Release Newsletter
Version 1.92
April 2008
Professional
Change Summary
We are pleased to announce the release of PC-ACE Pro32
version 1.92. This upgrade contains
several CMS Medicare Mandates and product enhancements effective 4/1/2008,
including these highlighted changes:
¨ New HCPCS Modifiers When Billing Patient Care in Clinical Research – Edits implemented to support new clinical service Modifiers
¨ CR5790 – 8-Digit Clinical Trial Number - Several changes made in support of the 8-digit Clinical Trial Number
ENCLOSED
Materials
¨ Pre-built PC-ACE Pro32 1.92 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers
¨ This
Newsletter
CMS
Medicare Mandates
CR5805 – New HCPCS Modifiers When
Billing Patient Care in Clinical Research Studies
ª Modified several
Professional claim edits to allow reporting of the new clinical service
Modifiers Q0 and Q1, which replace QA, QR and QV effective 1/1/2008
CR5699 – Reporting of Hematocrit
and/or Hemoglobin Levels on All Claims for Administration of Erythropoiesis
Stimulating Agents (ESAs) for Non-ESRD Indications and Implementation of New
Modifiers for Non-ESRD Indications
Made several Professional claim edit changes to
enforce new ESA billing requirements.
Specific change include:
ª
Added a new
Professional claim edit requiring that anemia quality Modifier EA, EB or EC
always be billed with non-ESRD ESAHCPCS codes J0881 or J0885 (effective
1/1/2008)
ª
Added
several Professional claim edits which prohibit reporting of more than one of
the anemia quality Modifiers EA, EB or EC on the same service line.
Also added EPO attachment trigger entries for HCPCS codes J0881 and J0882 to the Professional Claim Attachment Trigger File to insure that the Hemaglobin or Hematocrit reading is entered. Claim attachment trigger entries for HCPCS codes J0885, J0886 and Q4081 are already present in the trigger file.
CR5936 - Correct Coding Initiative (CCI)
Quarterly Update
ª
Installed the
April 2008 quarterly Correct Coding Initiative (CCI) edit update for
Professional claims. The CMS developed the CCI edits to promote national
correct coding methodologies and to control improper coding leading to
inappropriate payment in Part B claims. The purpose of the CCI edits is to
ensure the most comprehensive groups of codes are billed rather than the
component parts. Additionally, CCI edits check for mutually exclusive code
pairs. Note: PC-ACE Pro32 distributors decide whether or not to activate CCI
edits in their builds. As such, these edits may not be available on all PC-ACE
Pro32 installations.
CR5910 –
Clarification to CR5744 – Payment Allowance Update for the Influenza Vaccine
CPT 90660 and Further Instructions Regarding the Pneumococcal Vaccine CPT 90669
ª Modified the
Professional Roster Billing module to allow HCPCS code 90669 to be billed for
Pneumococcal Vaccine (effective 1/1/2008)
ª Modified the
Professional Roster Billing module to bill administration HCPCS code G0009 with
Pneumococcal Vaccine HCPCS code 90669.
CR5926 – HCPCS
Codes Subject to and Excluded from CLIA Edits
ª Modified the
Trigger Attachment control file to include new HCPCS codes that require CLIA
number. The new codes are 80047, 82610, 83993, 84704, 86356, 87500, 87809,
88381, 89322 and 89331.
CR5771 – Reporting
of NPI and “EY” Modifier on Claims for DMEPOS Items Dispensed Without
Physician’s Order to Obtain Medicare Denial for COB
ª Added a non-fatal Professional claim edit, which
prohibits submission of Medicare claims on or after 5/23/2008 that contain both
ordered and non-ordered DMEPOS supplies on the same claim. A non-ordered
service line is identified with the "EY" modifier. This edit requires
that if any service line contains the "EY" modifier, then all service
lines on the claim must report this "no-order" modifier.
ADDITIONAL CMS Mandated CHANGES
Provider Taxonomy Code (Source: WPC)
ª Updated the Provider Taxonomy Code reference file with the latest WPC
published code set. Code Added: 5 ; Codes Deleted: 0 ; Codes Modified: 1. The
new codes are: "111NP0017X - Chiropractor : Pediatric Chiropractor",
"173C00000X - Reflexologist", "173F00000X - Sleep Specialist,
PhD", "1835P0018X - Pharmacist : Pharmacist Clinician (PhC)/ Clinical
Pharmacy Specialist", and "253J00000X - Foster Care Agency". The
modified code is: "207NS0135X - Dermatology : Procedural
Dermatology".
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 - 4 ; Codes Deleted: Category - 0 , Status - 0 ;
Codes Modified: Category - 3 , Status - 17. The new status codes are: "685
- Claim could not complete adjudication in real time. Claim will continue
processing in a batch mode. Do not resubmit.", "686 - The claim/ encounter
has completed the adjudication cycle and the entire claim has been
voided", "687 - Claim estimation can not be completed in real time.
Do not resubmit." and "688 - Present on Admission Indicator for
reported diagnosis code(s)". The modified category codes are: P2, P3 and
P4. The modified status codes are: 4, 5, 7, 9, 21, 67, 68, 71, 112, 113, 114,
115, 283, 506, 585, 670 and 671.
Modifications in
Support of ANSI (HIPAA) IG Compliance Other HCPCS Update – Source: CMS Website
ª Reinstated HCPS codes:
§
J7611
- ALBUTEROL NON-COMP CON
§
J7612
- LEVALBUTEROL NON-COMP CON
§
J7613
- ALBUTEROL NON-COMP UNIT
§
J7614
- LEVALBUTEROL NON-COMP UNIT
ª Added new HCPCS Codes
effective 4/1/2008
§
K0672
- REMOVE SOFT INTERFACE, REPL
§
Q4096
- VWF COMPLEX, NOT HUMATE-P
§
Q4097
- INJ IVIG PRIVIGEN 500 MG
§
Q4098
- INJ IRON DEXTRAN
§
S3628 - PAMG-1 RAPID ASSAY FOR ROM
Update to the Category I Codes – Source: AMA Website
ª Added new HCPCS Codes
effective 4/1/2008
§
90650
- HPV TYP BIVAL 3 DOSE IM
§
90681
- ROTAVIRUS VACC 2 DOSE ORAL
§
90696
- DTAP-IPV VACC 406 YR IM
ª Added new HCPCS Codes
effective 7/1/2008
§
90738
- INACTIVATED JE VACC IM
Update to the Category II Codes – Source: AMA Website
ª Added new HCPCS Codes
effective 1/1/2008
§
0525F
- INITIAL VISIT FOR EPISODE
§
0526F
- SUBS. VISIT FOR EPISODE
§
1130F
- BK PAIN = FXN ASSESSED
§
1134F
- EPSD BK PAIN FOR =< 6 WKS
§
1135F
- EPSD BK PAIN FOR > 6 WKS
§
1136F
- EPSD BK PAIN FOR <= 12 WKS
§
1137F
- EPSD BK PAIN FOR > 12 WKS
§
2044F
- DOC MNTL TST B/4 BK TRXMNT
§
4240F
- INSTR XRCZ 4BK PN >12 WEEKS
§
4242F
- SPRVSD XRCZ BK PN >12 WEEKS
§
4245F
- PT INSTR, RESUME NRML LIFEST
§
4248F
- PT INSTR–NO BD REST>= 4 DAYS
§
4250F
- WRMNG 4 SURG - NORMOTHERMIA
§
5060F
- FNDNGS MAMMO 2PT W/IN 3 DAYS
§
062F
- DOC F2FMAMMO FNDNG IN 3 DAYS
§
6040F
- APPRO RAD DS DVCS TECHS DOCD
§
6045F
- RADXPS IN END RPRT4FLURO PXD
§
7020F
- MAMMO ASSESS CAT IN DBASE
§
7025F
- PT INFOSYS ALARM 4 NXT MAMMO
ª Added new HCPCS Codes
effective 11/ 1/2007
§
2040F - BK PN XM ON INIT VISIT DATE
§
3330F
- IMAGING STUDY ORDERED (BKP)
§
3331F
- BK IMAGING TST NOT ORDERED
ª Added new HCPCS Codes
effective 4/1/2008
§
3340F
- MAMMO ASSESS INC XRAY DOC'D
§
3341F
- MAMMO ASSESS "NEGATIVE.", DOC'D
§
3342F
- MAMMO ASSESS "BENGN", DOC'D
§
3343F
- MAMMO PROBABLYASSESS "?" BEN
§
3344F
- MAMMO ASSESS "SUSP", DOC'D
§
3345F
- MAMMO ASSESS "HGHLYMALIG DOC"
§
3350F
- MAMMO BX PROVEN MALIG DOC'D
ª Modified the description on
numerous Category II HCPCS codes to correct mostly punctuation errors.
Update to the Category III Codes – Source: AMA Website
ª Added new HCPCS Codes
effective 7/1/2008
§
0188T
- VIDEOCONF CRIT CARE 74 MIN
§
0189T
- VIDEOCONF CRIT CARE ADDL 30
§
0190T
- PLACE INTRAOC RADIATION SRC
§
0191T
- INSERT ANT SEGMENT DRAIN INT
0192T - INSERT ANT SEGMENT DRAIN EXT
Claim Adjustment Reason Code (CARC) Reference File
Update – Source: WPC
ª Updated the
Claim Adjustment Reason Codes reference file with the latest WPC published code
set. Codes Added: 10 ; Codes Deleted/Terminated: 0 ; Codes Modified: 5. The new
codes are: "213 - Non-compliance with the physician self referral
prohibition legislation or payer policy.", "214 - Workers'
Compensation claim adjudicated as non-compensable. This Payer not liable for
claim or service/treatment. (Note: To be used for Workers' Compensation
only)", "215 - Based on subrogation of a third party settlement",
"216 - Based on the findings of a review organization", "217 -
Based on payer reasonable and customary fees. No maximum allowable defined by
legislated fee arrangement. (Note: To be used for Workers' Compensation
only)", "218 - Based on entitlement to benefits (Note: To be used for
Workers' Compensation only)", "219 - Based on extent of injury (Note:
To be used for Workers' Compensation only)", "220 - The applicable
fee schedule does not contain the billed code. Please resubmit a bill with the
appropriate fee schedule code(s) that best describe the service(s) provided and
supporting documentation if required. ...", "221 - Workers'
Compensation claim is under investigation. (Note: To be used for Workers'
Compensation only. Claim pending final resolution)" and "D22 -
Reimbursement was adjusted for the reasons to be provided in separate
correspondence. ...". The modified codes are: 85, 100, 151, 189 and 201.
Remittance Remarks Code (RARC) Reference File Update – Source: WPC
ª Updated the
Remittance Remarks Codes reference file with the latest WPC published code set.
Codes Added: 1 ; Codes Deleted: 0 ; Codes Modified: 4. The new code is :
"433 - Resubmit this claim using only your National Provider Identifier
(NPI)". The modified codes are: MA97, MA116, N174 and N421.
GENERAL PRODUCT ENHANCEMENTS
Remittance Remark Codes (RARC) Enhancement of Effective and Termination
Dates
ª Added effective/terminate
dates to the Remittance Remark Codes (RARC) reference file. Added several
non-fatal Professional claim edits to insure the RARC codes reported on
Coordination of Benefits (COB) claims were valid when adjudication took place.
This change was prompted by a change in the ANSI code sets published by
Washington Publishing Company (WPC). They are now maintaining start/stop dates
for this code set.
Taxonomy Code
Enhancement of Effective and Termination Dates
ª Added effective/terminate
dates to the Taxonomy Codes reference file. Added several non-fatal
Professional claim edits to insure the Taxonomy codes reported on the claims
were valid for the applicable service date range. This change was prompted by a
change in the ANSI code sets published by Washington Publishing Company (WPC).
They are now maintaining start/stop dates for this code set.
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.