Program of All-Inclusive Care for the Elderly (PACE) Manual

• Program of All-Inclusive Care for the Elderly (PACE)
  • What is PACE?
  • PACE Procedure Code Types
  • Electronic Encounter Submission Format
  • Coding
  • Coding Information
  • PACE Program Revisions Log

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Program of All-Inclusive Care for the Elderly (PACE)

What is PACE?

Program of All-Inclusive Care for the Elderly (PACE) is operated by Health First Colorado (Colorado's Medicaid program) and Medicare. The PACE program provides comprehensive medical and social services to certain frail individuals 55 years of age and older. The goal of PACE is to help individuals live and stay in their homes and communities through comprehensive care coordination.

Visit the PACE web page for more information on the PACE program, including eligibility qualifications, benefits and services, the costs associated with PACE, and how to apply for PACE.

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PACE Procedure Code Types

PACE organizations may submit the following procedure codes for PACE services:

• Behavioral Health Services
• Center Manager
• Chaplin Services
• Clinic CNA
• Dental Services
• Durable Medical Equipment
• Home Health Services
• Integrated Care Model
• Medication Services
• Nursing Services
• Primary Care Physician Services
• Recreation Therapy
• Occupational and Physical Therapy Rehab Services
• Transportation Services
• And more

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Electronic Encounter Submission Format

PACE Encounters must follow the CMS 837 claims transaction format. There are three different formats for the 837, divided into three groups:

• 837D - for dental practices
• 837P - for professionals
• 837I - for institutions

For PACE organizations, the 837P (Professional) is the standard format to transmit health care claims electronically. For instructions relating to the 837P submission and related technical information, refer to the CMS 837P Companion Guide located on the Electronic Data Interchange (EDI) Support web page under the Companion Guides and Instructions section.

Effective April 14, 2021, the interChange system will be configured to meet the needs of the PACE program. The following guidance is intended to support the reporting of PACE Encounters on the 837 X12N.

Billing Provider IDs:
837P - 2010AA
837I - 2010AA 
837D – 2010AA
The Biller of the PACE encounter must match the location of the Managed Care Entity submitting the claim. The biller and the MC submitter must have the same NPI, taxonomy, address and zip code +4. 

Service Facility IDs:
837P – 2310C 
837I – 2310E  
837D – 2310C

The service facility fields should remain blank if the Biller is the same as the Service Facility on the PACE encounter. If the service was provided at the PACE Organization location, there should be no Service Facility ID submitted as the PACE Organization is always the biller of the PACE encounter.

The service facility NPI, address and zip code +4 should be submitted on the PACE encounter if the service was not provided at the PACE Organization location but at one of the sub-contracted locations. 

Managed Care Submitter:
837P – 2330B
837I – 2330B
837D – 2330B
PACE encounters should have the Payer ID for the PACE Organization ID submitting. 

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Coding

Correct coding is necessary for the submission of valid claims. There are two (2) types of coding that PACE organizations will use: diagnosis coding and procedure coding. Diagnosis coding will use the International Classification of Diseases, Procedure Coding System (ICD-10 PCS), procedure coding with use the Healthcare Common Procedure Coding System (HCPCS). Please ensure that diagnosis and procedure codes are current and correct.

HCPCS Level I and II codes are updated annually, which are presented in October and are implemented in January. Level II codes, however, may be issued quarterly.

If a PACE organization has a claim that cannot be identified with a current coding terminology, the PACE organization must submit to HCPF a document showing services that were provided to members that would like to be coded for future consideration.

Visit the Centers for Medicare & Medicaid Services ICD-10 web page for more information on ICD-10 codes.

Visit the CMS HCPCS web page for more information on HCPCS.

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Coding Information

Refer to the PACE Billing Manual Codes List for a comprehensive list of codes used within PACE centers.

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PACE Program Revisions Log