (eff 10/1/2007).

Other HCPCS C-Codes – Source: CMS Website

ª Added new HCPCS codes effective 1/1/2008:

§ C9237 - INJ, LANREOTIDE ACETATE

§ C9240 - INJECTION, IXABEPILONE

§ C9354 - VERITAS COLLAGEN MATRIX, CM2

§ C9355 - NEUROMATRIX NERVE CUFF, CM

Claim Status Response Codes Update – Source: WPC

ª Updated the Claim Status Response Codes reference file with the latest WPC published code set. Codes Added: Category - 0 , Status - 1 ; Codes Deleted: Category - 0 , Status - 0 ; Codes Modified: Category - 0 , Status - 1. The new status code is: "684 - Rejected. Syntax error noted for this claim/service/inquiry." The modified status code is: "145 - Entity's specialty code. This change to be effective 4/1/2008: Entity's specialty/taxonomy code."

Modifications in Support of ANSI (HIPAA) IG Compliance

Official UB-04 Data Specifications Manual Version 2.00 Clarifications/Errata/Updates

ª Restored the original description for Patient Discharge Status code "05 - Discharged/transferred to another type of institution not defined elsewhere in this code list". Also deleted the replacement Patient Discharge Status code "70" and the modified the edit added to enforce the effective date for this new code to reflect the delayed effective date 4/1/2008. Modified the fixed lookup lists on this Institutional claim form field to reflect these changes, which have been rescheduled for implementation on 4/1/2008.

ª Modified the description for Patient Discharge Status code "03" to read "Discharged/transferred to SNF with Medicare cert in anticipation of skilled care".

ª Modified the Institutional Claim Import Module to import National Drug Code (NDC) information from the Revenue Code Description (FL43) field on UB-04 print-image files. The printed NDC Code and Units/Type values must follow the format defined by NUBC in order for the import module to handle this information correctly. Refer to the official UB-04 manual available from NUBC for details on the expected format.

National Provider Identifier (NPI) – Stage 3 Implementation Update

ª Added the new "NPI Exempt" indicator field to the "Diagnosis/Procedure" tab of the Institutional claim form. This field specifies whether or not the claim is subject to National Provider Identifier (NPI) reporting requirements. Users may enter a value of "Y" in this field to bypass NPI requirement edits only when appropriate.

PC-ACE Pro32 Report Manager

ª Enhanced the PC-ACE Pro32 Report Manager to add the new preference option “Display the standard print dialog when printing from the report previewer”. This option is disabled by

default. Access to the print dialog while previewing a report can be useful if it’s common to print only a subset of the report’s pages. Note: The Report Manager may not be available on all PC-ACE Pro32 installations.

CORRECTIONS TO CUSTOMER REPORTED PROBLEMS

Annual ICD-9 Update – New Detailed Codes

ª Added a termination date of 9/30/2007, which was inadvertently omitted from 17 diagnosis and 4 procedure codes in the annual ICD-9 update included in the October 2007 release. These are all codes where the less-detailed code was terminated and replaced by more detailed codes. The new detailed codes were added correctly in each case. The impacted diagnosis codes are: 2333, 2554, 2580, 2848, 3592, 3648, 3892, 6240, 7872, 7895, 9993, V174, V181, V264, V268, V680 and V848. The impacted procedure codes are: 323, 324, 325 and 8458.

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.