Release Newsletter
Version 2.25
January 2011
Institutional Change Summary
We are pleased to announce
the release of PC-ACE Pro32 version 2.25.
This upgrade contains several CMS Medicare Mandates and product enhancements
effective 1/1/2011, including these highlighted changes:
¨ 2011 HCPCS
Annual Update Reminder – Updated
HCPCS file: 363 added; 236 deleted, and 565 modified.
¨ Update to
Medicare Deductible, Coinsurance and Premium Rates for CY 2011 – Updated Institutional claim edits to support
the new 2011 rates
¨ Support of the Version 5010 Errata (June
2010) of the ANSI Transactions: 837, 835
and 999 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
version 005010 errata (June 2010) transactions. A complete list of product
changes will be made available to distributors in a separate document to
facilitate Version 5010 errata testing activities.
ENCLOSED MATERIALS
· Pre-built PC-ACE Pro32 2.25 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers
·
This Newsletter
CMS
MEDICARE MANDATES
CR7224 – Update to Medicare Deductible, Coinsurance
and Premium Rates for CY 2011
ª Added three new Institutional claim edits to enforce the Medicare Deductible and Coinsurance amounts for Calendar Year 2011.
CR7227
– 2011 HCPCS Annual Update Reminder
ª Replaced the HCPCS file with the annual 2011 update
for claims processed on or after January 1, 2011. HCPCS Changes:
236 deleted; 363 added; 565 modified. Modifier Changes: 0 deleted; 8 added; 2 modified.
CR7024
- 5010 Implementation Changes to Present on Admission Indicator (POA)
"1" and the "K3" Segment
ª Added a "POA Exempt" field to the ICD-9 reference file's diagnosis code screen. This new indicator will be used to enforce POA reporting requirements for specific diagnosis codes. Populated this field in the standard ICD-9 reference file using the table data provided in this change request. Added and/or modified institutional claim edits to enforce POA reporting exemptions based on this reference file indicator.
ª Added and/or modified institutional claim edits to prohibit POA reporting for exempt ICD-9 diagnosis codes.
ª Confirmed that the institutional claim prepare module already suppresses POA indicator "1" on claims prepared in 5010 format
ª Confirmed that the institutional claim print module already suppresses POA indicator "1" on paper UB-04 printed claims
ª Confirmed that the institutional claim prepare module already suppresses POA reporting in the K3 segment for claims prepared in 5010 format.
CR7059
- HIPAA 005010 837 Institutional (837i) Edits and 00501 837 Professional (837p)
Edits - January 2011 Version
ª Implement version 5010 institutional claim and reference file edits where appropriate
CR7064
- ESRD PPS and Consolidated Billing for Limited Part B Services
ª Added an Institutional claim edit, which prohibits reporting of Revenue Code 0880 on Medicare claims (TOB = 72x; eff 1/1/2011)
ADDITIONAL
CMS MANDATED CHANGES
CR7019 - Revised Instructions for Reporting
Assessment Dates under the Inpatient Rehabilitation Facility (IRF), SNF, and
Swing Bed (SB) PPS
The following changes
are effective for claims with service dates on or after 1/1/2011:
ª Modified several
existing Institutional claim edits and added new edits as needed to implement
the Assessment Date reporting change for IRF PPS, SNF and SB PPS claims. All
previous requirement and validation edits pertaining to the line-level
Service/Assessment Date field have been rewritten to apply to the new
Occurrence Code 50 (Assessment Date).
ª Added an
institutional claim edit to require Occurrence Code 50 to be reported on all IRF
PPS claims (TOB = 11x).
ª Added an
institutional claim edit to require Occurrence Code 50 to be reported for
Revenue Code 0022 service lines on SNF and SB PPS claims (TOBs = 21x, 18x).
This requirement is bypassed for HIPPS rate codes AAAxx (where 'xx' is varying
digits).
ª Modified an
institutional claim edit to no longer require Revenue Code 0022 service lines
to have a line item date of service present.
ª Modified the Institutional Claim Import Module, the Institutional
Claim Prepare Module, and the Institutional ANSI-837 Translator to support this
change.
CR7111 - October 2010 Integrated Outpatient Code
Editor (I/OCE) Specifications Version 11.3
ª Added, deleted
and terminated ICD-9 diagnosis codes as listed in change request. These changes
were included in the annual ICD-9 update.
ª Added the
following HCPCS codes effective 4/1/2010:
·
C8931 - MRA, W/DYE,
SPINAL CANAL
·
C8932 - MRA, W/O DYE,
SPINAL CANAL
·
C8933 - MRA,
W/O&W/DYE, SPINAL CANAL
·
C8934 - MRA, W/DYE,
UPPER EXTREMITY
·
C8935 - MRA, W/O DYE,
·
C8936 - MRA,
W/O&W/DYE,
ª Added the
following HCPCS codes effective 7/1/2010:
·
C9801 - SMOKE/TOBACCO
ASYMP 3-10
·
C9802 - SMOKE/TOBACCO
ASYMP >10
ª Added the
following HCPCS codes effective 10/1/2010:
·
C1749 - ENDO,
·
C9269 - C-1 ESTERASE,
BERINERT
·
C9270 - GAMMAPLEX IVIG
·
C9271 - VELAGLUCERASE
ALFA
·
C9272 - INJ, DENOSUMAB
·
C9273 - SIPULEUCEL-T,
PER INFUSION
·
Q5010 - HOSPICE HOME
CARE IN HOSPICE
·
S0148 - PEG INTERFERON
ALFA-2B/10
·
S0169 - CALCITROL
ª Terminated HCPCS
codes S0146, S0161 and S0196 effective 10/1/2010
ª Modified the
description for HCPCS code G0435 from "ORAL HIV-1/HIV-2 SCREEN" to
"RAPID IMMUNOASSAY HIV-1,2"
CR7158 - Claim Status Category and Claim Status
Codes Update
ª Updated the Claim
Status Response Codes reference file with the latest WPC published code
set. Category Codes Added: 0 ; Status Codes Added:
10; Codes Deleted/Terminated: 0 ; Status Codes Modified: 121. The new
status codes are: "743 - Entity's credential/enrollment information. Note: This code requires use of an
Entity Code.", "744 - Services/charges related to the treatment of a
hospital-acquired condition or preventable medical error.", "745 -
Identifier Qualifier Note: At least one other status code is required to identify
the specific identifier qualifier in error.", "746 - Duplicate
Submission Note: use only at the information receiver level in the Health Care
Claim Acknowledgement transaction.", "747 - Hospice Employee
Indicator", "748 - Corrected Data Note: Requires a second status code
to identify the corrected data.", "749 - Date of
Injury/Illness", "750 - Invalid Auto Accident State or Province
Code", "751 - Invalid Ambulance Pick-up State or Province Code"
and "752 - Invalid Ambulance Drop-off State or Province Code". The
modified status codes are: 16 - 19, 23 - 26, 59, 60, 73, 85, 88 - 94, 96, 97,
106, 109, 114, 123 - 150, 153, 155, 157 - 168, 170 , 173 - 176, 182, 183, 220,
279, 288, 294, 318, 321, 322, 358 - 360, 363, 380, 383, 386, 387, 395, 414,
431, 466, 467, 470, 478, 480, 487, 491, 496, 499 - 506, 514, 560 - 563, 589,
633, 635, 663, 676, 677, 680, 689 and 695.
CR7159 - 2011 Annual Update of HCPCS Codes for
Skilled Nursing Facility (SNF) CB Update
ª Implemented
HCPCS code changes per the SNF/CB annual HCPCS code update (when available)
CR7133- Counseling to Prevent Tobacco Use
ª Added new HCPCS
codes effective 1/1/2011:
·
G0436 - TOBACCO-USE
COUNSEL 3-10 MIN
·
G0437 - TOBACCO-USE
COUNSEL >10 MIN
ª Modified the
existing temporary HCPCS codes C9801 and C9802 to add a 12/31/2010 termination
date
ª Added an
Institutional edit to ensure that the TOB = 12x, 13x, 22x, 23x, 34x, 71x, 77x,
or 85x if HCPCS codes G0436 or G0437 is present on the claim
CR7100 – Revenue Code Updates
ª Added an
Institutional claim edit prohibiting the use of Revenue Codes 0860 or 0861 on
any type of bills other than 11x, 13x, or 85x
CR7185 – Annual Type of Service (TOS) Update
ª New Codes added
with the annual HCPCS update (January 2011 QR)
CR7142 - Clarification of Payment Window for
Outpatient Services Treated as Inpatient Services
ª Added a new
Condition Code, 51, effective 6.25.2010
·
51 - ATTESTATION OF
UNRELATED OUTPATIENT NONDIAGNOSTIC SERVICES
ª Added a non-fatal
Institutional claim edit, which prohibits reporting of the new Condition Code
51 on claims with service dates prior to 6/25/2010
ª Added a
non-fatal Institutional claim edit, which prohibits use of Condition Code 51
prior to 4/1/2011 (transmit date)
CR7144 - National Uniform Billing Committee (NUBC)
Point of Origin Code Updates
ª Modified an
existing institutional claim edit which requires the Point of Origin (Admit
Source) to be reported on outpatient claims such that TOB = 14x is no longer
included in this requirement effective 4/1/2011
ª Modified an
existing institutional claim edit which prohibits reporting of Point of Origin
(Admit Source) value '9 - Information Not Available' on outpatient claims such
that it is no longer enforced for claim service dates on or after 4/1/2011
NUBC Conference
Call Minutes (Source: August 2010)
ª Modified the
description for Point of Origin (Admit Source) code “F” to read “TRANSFER FROM
A HOSPICE FACILITY”
CR7181 - January 2011 Quarterly Update for DEMPOS
Competitive Bidding Program
ª Added new codes
with the Annual HCPCS update, effective 1/1/2011
·
E2622 - ADJ SKIN PRO
W/C CUS WD<22IN
·
E2623 - ADJ SKIN PRO
WC CUS WD>=22IN
·
E2624 - ADJ SKIN
PRO/POS CUS<22IN
·
E2625 - ADJ SKIN
PRO/POS WC CUS>=22
ª Terminated the
following codes effective 1/1/2011 with the Annual HCPCS update: K0734, K0735,
K0736, K0737
CR7170 - Correct Reporting of Modifiers and Revenue
Codes on Claims for Therapy Services
ª Added a new
Institutional claim edit prohibiting more than one occurrence of the modifiers
GN, GO or GP on the same service line (effective 4/1/2011).
CR7234 - New HCPCS Q-Codes for 2010-2011 Seasonal
Influenza Vaccines
ª Added new
influenza Vaccine HCPCS codes effective 10/1/2010:
·
Q2035 - Afluria vacc,
3 yrs & >, im
·
Q2036 - Flulaval vacc,
3 yrs & >, im
·
Q2037 - Fluvirin vacc,
3 yrs & >, im
·
Q2038 - Fluzone vacc,
3 yrs & >, im
·
Q2039 - NOS flu vacc,
3 yrs & >, im
ª Added an
Institutional claim edit which prohibits transmission of these new Vaccine
codes prior to 1/1/2011
ª Modified several
existing Institutional claim edits to replace Vaccine HCPCS code 90658 with new
HCPCS codes Q2035, Q2036, Q2037, Q2038, and Q2039.
ª Added an
institutional claim edit which terminates Vaccine HCPCS code 90658 for Medicare
claims effective 1/1/2011.
CR7248 - CY 2011 Fee Schedule Update for Durable
Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
ª Codes added with
the HCPCS file annual update, see CR 6991
CR6777 - Billing
and Processing Claims with Unlimited Occurrence Span Codes (OSCs)
ª Added two
additional Occurrence Span Code/Date field sets to the institutional claim
form's "Ext. General (2)" tab. This brings the total Occurrence Span
Codes supported per claim to ten (10), which permits unlimited OSC billing as
described in this change request.
ª Modified the
Institutional Claim Import Module, the Institutional Claim Prepare Module, and
the Institutional ANSI-837 Translator as needed to accommodate this enhancement
CR7038 - Affordable
Care Act (ACA) Mandated Collection of Federally Qualified Health Center (FQHC)
Data and Updates to Preventive Services Provided by FQHCs
Made
several modifications in anticipation of the FQHC prospective payment system. The changes
include:
ª Added an
institutional claim edit requiring a valid HCPCS code on all service lines for
TOB = 77x claims with service dates on or after 1/1/2011. Only service lines
with Revenue Codes 025x are exempt from HCPCS
reporting
ª Modified the
Revenue Code reference file to enforce the requirement that all valid Revenue
Codes except for 002x, 024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x,
067x-072x, 080x-088x, 093x, or 096x-310x are now allowed on TOB = 77x claims
with service dates on or after 1/1/2011
ª Modified an
existing institutional claim edit which enforces Revenue Code restrictions for
TOB = 77x such that it expires effective 1/1/2011. These restrictions will now
be enforced by the Revenue Code reference file settings
CR7087 - National
Modifier and Condition Code to Identify Items or Services Related to the 2010
Oil Spill in the Gulf of Mexico
ª Added a new HCPCS modifier "CS - GULF OIL SPILL
2010 RELATED" and Condition Code "BP - GULF OIL SPILL OF 2010"
for use in billing claims related to the Gulf oil spill of 2010. Both new codes
are effective for service dates on or after 4/20/2010
ª Added an institutional claim edit to enforce the
4/20/2010 effective date for the new "BP" condition code
Claim Adjustment Reason Codes Update (Source: WPC)
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: 6. The new
code is: "W2 - Payment reduced or denied based on workers' compensation
jurisdictional regulations or payment policies, use only if no other code is
applicable.". The modified codes are: 191, 214, 218, 219, 221 and W1.
Remittance Advice Remark Codes Update (Source: WPC)
ª Updated the
Remittance Remarks Codes reference file with the latest WPC published code set.
Codes Added: 2 ; Codes Deleted/Terminated: 0 ; Codes
Modified: 2. The new codes are: "N540 - Payment adjusted based on the
interrupted stay policy.|Payment adjusted based on the interrupted stay
policy." and "N541 - Mismatch between the submitted insurance type
code and the information stored in our system.|Mismatch between the submitted
insurance type code and the information stored in our system." The
modified codes are: M25 and N291.
MODIFICATIONS
IN SUPPORT OF ANSI (HIPAA) IG COMPLIANCE
Added Support for
Version 5010 Errata (June 2010) ANSI Transactions for In-house
– 837, 835, and 999
ª Support for
Version 5010 Errata (June 2010) ANSI Transactions Enhanced PC-ACE Pro32 to
support changes mandated by the June 2010 errata of the Institutional ANSI-837Health
Care Claim Implementation Guide (ASC X12N/005010X223A2), the ANSI-835 Health
Care Claim Payment/Advice Implementation Guide (ASC X12N/005010X221A1) and the
ANSI-999 Implementation Acknowledgment Implementation Guide (ASC
X12N/005010X231A1). 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, and should experience no impact from these errata
changes.
ANSI-835
Remittance Processors (ETRA) Version 5010 Errata (June 2010)
ª Enhanced the
ANSI-835 Remittance Processors (ETRA) to add support for the version 5010
errata (June 2010). Providers should experience no impact to current 4010A1
processing from these 5010 errata changes.
ANSI-999 Report
Utility Version 5010 Errata (June 2010)
ª Enhanced the
ANSI-999 Report Utility to add support for the version 005010 errata (June
2010). Providers should experience no impact to current 4010A1 processing from
these 5010 errata changes.
GENERAL
PRODUCT ENHANCEMENTS
Institutional
Claim Form Change – Length of Units Field
ª Modified the
Institutional claim form to add a tenths decimal position to the service line
Units field. This change was made in anticipation of pending CMS
mandates which will require reporting Units values to the tenths position.
Additional modifications were made to the core program module, system-level
edits, the Institutional Claim Import Module, the Institutional Claim Prepare
Module, the Institutional ANSI-837 Translator and the Institutional Claim Print
Module to accommodate this format change.
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.