Release Newsletter

Version 2.18

January 2010

Institutional Change Summary

We are pleased to announce the release of PC-ACE Pro32 version 2.18. This upgrade contains several CMS Medicare Mandates and product enhancements effective 1/1/2010, including these highlighted changes:

¨ HCPCS Annual Update Reminder – Replaced the HCPCS file with the annual 2010 update applicable to claims with service dates on or after January 1, 2010.

ENCLOSED MATERIALS

¨ Pre-built PC-ACE Pro32 2.18 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers

¨ This Newsletter

CMS MEDICARE MANDATES

CR 6620 – 2010 HCPCS Annual Update Reminder

ª Replaced the HCPCS file with the annual 2010 update for claims processed on or after January 1, 2010. HCPCS Changes: 465 deleted; 332 added; 378 modified. Modifier Changes: 3 deleted; 12 added; 1 modified.

ADDITIONAL CMS MANDATED CHANGES

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

CR 6632 – FDG PET for Solid Tumors and Myeloma

ª Added an institutional claim edit requiring that PET Modifier 'PI' or 'PS' be present with PET/PET/CT CPT code (78608, 78811, 78812, 78813, 78814, 78815,78816) on claims with service dates on or after 4/3/2009.

CR6676 - Implementation of the Updated HIPAA 00510 837 Institutional (837i) Edits and 005010 837 Professional (837p) Edits

ª SDI will implement 005010 claim edits to insure implementation guide compliance, and will review and implement Medicare business edits where practical and beneficial to the provider community.

CR 6575 – Version 005010 Inbound 837 Institutional (837I) and Inbound 837 Professional (837P) Flat Files Implementation

ª Implemented version 5010 institutional claim and reference file edits where appropriate

CR 6563 – Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)

ª Added new modifier, GX - NOTICE OF LIABILITY, VOLNTRY

ª Added an Institutional edit to not allow the GX modifier on a line item whereby there is a covered charge reported

ª Added an Institutional edit prohibiting the use of Modifier GX on the same line item as a liability-related modifier: EY, GA, GL, GZ, KB, QL, and TQ

ª Modified the description of "GA" from "WAIVER OF LIABILITY ON FILE" to "WAIVER OF LIABILITY ISSUED".

CR6690 – Update to Medicare Deductible, Coinsurance and Premium Rates for CY 2010

ª Added three new Institutional claim edits to enforce the Medicare Deductible and Coinsurance amounts for Calendar Year 2010.

MODIFICATIONS IN SUPPORT OF ANSI (HIPAA) IG COMPLIANCE

ANSI-276/277 Health Care Claim Status Request and Response Enhancement (if applicable)

ª Enhanced PC-ACE Pro32 to support changes mandated by the new ANSI-276/277 Health Care Claim Status Request and Response Implementation Guide (ASC X12N/005010X212) and Dental ANSI-277CA Health Care Claim Acknowledgment Implementation Guide (ASC X12N/005010X214). 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.

Category II Code Update (Source: AMA Website)

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

· 1200F - SEIZURE TYPE(S)+ FRQ DOCD

· 1205F - EPI ETIOL SYND RVWD AND DOCD

· 3038F - PULM FX W/IN 12 MON B/4 SURG

· 3323F - CLIN NODE STGNG DOCDB/4 SURG

· 3324F - MRI CT SCAN RD RVWD RQSTD

· 3328F - PRFRMNC DOCD 2 WKS B/4 SURG

· 3650F - EEG ORDERED RVWD REQSTD

· 4255F - ANESTH>=60 MIN AS DOCD

· 4256F - ANESTH < 60 MIN AS DOCD

· 4330F - CNSLNG EPI SPEC SFTY ISSUES

· 4340F - CNSLNG CHLDBRNG+ WOMEN EPI

· 5200F - EVAL APPROS SURG THXPY EPI

· 6070F - PT ASKED/CNSLD AED EFFECTS

H1N1 Information (Source: AMA Website)

ª Added new HCPCS code "90470 - IMMUNE ADMIN INTRA, H1N1" (eff 9/29/2009)

ª Modified the description for HCPCS code 90663 to read, "FLU VACC PANDEMIC, H1N1", which reflects the H1N1 specification

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: 1 ; Codes Deleted/Terminated: 2 ; Codes Modified: 9. The new code is: '702 - Repriced Claim Reference Number". The terminated codes are: 482 and 641. The modified status codes are: 127, 195, 402, 448, 510, 511, 512, and 516. The modified category code is: D0.

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: 2 ; Codes Deleted/Terminated: 1 ; Codes Modified: 44. The new codes are: "232 - Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions." and "D23 - This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)". The terminated code is: 87. The modified codes are: 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 40, 49, 50, 51, 54, 55, 56, 58, 59, 61, 96, 97, 107, 108, 125, 148, 152, 167, 170, 171, 172, 179, 183, 184, 185, 187, 222, 226, 227, 231, A1, B7, B8 and B15.

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: 5. The new codes are: "N521 - Mismatch between the submitted provider information and the provider information stored in our system." and "N522 - Duplicate of a claim processed as a crossover claim." The modified codes are: M39, M118, N59, N130 and N202.

Provider Taxonomy Code Reference File Update

ª Changes described in this mandate were included in a previous release.

ANSI Version (837) Field Values Updated- Submitter Reference File

ª Modified the fixed list lookup and validation edit for the "ANSI Version (837)" field on the Institutional Submitter reference file record to eliminate the entry for the original "005010" version. The Addendum 1 version "005010A1" has been mandated to replace the original version.

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.