Release Newsletter

Version 2.30

July 2011

Professional Change Summary

We are pleased to announce the release of PC-ACE Pro32 version 2.30. This upgrade contains several CMS Medicare Mandates and product enhancements effective 7/1/2011, including these highlighted changes:

¨ Support for Version 5010 Errata (June 2010) ANSI Transactions – Reminder that PC-ACE Pro32 was enhanced in the January 2011 release to support the version 005010 errata (June 2010) transactions (837, 835, 999, 270/271)

ENCLOSED MATERIALS

· Pre-built PC-ACE Pro32 2.30 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers

· This Newsletter

CMS MEDICARE MANDATES

CR7348 - 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: 1 ; Status Codes Added: 9; Status Codes Deleted/Terminated: 0 ; Status Codes Modified: 61. The new category code is: "E4 - Trading partner agreement specific requirement not met: Data correction required. (Note: A status code identifying the type of information requested must be sent)". The new status codes are: "753 - Co-pay status code.", "754 - Entity Name Suffix. Note: This code requires the use of an Entity Code.", "755 - Entity's primary identifier. Note: This code requires the use of an Entity Code.", "756 - Entity's Received Date. Note: This code requires the use of an Entity Code.", "757 - Last seen date.", "758 - Repriced approved HCPCS code.", "759 - Round trip purpose description.", "760 - Tooth status code." and "761 - Entity's referral number. Note: This code requires the use of an Entity Code." The modified status codes are: 48, 252, 254, 278, 280, 285, 289, 304, 305, 317, 355 - 357, 361, 362, 367 - 373, 376 - 379, 381, 392, 393, 399, 404, 405, 410 - 413, 415, 416, 418, 421, 422, 424 - 427, 429, 436 - 440, 444 - 447, 466, 509, 514 and 750 - 752.

CR7409 - Flat File Update for Institutional Claim Transaction 837I, Professional Claim Transaction 837P, and Claim Payment/Advice Transaction 835

ª Modified the ANSI-835 Remittance Modules (ETRA) to support an expanded S9(7)V999 format for all Adjustment Quantity (CAS04/CAS07/CAS10/CAS13/CAS16/CAS19) elements

ª Modified the impacted ANSI-835 reports to accommodate this change

ADDITIONAL CMS MANDATED CHANGES

CR7416 - July Quarterly Update for 2011 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

ª Added a professional claim edit which terminates HCPCS code E0571 for Medicare claims effective 7/1/2011

CR7445 - July 2011 Update of the Ambulatory Surgical Center (ASC) Payment System

ª Added a professional claim edit which terminates HCPCS code J7184 for Medicare claims effective 7/1/2011. Wilate infection HCPCS code Q2041 is replacing HCPCS code J7184 beginning on July 1, 2011.

Category II Code Update (Source: AMA website)

ª Added new HCPCS codes (effective 7/1/2011):

· 0550F - CYTOPTH REPORT-NONGYN SPCMN

· 0551F - CYTOPATH REPORT NON-ROUTINE

· 3125F - ESOPH BX RPRT W/DYSPL INFO

· 3267F - PATH RPRT W/PT PN CAT ET AL

· 3394F - QUANT HER2 IHC EVAL BRST CX"

· 3395F - QUANT HER2 IHC EVAL BRST CX

· 6100F - VERIFY PT SITE PXD DOCD

HCPCS Update – Other Codes (Source: CMS website)

ª Added new HCPCS codes (effective 7/1/2011):

· K0741 - PORTABLE GASEOUS OXYGEN SYS

· K0742 - PORTABLE GASEOUS OXYGEN

· K0743 - PORTABLE HOME SUCTION PUMP

· K0744 - ABSORP DRG <= 16 SUC PUMP

· K0745 - ABSORP DRG >16 <=48 SUC PUMP

· K0746 - ABSORP DRG >48 SUC PUMP

· Q2041 - WILATE INJECTION (eff 7/1/2011)

· Q2042 - HYDROXYPROGESTERONE CAPROATE

· Q2043 - SIPULEUCEL-T AUTO CD54+

· Q2044 - BELIMUMAB INJECTION

ªModified HCPCS code "J7184 - WILATE INJECTION" to change the effective date from 1/1/2011 to 7/1/2011

ªTerminated HCPCS codes "S3628 - PAMG-1 RAPID ASSAY FOR ROM" and "S9075 - SMOKING CESSATION TREATMENT" effective 7/1/2011

C-Codes HCPCS Update (Source – CMS Website)

ª Added the following HCPCS codes effective 7/1/2011:

· C9283 - INJECTION, ACETAMINOPHEN

· C9284 - INJECTION, IPILIMUMAB

· C9285 - PATCH, LIDOCAINE/TETRACAINE

· C9365 - OASIS ULTRA TRI-LAYER MATRIX

· C9406 - DX I-123 IOFLUPANE, PER DOS

· C9730 - BRONCHIAL THERMO, 1 LOBE

· C9731 - BRONCHIAL THERMO, >1 LOBE

ª Terminated the following HCPCS Codes effective 6/30/2011:

· C9273 - SIPULEUCEL-T, PER INFUSION

· C9729 - PERCUT LUMBAR LAMI

MODIFICATIONS IN SUPPORT OF ANSI (HIPAA) IG COMPLIANCE

Support for Version 5010 Errata (June 2010) ANSI Transactions

ª Reminder that PC-ACE Pro32 was enhanced in the January 2011 release to comply with changes mandated by the June 2010 errata of the Institutional ANSI-837 Health Care Claim Implementation Guide (ASC X12N/005010X223A2), the Professional ANSI-837 Health Care Claim Implementation Guide (ASC X12N/005010X222A1), the Dental ANSI-837 Health Care Claim Implementation Guide (ASC X12N/005010X224A2), the ANSI-835 Health Care Claim Payment/Advice Implementation Guide (ASC X12N/005010X221A1), the ANSI-999 Implementation Acknowledgment Implementation Guide (ASC X12N/005010X231A1) and the ANSI-270/271 Health Care Eligibility Benefit Inquiry and Response Implementation Guide (ASC X12N/005010X279A1). Providers will receive communication from their software distributor concerning version 5010 testing and production schedules.

Implementation of “Do Not Send” Instructions for ANSI-837 Transaction, version 5010A1

Modified the professional claim edits and claim prepare suppression logic to implement a more strict interpretation of the ANSI version 5010 implementation guide's "do not send" instructions. The changes include:

ª Subscriber Address (N3/2010BA) -- Added logic to suppress this segment when patient and subscriber are not the same person

ª Subscriber City, State, ZIP Code (N4/2010BA) -- Added logic to suppress this segment when patient and subscriber are not the same person

ª Subscriber Demographic Information (DMG/2010BA) -- Added logic to suppress this segment when patient and subscriber are not the same person

ª Acute Manifestation Date (DTP*453/2300) -- Added a fatal professional claim edit which prohibits entry of this date on the Chiropractic (CHI) attachment tab for all non-Medicare claims as well as for Medicare claims where the Nature of Condition is any value other than "A" or "M"

ª Admission Date (DTP*435/2300) -- Modified existing professional claim edits which require an Admission Date such that they are now fatal for 5010 claims. This includes Ambulance claims which indicate the patient was admitted to a hospital and any claims involving Place of Service (POS) codes '21', '51' or '61'. Added logic to suppress this segment for all other claims.

ª Attachment Control Qualifier/Number PWK05/06/2300/2400) - Added a fatal professional claim edit which prohibits entry of the Attachment Control Number field when the Attachment Type = "AA" (Available on Request at Provider Site)

ª Payer Claim Control Number (REF*F8/2300) -- Modified an existing professional claim edit which requires the Payer Claim Control Number (ICN/DCN) on replacement or void claims such that it is now fatal for 5010 claims. Added new fatal professional claim edits which disallow the Payer Claim Control Number (REF*F8) for all frequencies (CLM05-3) other than '7' and '8'.

ª EPSDT Referral (CRC*ZZ/2300) -- Added a fatal professional claim edit which prohibits entry of the "EPSDT Ind" field unless the "Special Program Indicator" field = "01" or the service line's "EP" (EPSDT) flag is indicated on at least one service line

ª Service Facility Location Name (2310C) -- Added logic to suppress this loop when the Service Facility Name and Primary ID or the Service Facility Address duplicates those of the Billing Provider (2010AA) loop. Also suppress this loop when reporting ambulance services, since the implementation guide instructs users to instead include the Ambulance Pick-up Location (2310E) and Ambulance Drop-off Location (2310F) loops.

ª Service Facility Contact Information (PER/2310C) -- Added logic to suppress this segment when the information matches that already reported in the Submitter EDI Contact Information (PER/1000A) or the Billing Provider Contact Information (PER/2010AA) segment

ª Last Certification Date (DTP*461/2400) -- Modified the professional claim edit which required the Last Certification Date such that it now applies to all Certificate or Medical Necessity (CMN) types. Previously, this date was required for Oxygen CMNs only.

ª Service Facility Location Name (2420C) -- Added logic to suppress this loop when the line-level Service Facility Name and Primary ID or the Service Facility Address duplicates those of the Billing Provider (2010AA) of the claim-level Service Facility (2310C) loops. Also suppress this loop when reporting ambulance services, since the implementation guide instructs users to instead include the Ambulance Pick-up Location (2310E/2420G) and Ambulance Drop-off Location (2310F/2420H) loops.

Professional Claim Edits for Version 5010 - Service Facility Loop (2310D)

ª Modified the professional claim edits for Version 5010 claims to reverse enforcement of the Version 4010A1 requirement that prohibits the Service Facility loop (2310D) from being reported when the Place of Service (POS) code reported in CLM05-1 (Loop 2300) equals "12" (Patient's Home). This restriction was based on Note 5 on Page 303 of the Professional ANSI-837 (4010) implementation guide. The original edits directed the user to populate the line-level Service Facility information instead of the claim-level counterpart whenever facility data is required. This restriction is no longer in effect for Version 5010 claims. The edits have been relaxed to allow reporting of the claim-level Service Facility (2310C) information when services were rendered in the patient's home.

GENERAL PRODUCT ENHANCEMENTS

E-Mail Field Added to Submitter Information Screen

ª Added an "E-Mail" field to "General" tab of the Submitter Information screen. Users are encouraged to enter the submitter contact's e-mail address in this field as an alternate means of communication. The e-mail address will be reported in the "Submitter EDI Contact Information" (PER/1000A) segment, when specified.

Advanced Filter Options Modified to Include Patient’s First Name

ª Enhanced the "Advanced Filter Options" feature of the claim and eligibility/benefit request lists to include the patient's First Name in the filter criteria. The "Patient Last Name" field on the Advanced Filter Criteria has been relabeled "Patient Last, First Name". Users may continue to enter only a full or partial Last Name value, or they may now enter patient name values in LAST, FIRST format. For example, by entering "DOE,JOHN" in both the "from" and "thru" fields, the respective list will be filtered to include only patients whose Last Name starts with "DOE" and First Name starts with "JOHN". The patient HENRIETTA DOE would not be included in the filtered list. This enhancement will make it easier to locate patients with common last names.

Report Previewer Modified to Handle Common Navigation Keys

ª Modified the built-in report previewer to handle common navigation keys in a more intuitive manner. The up/down arrow keys will now scroll the current page vertically within the preview window. The page up/down keys will move page-by-page through a multi-page report. The HOME key will move immediately to the report's first page, while the END key will move immediately to the report's last page.

277CA Claim Acknowledgement Report Prompt Added to Include Only Rejected Claims

ª Added the new "Prompt to include only rejected claims in the Claim Acknowledgment (277CA) reports" option to the "General" tab of the PC-ACE Pro32 preference settings. When enabled, the user will be prompted to include either all claims or only rejected claims when printing Claim Acknowledgment (ANSI-277CA) reports. When disabled, the prompt will not be displayed and all claims will be included in the response report. This option is enabled by default. Users can disable this option in the preference settings if desired. Note: This feature was a last-minute addition to the July 2011 release and may not be available in all distributor builds. If this preference option is grayed in your copy of PC-ACE Pro32, then the feature will be available in the October 2011 release.

CORRECTIONS TO CUSTOMER-REPORTED PROBLEMS

Service Line Diagnosis Pointer, Referencing Codes 10, 11 and 12 – Version 5010 Claims

ª Modified the PC-ACE Pro32 edit module and Professional Claim Prepare Module to correct two problems with the service line Diagnosis Pointer when referencing Diagnosis Codes 10, 11 and 12 on ANSI Version 5010 claims. The edit module was inappropriately reporting an "invalid diagnosis code pointer" edit error on valid pointer combinations "11,1" and "12,2". In addition, the edit module was accepting pointer values like "11,1," and "12,2,", which include an unnecessary trailing comma, but was subsequently suppressing the final pointer value when generating the professional ANSI-837 output file. Both problems have been corrected.

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.