Release Newsletter

Version 2.16

October 2009

Professional Change Summary

We are pleased to announce the release of PC-ACE Pro32 version 2.16. This upgrade contains several CMS Medicare Mandates and product enhancements effective 10/1/2009, including these highlighted changes:

¨ Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-9 Annual Update – 313 new diagnosis codes; 41 new procedure codes

¨ Support for the 5010 Version of the professional ANSI Transactions - 837, 997/999, and 835 for In-House and Selected Provider Testing - PC-ACE Pro32 has been enhanced to support in-house distributor and selected provider testing of the upcoming professional version 005010 transactions. A complete list of product changes will be made available to distributors in a separate document to facilitate 5010 testing activities.

ENCLOSED MATERIALS

¨ Pre-built PC-ACE Pro32 2.16 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers

¨ This Newsletter

CMS MEDICARE MANDATES

CR 6520 – 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 2009 release. This update includes 313 new diagnosis codes, 41 new procedure codes, 68 modified diagnosis codes, and 14 modified procedure codes.

CR 6475 – Implementation of HIPAA Version 005010 837 Professional (837p) Edits

ª Implemented version 5010 Professional claim and reference file edits where appropriate.

ADDITIONAL CMS MANDATED CHANGES

CR 6525 – Claim Status Category Code and Claim Status Code Update

ª Updated the Claim Status Response Codes reference file with the latest WPC published code set. Codes Added: 0; Codes Deleted/Terminated: 0; Codes Modified: 2. The new codes are: "697 - Invalid Decimal Precision", "698 - Form Type Identification", "699 - Question/Response from Supporting Documentation Form", "700 - ICD10" and "701 - Initial Treatment Date". The modified codes are: 486 and 508.

CR 6431 – Billing Routine Cost of Clinical Trials

ª Modified a professional claim added in the July 2009 release per Transmittal 1721 requiring that diagnosis Code V70.7 be present when HCPCS modifiers 'Q1' or 'QV' are present on Medicare claims with service dates on or after 1/1/2008 such that it is now effective for claims processed on or after 9/28/2009. Previously, this edit was effective 7/10/2009.

CR 6034 – Implementation of New Version 835 Transaction

ª SDI will implement changes to support 5010 requirements over a period of several quarters beginning in the Q2 2009

CR 6480 – July 2009 I/OCE Specifications Version 10.2

Made the following changes to recently added HCPCS modifiers:

ª Changed the effective date on modifiers "PA - SURGERY, WRONG BODY PART", "PB - SURGERY, WRONG PATIENT", and "PC - WRONG SURGERY ON PATIENT" from 7/1/2009 to 1/1/2009

ª Changed the effective date on modifiers "PI - PET TUMOR INIT TX STRAT" and "PS - PET TUMOR SUBSQ TX STRATEGY" from 7/1/2009 to 4/1/2009

ª Deleted the "K8" modifier

CR6626 - October 2009 Update of the Hospital Outpatient PPS

ª Added new HCPCS codes effective 9/1/2009:

· G9141 - INFLUENZA A (H1N1) IMZ ADMIN

· G9142 - INFLUENZA A (H1N1) VACCINE

CR6589 - Implementation of HIPAA Version 5010 for Transaction 835 - Health Care Claim Payment/Advice and Updated Standard Paper Remit (SPR)

ª SDI will implement changes to support 5010 requirements over a period of several quarters beginning in the Q2 2009

Other HCPCS Codes – October 2009 (Source: CMS Website)

ª Added the following HCPCS codes (effective 10/1/2009):

· Q2024 - BEVACIZUMAB INJECTION

· S3713 - KRAS MUTATION ANALYSIS

ª Terminated HCPCS code, S0162, effective 9/30/2009

MODIFICATIONS IN SUPPORT OF ANSI (HIPAA) IG COMPLIANCE

Support for 5010 ANSI Transactions Enhanced PC-ACE Pro32

Support for 5010 ANSI Transactions Enhanced PC-ACE Pro32 to support changes mandated by the new Professional ANSI-837 Health Care Claim Implementation Guide (ASC X12N/005010X222) and Dental ANSI-837 Health Care Claim Implementation Guide (ASC X12N/005010X224). This new functionality is limited to in-house distributor and selected provider testing during the transition from the 4010A1 release to the 5010 release. Providers will continue to use PC-ACE Pro32 normally to produce 4010A1 output files. The design changes for 5010 were made with the goal of minimizing the impact on users during the transition period. The following 5010 related changes are relevant to providers using this PC-ACE Pro32 release:

ª The discrete payer-level and line-level Reference Identification / Type control sets have been replaced by scrolling array control sets which allow an unlimited number of ID/Type pairs to be entered as needed.

ª The obsolete service line Type of Service (TOS) field has been replaced with the "24c – EMG" emergency indicator field. This change is consistent with the enhanced CMS-1500 claim form layout, and has the added benefit of preserving the tab count for hand-keyed claims. Also removed the "TOS" (Type of Service) button located on the Misc tab of the Reference File Maintenance screen.

ª Several of the less frequently used line-level fields have been repositioned on the various extended service line sub tabs.

ª The line-level Purchased Service provider name and identification fields have been repositioned and are located with the other line-level supporting providers.

ª Most of the legacy payer-level and line-level COB-related numeric fields have been removed (e.g., "Paid", "Deductible", "Coinsurance"). These fields existed solely to facilitate NSF output file production (no longer supported). Users will now be required to enter these amounts using the appropriate AMT or CAS type codes (e.g., CAS PR*1 = deductible ; AMT D = paid).

ª The payer-level "Insurance Type" field has been removed from the Common Payer MSP Information control group located on the payer-level COB Info (Primary) and COB Info (Secondary) sub tabs. The special Medicare Secondary Insurance Type code is now reported in the standard payer-level "Insurance Type" field located on the professional claim form's Ext. Payer/Insured tab. This code should now be reported on the Medicare (MCB) payer line. Edits will prompt for this special insurance type code when expected.

ª Removed the document indicator, type, sent date and attachment control number fields from the Ext. Patient/General tab. This information must now be reported using the "Claim Supplemental Information (PWK)" fields on the Ext. Pat/Gen (2) tab. The document sent date is no longer required. Note: When reporting a Certificate of Medical Necessity (CMN) attachment, it is not necessary to explicitly enter the "CT – Certification" document reporting entry. The required line-level PWK*CT*AD~ segment is generated automatically by the program.

ª The line-level Narrative memo field has been removed from the Extended Details (Line NN) sub tab. Line-level narrative text must now be reported using the "Line Notes (NTE) / File Information (K3)" fields on the Ext Details 3 (Line NN) sub tab. Note: The hotkey "<ALT>N" is still available to jump directly to the Line Notes controls when keying service line information. After entering a single Line Note type code and narrative, a subsequent tab will return the user to the previous service line field.

ª Added support for reporting the Clinical Laboratory Improvement Amendment (CLIA) Number using the payer-level "Payer / Insured Reference IDs/ Types" field set on the Ext. Payer/Insured tab. This enhancement permits reporting of CLIA numbers (Type Code = "X4") without triggering the service line CLIA attachment.

ª The Care Plan Oversight (CPO) Number field has been removed from the Ext. Patient/General tab. Report the CPO Provider Number umber as one of the claim-level Service Facility reference identifiers (Type Code = "LU"). The edits will prompt for this value as it did for the discrete CPO Provider Number field in previous releases.

ª The various ANSI Version fields on the Submitter record have been widened to accept complete version and addenda specifications. A new version field has been added for dental transactions in order to allow separate version selection for professional versus dental when needed. The currently valid ANSI versions are "004010A1", "005010", and for some transactions "005010A1". The product no longer supports the original 004010 version (pre-addenda). Users are prohibited by fatal edits from selecting the 5010 options at this time (requires activation as described above).

ª Numerous new fields have been added to the Professional Claim Form in order to support the 5010 release. While the 4010A1 version is still the standard, these fields should simply be ignored by users. The existence of these additional fields should not complicate the user's ability to bill claims.

New claim-level fields include:

§ Diagnosis Codes 9 thru 12

§ Anesthesia Procedure Codes (2 available)

§ Condition Codes (12 available)

§ Date Last Worked

§ Prescription Date (Hearing & Vision claims)

§ First Contact Date (Property & Casualty claims)

§ Service Facility Contact Name / Phone / Ext.

§ Referring Provider Name / Identifiers (second "P3" occurrence)

§ Supervising Provider Name / Identifiers

§ Assistant Surgeon Name / Identifiers (dental)

New payer-level fields include:

§ Insured's Contact Name & Phone Ext. (Property & Casualty claims)

New line-level fields include:

§ Co-Pay Status

§ Shipped Date

§ Initial Treatment Date

§ Sales Tax

§ Postage Claim (Postage Claimed Amount)

§ Procedure Code Type / Description

§ Obstetric Anesthesia Additional Units

§ Drug Ref. No. Type

§ Drug Prescription Date

§ Rendering Provider Identifiers (payer-specific only)

§ Referring Provider Name / Identifiers (second "P3" occurrence)

§ Assistant Surgeon Name / Identifiers (dental)

§ Ordering Provider Address Information (for non-CMN use)

§ Line Supplemental Information (PWK)

§ Line Note (NTE) / File Information (K3)

§ Patient Count (on Ambulance attachment)

§ Ambulance Pick-Up Location (on Ambulance attachment)

§ Ambulance Drop-Off Location (on Ambulance attachment)

§ Prior Placement Date: Estimated (on Dental attachment)

§ Treatment Period Start / End Dates (on Dental attachment)

§ Remaining Owed (for COB use)

ª New codes have been added, and existing codes deleted, from numerous indicator and qualifier type fields throughout the product. These changes are reflected in the various lookup lists, with notations like "(4010 only)" added where appropriate. Users will eventually need to be educated on these change where applicable. Code enforcement is performed by system edits based on the ANSI version established in the Submitter reference file. This prevents users from inadvertently selecting 5010-only codes on a claim to be prepare in 4010A1 format.

ª Numerous legacy fields have been removed from the Professional Claim Form, the Patient Information form, the Payer Information form, the Professional Provider Information form and the Professional Submitter Information form. The information held in these obsolete fields was not used in the production of ANSI/X12 compliant output files.

Category I Code Update – Vaccine (Source: AMA Website)

ª Added new HCPCS code, effective 1/1/2010:

· 90644 - HIB/MEN/TT VACCINE, IM

Category II Code Update (Source: AMA Website)

ª Added new HCPCS codes, effective 1/1/2010:

· 0545F - FOLLOWUP CARE PLAN MDD DOCD

· 2060F - PT TALK EVAL HLTHWKR RE MDD

· 3008F - BODY MASS INDEX DOCD

· 3015F - CERV CANCER SCREEN DOCD

· 3293F - ABO RH BLOOD TYPING DOCD

· 3294F - GRP B STREP SCREENING DOCD

· 4004F - PT TOBACCO USE DONE RCVD TLK

· 4063F - ANTIDEPRES RXTHXPY NOT RXD

Category III Code Update (Source: AMA Website)

ª Added new HCPCS codes, effective 1/1/2010:

· 0203T - UNATTEND SLEEP STUDY W/TIME

· 0204T - UNATTENDED SLEEP STUDY

· 0205T - INIRS EACH VESSEL ADD-ON

· 0206T - REMOTE ALGORITHM ANALYS ECG

· 0207T - CLEAR EYELID GLAND W/HEAT0208T - AUTOMATED AUDIOMETRY AIR

· 0209T - AUTO AUDIOMETRY AIR/BONE

· 0210T - AUTO AUDIOMETRY SP THRESH

· 0211T - AUTO AUDIOMETRY SP RECOG

· 0212T - COMPREHEN AUTO AUDIOMETRY

· 0213T - US FACET JT INJ CERV/T 1 LEV

· 0214T - US FACET NJ INJ CERV/T 2 LEV

· 0215T - US FACET JT INJ CERV/T 3 LEV

· 0216T - US FACET JT INJ LS 1 LEVEL

· 0217T - US FACET NJ INJ LS 2 LEVEL

· 0218T - US FACET JT INJ LS 3 LEVEL

· 0219T - FUSE SPINE FACET JT CERV

· 0220T - FUSE SPINE FACET JT THOR

· 0221T - FUSE SPINE FACET JT LUMBAR

· 0222T - FUSE SPINE FACET JT ADD SEG

Claim Status Response Codes Reference File Update

ª Updated the Claim Status Response Codes reference file with the latest WPC published code set. Codes Added: 0; Codes Deleted/Terminated: 0; Codes Modified: 6. The modified codes are: 694, 697, 698, 699, 700 and 701.

Claim Adjustment Reason Code Reference File Update

ª Updated the Claim Adjustment Reason Codes reference file with the latest WPC published code set. Codes Added: 1 ; Codes Deleted/Terminated: 0 ; Codes Modified: 9. The new code is: "231 - Mutually exclusive procedures cannot be done in the same day/setting." The modified codes are: 40, 50, 54, 55, 56, 58, 59, 90, and 148.

Remittance Remarks Codes Reference File Update

ª Updated the Remittance Remarks Codes reference file with the latest WPC published code set. Codes Added: 2; Codes Deleted/Terminated: 0; Codes Modified: 0. The new codes are: "519 - Invalid combination of HCPCS modifiers." and "520 - Alert: Payment made from a Consumer Spending Account."

Provider Taxonomy Code Reference File Update

ª Updated the Provider Taxonomy Code reference file with the latest WPC published code set. Codes Added: 4; Codes Deleted/Terminated: 0; Codes Modified: 4. The new codes are: "74H00000X - Other Service Providers: Health Educator", "2080C0008X - Allopathic & Osteopathic Physicians: Pediatrics: Child Abuse Pediatrics", "374J00000X - Nursing Service Related Providers: Doula" and "374K00000X - Nursing Service Related Providers: Religious Nonmedical Practitioner". The modified codes are: 111NX0100X, 287300000X, 317400000X and 374T00000X.

CORRECTIONS TO CUSTOMER REPORTED PROBLEMS

Bypass Effective/Terminate Date Edit for Special Ambulance Modifiers

ª Modified several Institutional claim edits, which enforce HCPCS Modifier effective and termination dates such that they are bypassed when an Ambulance HCPCS code is present on the service line. This change is necessary to prevent these edits from triggering inappropriately on the special Ambulance origin/destination modifiers. The list of Ambulance related HCPCS codes which trigger this edit bypass are as follows: A0xxx, Q3019, Q3020, S0208, S0215, T2001, T2002, T2003, T2004, T2005, and T2007.

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.

ATTENTION USERS:

Numerous database structural changes have been made in this release in support of the upcoming ANSI version 005010implementation. The database update phase of the quarterly update process may take significantly longer than usual to complete. This is especially true for sites with a large number of claims in the database or numerous claim archives. Please be patient and allow the update to complete. It is important that you do NOT interrupt the update process. Doing so may render your databases unusable. While it is always recommended that you perform a safety backup prior to applying any update, that recommendation is especially relevant this quarter. Note: Do not restore the safety backup after successfully applying the program update. Doing so will render your installation unusable. The update program preserves all claim and reference file data. The safety backup is an insurance policy, which is only to be used in the event the update is unsuccessful.