Release Newsletter
Version 2.19
April 2010
Institutional Change Summary
We are pleased to announce
the release of PC-ACE Pro32 version 2.19.
This upgrade contains several CMS Medicare Mandates and product enhancements
effective 4/1/2010, including these highlighted changes:
ENCLOSED MATERIALS
¨ Pre-built PC-ACE Pro32 2.19 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers
¨ This Newsletter
CMS
MEDICARE MANDATES
CR6557
- Coverage of Kidney Disease Patient Education Services
ͺ
Added a new institutional claim edit which requires that HCPCS codes G0420 and
G0421 are billed with Revenue Code 0942 when Stage IV Diagnosis Code 585.4 is
present on TOB 22x, 23x, 34x, 75x, 81x, 82x, or 85x claims.
ͺ
Updated Revenue Code Table to make the Revenue Code 0942 valid for Hospice Type
of Bills, (i.e., 81x and 82x).
ͺ
Added an Institutional edit prohibiting any other revenue codes from being
present on a Hospice claim if Revenue Code 0942 is present.
ͺ
Added an Institutional claim edit to ensure that if the TOB equals 81x or 82x
and the HCPCS codes G0420 or G0421, then Value Code 61 or G8 is present.
ͺ
Modified an existing institutional claim edit and added a new edit to permit
billing of Revenue Code 0942 on Hospice claims (TOB = 81x/82x).
ͺ
Modified an existing institutional claim edit and added a new edit to permit
billing of Revenue Code 0942 on CORF claims (TOB = 75x).
CR 6715
Pharmacogenomic Testing for Warfarin Response
ͺ Added an Institutional claim edit to insure
that Warfarin testing HCPCS code G9143 is always billed with Modifier 'Q0'.
ͺ Added an Institutional claim edit to insure
that Diagnosis Code V707 is present on claims which include Warfarin testing
HCPCS code G9143 (billed with Modifier 'Q0').
CR 6840 Healthcare Provider Taxonomy Codes
(HPTC) Update April 2010
ͺ Updated the
Provider Taxonomy Code reference file with the latest WPC published code set.
Codes Added: 1 ; Codes Deleted/Terminated: 0 ; Codes Modified: 1. The new code
is: "344800000X - Transportation Services : Air Carrier". The
modified code is: 2080P0201X.
CR 6676 Implementation of the Updated HIPAA
00510 837 Institutional (837i) Edits and 005010 837 Professional (837p) Edits
ͺ 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.
CR6589 HIPAA Version 5010 for Transaction 835 -
Health Care Claim Payment / Advice and Updated Standard Paper Remit
ͺ SDI will implement changes to support 5010 requirements over a period of several quarters beginning in the Q2 2009.
ADDITIONAL
CMS MANDATED CHANGES
CR6723 - Claim
Status Category Code and Claim Status Code Update
ͺ Changes described
in this mandate were included in a previous release.
CR6788 - Non-systems
Internet Only Manual (IOM) Chapter 25 Changes
ͺ Changed the description for Condition Code 69
to "IME/DGME/N&AH PAYMENT ONLY"
ͺ Changed the description for Condition Code D4
to "CHANGES IN CLINICAL CODES (ICD) FOR DIAGNOSIS AND/OR PROCEDURE
CODE"
ͺ Changed the description for Occurrence Span
Code 72 to "FIRST/LAST VISIT DATES"
ͺ Changed the description for Occurrence Span
Code 75 to "SNF LEVEL OF CARE DATES"
ͺ Changed the description for Occurrence Span Code M2 to "INPATIENT RESPITE DATES"
CR6775 - Outpatient Intravenous Insulin Treatment
(Therapy)
ͺ Added a new HCPCS code effective 4/5/2010, G9147 OIVIT
CR6778 - Medicare Systems Edit Refinements
Related to Hospice Services
Added several institutional claim edits to enforce rules preventing hospice services from being billed in non-covered settings. These edits apply to TOB = 81x/82x on claims submitted on or after 7/6/2010. The specific edit additions are:
ͺ Added an institutional claim edit, which prohibits billing of HCPCS codes Q5001, Q5002, and Q5003 with GIP revenue code 0656 on Hospice claims.
ͺ Added an institutional claim edit, which prohibits billing of HCPCS codes Q5001 and Q5002 with respite revenue code 0655 on Hospice claims.
ͺ Added an institutional claim edit, which prohibits billing of HCPCS codes Q5004, Q5005, Q5006, Q5007, and Q5008 with CHC revenue code 0652 on Hospice claims.
CR6776 - Billing and Processing for Health
Control Group Volunteers in a Qualified Clinical Trial
ͺ Modified several
institutional claim edits to support Healthy Control Group Volunteer
participation in clinical trials. These participants, by definition, do not
have any underlying conditions. Therefore, providers need to report Diagnosis
Codes V70.5 (Health examination, group survey) or V70.7 (Examination of
participant in clinical trial), as the primary diagnosis instead of the
secondary diagnosis, as no primary diagnosis exists.
CR6782 - Dialysis Adequacy, Infection and
Vascular Access Reporting
Added several
institutional claim edits to enforce tighter Dialysis Adequacy, Infection and
Vascular Access Reporting rules for ESRD claims. The new edits include:
ͺ Added an
institutional claim edit requiring that Value Code D5 be present on all TOB 72x
claims (effective 7/1/2010).
ͺ Added an
institutional claim edit requiring that Occurrence Code 51 be present on all
TOB 72x claims (effective 7/1/2010) except those reporting Value Code D5 with
value equal 9.99.
ͺ Added an
institutional claim edit requiring that HCPCS Modifier V5, V6 or V7 be present
on TOB = 72x claims billing Hemodialysis Revenue Code 0821 (effective
7/1/2010). This modifier should be reported on the latest line item date of
service billing for Revenue Code 0821.
ͺ Added an
institutional claim edit requiring that HCPCS Modifier V8 or V9 be present on
each dialysis Revenue Code line (0821, 0831, 0841, 0851) on all TOB = 72x
claims (effective 7/1/2010).
CR6774 - Correction to Processing of
Non-Covered Revenue Codes
ͺ Modified an
existing Institutional claim edit to allow billing of invalid Revenue Codes
when charges are non-covered, modifiers GA, GL, GX, GS and TS are not present
on the line, and Condition code 20 is not present on the claim.
CR6857 - April 2010 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
ͺ Added the
following HCPCS codes (eff 4/1/2010):
·
C9258 - INJECTION,
TELAVANCIN, 10 MG
·
C9259 - INJECTION,
PRALATREXATE,1 MG
·
C9260 - INJECTION,
OFATUMUMAB, 10 MG
·
C9261 - INJECTION, USTEKINUMAB,
1 MG
·
C9262 - FLUDARABINE
PHOSPHATE,OR,1MG
·
C9263 - INJECTION,
ECALLANTIDE, 1 MG
·
G0432 - INFECT ANTIGEN
DETECT, EIA
·
G0433 - INFECT ANTIGEN
DETECT, ELISA
·
G0435 - INFECT ANTIGEN
DETECT, RAPID"
CR6801 - Point of Origin for Admission or Visit
Codes Update to the UB-04 (CMS-1450) Manual Code List
ͺ Modified the description
for Condition Code 47 to read "Transfer from Another Home Health
Agency".
CR6783 - Implementation of the Health Insurance
Portability and Accountability Act (HIPAA) Version 5010 Acknowledgements
Instructions
ͺ SDI will
implement changes to support 5010 requirements over a period of several
quarters beginning in the Q2 2009.
CR6757 - Coding Patient Transfers Under the HH PPS
ͺ Added an
institutional claim edit which terminates Admission Source codes B and C
effective 7/1/2010.
January 2010 HCPCS Update (Source CMS Website)
ͺ Added the
following HCPCS codes (effective 1/1/2010):
·
G0428 - INPT
TELEHEALTH CONSULT 80M
·
G0429 - INPT
TELEHEALTH CONSULT 110M
ͺ Modified the
descriptions for the following HCPCS codes:
·
G0425 - INPT
TELEHEALTH CONSULT 20M
·
G0426 - INPT
TELEHEALTH CONSULT 40M
·
G0427 - INPT
TELEHEALTH CONSULT 55M
April 2010 HCPCS Update (Source CMS
Website)
ͺ Modified the description for the following HCPCS modifiers:
· GA - REQUIRED LIABILITY NOTICE
· GX - VOLUNTARY LIABILITY NOTICE
· RA - REPLACEMENT ITEM
· RB - REPLACEMENT PART OF ITEM
Category III Codes Update (Source CMS
Website)
ͺ Added new HCPCS codes effective 7/1/2010:
0223T - ACOUSTIC/ELECTR CARDGRPHY
0224T - ACSTIC/ELEC CARDGRPHY AV/VV
0225T - ACSTIC/ELEC CARDGRPHY AV+VV
0226T - ANOSC HIGH RESOL DX+-COLL
0227T - ANOSC HIGH RESOL DX W/BX
0228T - US TFRML EDRL INK CRV/T 1LVL
0229T - US TFRML EDRL INJ CRV/T +LVL
0230T - US TFRML EDRL INJ L/S 1LVL
0231T - US FRMTL EDRL INJ L/S 1LVL
0232T - INJ PLSM IMG GUID HRVSTG&PREP
0233T - SKN AGE MEAS SPCTRSCPY
Claim Adjustment Reason Code Reference File
Update
ͺ Updated the
Claim Adjustment Reason Codes reference file with the latest WPC published code
set. Codes Added: 2 ; Codes Deleted/Terminated: 0 ; Codes Modified: 1. The new
codes are: "233 - Services/charges related to the treatment of a
hospital-acquired condition or preventable medical error." and "234 -
This procedure is not paid separately. 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 modified code
is: 40.
Claim Status Response Codes Reference File
Update
ͺ Updated the Claim Status Response Codes reference file with the latest WPC published code set. Category Codes Added: 1 ; Status Codes Added: 31; Codes Deleted/Terminated: 0 ; Status Codes Modified: 107. The new category code is: "E3 - Correction required - relational fields in error.". The new status codes are: "703 - Advanced Billing Concepts (ABC) code", "704 - Claim Note Text", "705 - Repriced Allowed Amount", "706 - Repriced Approved Amount", "707 - Repriced Approved Ambulatory Patient Group Amount", "708 - Repriced Approved Revenue Code", "709 - Repriced Approved Service Unit Count", "710 - Line Adjudication Information. Note: At least one other status code is required to identify the data element in error.", "711 - Stretcher purpose", "712 - Obstetric Additional Units", "713 - Patient Condition Description", "714 - Care Plan Oversight Number", "715 - Acute Manifestation Date", "716 - Repriced Approved DRG Code", "717 - This claim has been split for processing.", "718 - Claim/service not submitted within the required timeframe (timely filing).", "719 - NUBC Occurrence Code(s)", "720 - NUBC Occurrence Code Date(s)", "721 - NUBC Occurrence Span Code(s)", "722 - NUBC Occurrence Span Code Date(s)", "723 - Drug days supply", "724 - Drug dosage", "725 - NUBC Value Code(s)", "726 - NUBC Value Code Amount(s)", "727 - Accident date", "728 - Accident state", "729 - Accident description", "730 - Accident cause", "731 - Measurement value/test result", "732 Information submitted inconsistent with billing guidelines. Note: At least one other status code is required to identify the inconsistent information.", and "733 - Prefix for entity's contract/member number.". The modified status codes are: 16, 17, 18, 19, 23, 24, 25, 26, 73, 85, 88, 89, 90, 91, 92, 93, 94, 96, 97, 106, 109, 114, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 153, 155, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 170, 173, 174, 175, 176, 182, 183, 387, 395, 466, 467, 470, 478, 487, 491, 496, 499, 500, 501, 502, 503, 504, 505, 506, 508, 514, 560, 561, 562, 563, 635, 663, 676, 677, 680, 689, and 695.
Remittance Advice Remark Codes Reference
File Update
ͺ
Updated the
Remittance Remarks Codes reference file with the latest WPC published code set.
Codes Added: 10 ; Codes Deleted/Terminated: 0 ; Codes Modified: 2. The new
codes are: "523 - The limitation on outlier payments defined by this payer
for this service period has been met. The outlier payment otherwise applicable
to this claim has not been paid.", "524 - Based on policy this
payment constitutes payment in full.", "525 - These services are not
covered when performed within the global period of another service.",
"526 - Not qualified for recovery based on employer size.", "527
- We processed this claim as the primary payer prior to receiving the recovery
demand.", "528 - Patient is entitled to benefits for Institutional
Services.", "529 - Patient is entitled to benefits for Professional
Services.", "530 - Our records indicate a mismatch in enrollment
information for this patient.", "531 - Not qualified for recovery
based on direct payment of premium.", and "532 - Not qualified for
recovery based on disability and working status.". The modified codes are:
N216 and N522.
NUBC Conference Call Minutes (August 2009)
Per a review of the NUBC conference call minutes (August 2009), made the following change:
ͺ Added new
Magnetoencephalography (MEG) Revenue Codes "0860 - General
Classification" and "0861 - MEG" (eff 4/1/2010).
NUBC Conference Call Minutes (October 2009)
Per a review of the NUBC conference call minutes (October 2009), made the following changes:
ͺ Added a non-fatal institutional claim edit which terminates Admission Source codes "7" (Emergency Room), "B" (Transfer from Another Home Health Agency) and "C" (Readmission to Same Home Health Agency) effective 7/1/2010.
ͺ Added a new Occurrence Code "50 - Assessment Date" (eff 1/1/2011). Added a non-fatal institutional claim edit to enforce the effective date.
ͺ Added a new Occurrence Code "51 - DATE OF LAST KT/V READING" (eff 7/1/2010). Added a non-fatal institutional claim edit to enforce the effective date.
ͺ Added a new Value Code "D5 - LAST KT/V READING" (eff 7/1/2010). Added a non-fatal institutional claim edit to enforce the effective date.
NUBC Conference Call Minutes (November
2009)
Per a review of the NUBC conference call minutes (November 2009), made the following change:
ͺ Added a new Condition Code "P7 - DIRECT INPATIENT ADMISSION FROM EMERENCY ROOM" (eff 7/1/2010). Added a non-fatal institutional claim edit to enforce the effective date.
MODIFICATIONS
IN SUPPORT OF ANSI (HIPAA) IG COMPLIANCE
ANSI-276/277 Health Care Claim Status
Request and Response Enhancement (if applicable)
ͺ 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 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.
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 servers 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.