Release 3.3 Institutional Newsletter

January 2017

Hot topics CR9752 Integrated the annual HCPCS and HCPCS Modifiers update from CMS. HCPCS Changes: 434 added; 228 deleted; 414 modified. Modifier Changes: 6 added; 0 deleted; 3 modified. See accompanying report for a list of new, deleted and modified codes.

CR9902 Added several new institutional claim edits to enforce the Medicare Deductible and Coinsurance amounts for Calendar Year 2017.

Enclosed materials • Pre-built ABILITY PC-ACE 3.3 upgrade file named PCACEUP.EXE and replacement SETUP.EXE file for any new providers • This newsletter

ABILITY | PC-ACE Release 3.3 Institutional Newsletter • January 2017

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CMS mandated changes CR9598 – Changes to the End-Stage Renal Disease (ESRD) Facility Claim (Type of Bill 72X) to Accommodate Dialysis Furnished to Beneficiaries with Acute Kidney Injury (AKI) Implemented several changes to ESRD billing to accommodate dialysis furnished to beneficiaries with Acute Kidney Injury (AKI): • Added a new Condition Code “84 – DIALYSIS FOR ACUTE KIDNEY INJURY (AKI).” • Add an institutional claim edit prohibiting use of CC 84 prior to Jan. 1, 2017. • Added a new HCPCS code (effective Jan. 1, 2017): G0491 – DIALYSIS ACU KIDNEY NO ESRD

CR9674 – New Revenue Code 0815 for Allogeneic Stem Cell Acquisition Services • Added a new Revenue Code “0815 – STEM CELLS – ALLOGENEIC” valid on TOBs 11x, 12x, 13x and 85x (effective Jan. 1, 2017). CR9680 – Claim Status Category and Claim Status Codes Update Updated the Claim Status Response Codes reference file with the latest WPC published code set. Category Codes Added: 0; Status Codes Added: 2; Status Codes Deleted/Terminated: 0; Status Codes Modified: 3. • The new Status codes are (effective Nov. 1, 2016): 773 – One calendar year per claim.

• Added an institutional claim edit for ESRD claims (TOB = 72X) which reports the new Condition Code 84. These claims must also report HCPCS code G0491 and one of the following ICD-10 Diagnosis Codes: N17.0, N17.1, N17.2, N17.8, N17.9, T79.5XXA, T79.5XXD, T79.5XXS or N99.0.

• The modified Status codes are: 163, 252 and 724.

• Added an institutional claim edit which prohibits reporting of HCPCS Modifier AY on AKI claims (TOB = 72X; CC 84 present).

• Added a new HCPCS modifier (effective Jan. 1, 2017):

• Added an institutional claim edit which prohibits billing of HCPCS code 90999 on AKI claims (HCPCS G0491 present). CR9609 – Updates to the 72X Type of Bill for Home and Self-Dialysis Training, Retraining and Nocturnal Hemodialysis Implemented several changes to support billing requirements for retraining and reporting for nocturnal hemodialysis:

774 – Experimental/Investigational

CR9727 – Payment Reduction for X-Rays Taken Using Film

FX – X-RAY TAKEN USING FILM CR9736 – Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment System Implemented several changes in support of Home Health claim billing requirements: • Added the following HCPCS codes (effective Jan. 1, 2017): G0493 – RN CARE EA 15 MIN HH/HOSPICE

• Added a new Condition Code “87 – ESRD SELF CARE RETRAINING”

G0494 – LPN CARE EA 15 MIN HH/HOSPICE

• Added an institutional claim edit prohibiting the use of CC 87 prior to July 1, 2017.

G0496 – LPN CARE TRAIN/EDU IN HH

• Added an institutional claim edit prohibiting the use of Condition Codes 71, 72, 73, 74 or 76 on ESRD claims (TOB = 72x) where CC 87 is present (effective July 1, 2017).

ABILITY | PC-ACE Release 3.3 Institutional Newsletter • January 2017

G0495 – RN CARE TRAIN/EDU IN HH • Terminated HCPCS codes G0163 and G0164 (effective Jan. 1, 2017). • Added an institutional claim edit which allows only HCPCS codes 97607 and 97608 to be billed with Revenue Code 0559 on TOB 34x claims.

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CMS mandated changes continued … • Added an institutional claim edit which requires that HCPCS codes 97607 and 97608 be billed only with Revenue Codes 042x, 043x or 0559 on TOB 34x claims.

CR9774 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

• Added an institutional claim edit which prohibits a Units value greater than 96 on any HH PPS claim (TOB = 032x) service line with Revenue Code 042x, 043x, 044x, 055x, 056x or 057x.

Updated the Remittance Remarks Codes reference file with the latest WPC published code set. Codes Added: 12; Codes Deleted/Terminated: 0; Codes Modified: 3.

CR9752 – 2017 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder

• The new codes are (effective Nov. 1, 2016): N775 – Payment adjusted based on x-ray radiograph on film.

• Integrated the annual HCPCS and HCPCS Modifiers update from CMS. HCPCS Changes: 434 added; 228 deleted; 414 modified. Modifier Changes: 6 added; 0 deleted; 3 modified. See accompanying report for a list of new, deleted and modified codes.

N776 – This service is not a covered Telehealth service.

CR9766 – Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)

N779 – Replacement/Void claims cannot be submitted until the original claim has finalized. Please resub ...

• Updated the ANSI-835 Remittance Modules (ETRA) reports to include the October 2016 (Version 3.3.1) release of the CORE Phase III Claim Adjustment/Denial Business Scenario code combinations. CR9774 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update Updated the Claim Adjustment Reason Codes reference file with the latest WPC published code set. Codes Added: 1; Codes Deleted/Terminated: 0; Codes Modified: 0.

N777 – Missing Medicare Assignment of Benefits Indicator. N778 – Missing Primary Care Physician Information.

N780 – Missing/incomplete/invalid end therapy date. N781 – Alert: No deductible may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. ... N782 – Alert: No coinsurance may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. ... N783 – Alert: No co-payment may be collected as patient is a Medicaid/Qualified Medicare Beneficiary. ... N784 – Missing comprehensive procedure code. N785 – Missing current radiology film/images. N786 – Benefit limitation for the orthodontic active and/or retention phase of treatment. • The modified codes are M7, N116 and N305.

• The new code is (effective Nov. 1, 2016): 279 – Services not provided by preferred network providers.

ABILITY | PC-ACE Release 3.3 Institutional Newsletter • January 2017

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CMS mandated changes continued … CR9782 – 2017 Annual Update to the Therapy Code List Implemented several changes in support of new billing requirements for physical therapy (PT) and occupational therapy (OT) evaluative procedures: • Added the following CPT codes (effective Jan. 1, 2017): 97161 – PT EVAL LOW COMPLEX 20 MIN 97162 – PT EVAL MOD COMPLEX 30 MIN 97163 – PT EVAL HIGH COMPLEX 45 MIN 97164 – PT RE-EVAL EST PLAN CARE 97165 – OT EVAL LOW COMPLEX 30 MIN 97166 – OT EVAL MOD COMPLEX 45 MIN 97167 – OT EVAL HIGH COMPLEX 60 MIN 97168 – OT RE-EVAL EST PLAN CARE • Terminate CPT codes 97001, 97002, 97003 and 97004 (effective Jan. 1, 2017). • Modified several institutional claim edits to continue enforcing billing requirements for therapy modifiers GP and GO on PT and OT claims, respectively. CR9793 – Implementation of New Influenza Virus Vaccine Code • Added a new influenza virus vaccine HCPCS code (effective Aug. 1, 2016): 90674 – CCIIV4 VAC NO PRSV 0.5 ML IM

CR9807 – Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2017 • Added an institutional claim edit prohibiting nonESRD HCPCS code J0883 on ESRD (TOB=72x) claims (effective Jan. 1, 2017). CR9818 – Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported With Value Code (VC) 42 • Added an institutional claim edit which enforces the VA billing requirement that Condition Code 26 must be billed with Value Code 42, and vice versa. This edit is effective for claims with service dates on or after Oct. 1, 2013, and impacts bill types 11X, 18X, 21X, 41X and 51X. CR9888 – HCPCS Code Update for Preventive Services • Added a new HCPCS code (effective Jan. 1, 2017): 76706 – US ABDL AORTA SCREEN AAA This code replaces G0389, which is being retired. CR9902 – Update to Medicare Deductible, Coinsurance and Premium Rates for 2017 • Added several new institutional claim edits to enforce the Medicare Deductible and Coinsurance amounts for Calendar Year 2017.

Product Enhancements Improved Support for Removable Media Backup Devices Disabled the long-standing removable media check performed during ABILITY|PC-ACE backups. This check supported multi-volume media like floppies, which are no longer used. The check has been identified as a cause for backup failures to USB devices (e.g., flash drives).

ABILITY | PC-ACE Release 3.3 Institutional Newsletter • January 2017

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Installing the upgrade Perform a full ABILITY|PC-ACE database backup before installing the upgrade. To install the upgrade, run the attached PCACEUP.EXE file using Windows Explorer or the 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.

About ABILITY® ABILITY Network is a leading healthcare information technology company helping providers and payers simplify the administrative and clinical complexities of healthcare through innovative applications and data analytics. ABILITY is headquartered in Minneapolis with principal offices in Boston and Tampa. © 2017 ABILITY Network Inc. All Rights Reserved. ABILITY | PC-ACE Release 3.3 Institutional Newsletter • January 2017

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