Provider Manual. Billing and Payment

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Provider Manual

 Billing and Payment

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This section of the Manual was created to help guide you and your staff in

working with Kaiser Permanente’s billing and payment policies and procedures.

It provides a quick and easy resource with contact phone numbers, detailed

processes and site lists for services.

If, at any time, you have a question or concern about the information in this

section, please call 1-888-681-7878.

Billing and

Payment

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Kaiser Permanente Provider Manual

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Table of Contents

SECTION 5: BILLING AND PAYMENT ... 8

5.1. WHOM TO CONTACT WITH QUESTIONS ... 8

5.2. METHODS OF CLAIMS FILING ... 9

5.2.1 Paper Claim Forms ... 9

5.2.1.1 Record Authorization Number ... 9

5.2.1.2 One Member/ Provider per Claim Form ... 9

5.2.1.3 No Fault/ Workers’ Compensation/Other Accident ... 10

5.2.1.4 Record the Name of the Provider You Are Covering For ... 10

5.2.1.5 Submission of Multiple Page Claim ... 10

5.2.1.6 Entering Dates ... 10

5.2.1.7 Multiple Dates of Services and Place of Services ... 10

5.2.1.8 Surgical and/or Obstetrical Procedures ... 11

5.2.1.9 Billing Inpatient Claims That Span Different Years ... 11

5.2.1.10 Interim Inpatient Bills ... 11

5.2.1.11 Supporting Documentation for Paper Claims ... 12

5.2.1.12 Where to Mail/Fax Paper Claims ... 12

5.2.2 Electronic Data Interchange (EDI) ... 13

5.2.2.1 Electronic Claims Forms / Submissions ... 13

5.3. CLAIM FILING REQUIREMENTS ... 16

5.3.1 Clean Claims ... 16

5.3.2 Claims Submission Timeframes ... 16

5.3.3 Claims Processing Turn-Around Time ... 17

5.3.4 Proof of Timely Claims Submission ... 17

5.3.5 Appeal of Timely Claims Submission ... 17

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5.4.1 Incorrect Claims Payments ... 19

5.4.2 Rejected Claims Due to EDI Claims Error ... 20

5.5. REQUIRED IDENTIFICATION INFORMATION ... 20

5.5.1 Federal Tax ID Number ... 20

5.5.2 Changes in Federal Tax ID Number ... 21

5.5.3 National Provider Identification (NPI) ... 21

5.6. MEMBER COST SHARE ... 22

5.7. MEMBER CLAIMS INQUIRIES ... 22

5.8. VISITING MEMBERS ... 22

5.9. CODING FOR CLAIMS ... 22

5.9.1 Coding Standards ... 22

5.9.2 Modifiers in CPT and HCPCS ... 23

5.9.3 Modifier Review ... 25

5.9.4 Coding & Billing Validation ... 25

5.9.4.1 Claims Editing Software Programs ... 26

5.9.4.2 Types of edits ... 26

5.9.4.3 Modifiers ... 29

5.9.5 Coding Edit Rules ... 30

5.10. MEDICAL CLAIMS REVIEW (REQUIRED) ... 33

5.10.1 Major Categories of Claim Coding Errors/Inconsistencies ... 33

5.10.1.1 Procedure Unbundling ... 33

5.10.1.2 Incidental Procedures ... 34

5.10.1.3 Separate Procedures ... 34

5.10.1.4 Mutually Exclusive Procedures ... 34

5.10.1.5 Age and Gender (Sex) Conflicts ... 35

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5.10.1.7 Multiple/ Duplicate Component Billing ... 35

5.11. THIRD PARTY LIABILITY (TPL) ... 35

5.12. WORKERS’COMPENSATION ... 36

5.13. THIRD PARTY ADMINISTRATOR (TPA) (REQUIRED) ... 36

5.14. PROVIDER CLAIMS APPEALS (REQUIRED) ... 36

5.14.1 Provider Claim Payment Appeals Process ... 36

5.15. CLAIM FORM EXAMPLES AND INSTRUCTIONS ... 36

5.15.1 CMS-1500 (08/05) FIELD DESCRIPTIONS ... 36

5.15.2 CMS-1450 (UB-04) Field Descriptions ... 46

5.16. BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ... 51

5.16.1 Capitation Payments ... 51

5.16.2 Evaluation Management (E/M) Services ... 52

5.16.2.1 Inpatient E/M Services: ... 52

5.16.2.2 Surgical Procedure that Include E/M Services: ... 53

5.16.2.3 Preventive Medicine Services: ... 57

5.16.3 Emergency Rooms ... 58

5.16.3.1 Two Physicians Involved in Admitting a Patient from the ER ... 58

5.16.3.2 “Emergency” in the Office Setting... 58

5.16.3.3 “Non-Emergency” Services Provided in the Emergency Department ... 58

5.16.3.4 Emergency Room and Urgent Care Services Submitted on a UB-92 ... 59

5.16.4 Critical Care Services ... 59

5.16.4.1 Patient Located in a Critical Care Unit Not Receiving Critical Care Services ... 59

5.16.5 Observation Services ... 59

5.16.6 Injection/ Immunizations ... 59

5.16.6.1 Vaccine Immunizations ... 59

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5.16.7 Obstetrical Services ... 60

5.16.7.1 Admissions for False Labor ... 60

5.16.7.2 Anesthesia Services Provided with Deliveries ... 60

5.16.7.3 Multiple Physicians Provide Different Components of the Obstetrical Care ... 61

5.16.7.4 Antepartum Care ... 61

5.16.8 Newborn Services ... 61

5.16.8.1 Newborn Care When Baby Is Discharged with Mother ... 61

5.16.8.2 Newborn Care When Baby is Discharged without Mother ... 62

5.16.8.3 Boarder Babies Who Stay Beyond Their Mother’s Discharge Date ... 62

5.16.8.4 Mother who stays beyond their baby discharge date. ... 63

5.16.9 Surgery ... 63

5.16.9.1 Global Period / Surgical Package ... 63

5.16.9.2 Endoscopic Procedures Included in the Surgical Package ... 67

5.16.9.3 Anesthesia Procedures Included in the Surgical Package ... 68

5.16.9.4 Topical/Local/Digital Block Anesthesia Included in the Surgical Package ... 68

5.16.9.5 Preoperative Care/Services Included in the Surgical Package ... 68

5.16.9.6 Preoperative Care/Services Excluded from the Surgical Package ... 69

5.16.9.7 Postoperative Follow-Up Care Included in the Surgical Package ... 69

5.16.9.8 Postoperative Follow-Up Care Excluded from the Surgical Package ... 69

5.16.9.9 Same-Day Services Excluded from the Surgical Package ... 70

5.16.9.10 Assistant Surgeon ... 70

5.16.9.11 Co-Surgery (Two Surgeons) ... 71

5.16.9.12 Team Surgery ... 71

5.16.9.13 Duplicate / Bilateral Procedures ... 71

5.16.9.14 Multiple Surgery Reimbursement for Professional and Facility Claims ... 72

5.16.9.15 Exploratory/Diagnostic Procedures ... 72

5.16.10 Cardiac Procedures ... 72

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5.16.10.2 Electrophysiologic Studies (EPS), Cardiac Mapping and Ablations ... 73

5.16.10.3 EPS and Cardiac Catheterization ... 74

5.16.10.4 Cardiac Rehabilitation ... 74

5.16.11 Transplants ... 74

5.16.12 Anesthesia ... 75

5.16.13 Behavioral Health Services ... 76

5.16.14 Durable Medical Equipment ... 77

5.16.15 Laboratory Procedures ... 77

5.16.16 Radiology Services ... 78

5.16.17 Radiation Treatment ... 79

5.16.18 Interventional Radiology ... 80

5.16.19 Therapy: Physical/ Occupational/Speech (P.O.S.) ... 80

5.17. COORDINATION OF BENEFITS (COB) (REQUIRED) ... 82

5.17.1 How to Determine the Primary Payor ... 82

5.17.2 Description of COB Payment Methodologies ... 83

5.17.3 COB Claims Submission Requirements and Procedures ... 83

5.17.4 Members Enrolled in Two Kaiser Permanente Plans... 83

5.17.5 COB Claims Submission Timeframes ... 83

5.17.6 COB FIELDS ON THE UB-92 and UB-04 CLAIM FORM ... 84

5.17.7 COB FIELDS ON THE CMS-1500 (HCFA-1500) CLAIM FORM ... 86

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Section 5: Billing and Payment

Section 5: Billing and Payment

The applicable Payor identified in your Agreement is responsible for payment of covered services in accordance with your Agreement and applicable law. It is your responsibility to submit itemized claims for services provided to Members in a complete and timely manner in accordance with your Agreement, this Manual and applicable law. The Member’s Payor is responsible for payment of claims in accordance with your Agreement. Please note that this manual does not address submission of claims under tier 2 and 3 of POS product.

Reimbursement based on a new or revised Resource Based Relative Value Scale (RBRVS) Fee Schedule will begin upon system implementation of the new fee schedule by the Health Plan. Health Plan agrees to implement any new or revised RBRVS Fee Schedule within 45 calendar days after the CMS RBRVS File Publish Date or CMS Implementation Date, whichever is later.

5.1. Whom to Contact with Questions

Central Pre-authorization Department (303) 636-3131

FAX (303) 636-3101 Provides authorization prior to rendering services. Specialists are limited to procedures and services defined on the Referral Authorization Form. Members must return to Kaiser Permanente for services that have not been pre-authorized.

Claims and Referral Payment Department (303) 338-3600

Provides information related to claims payment for services provided. All billings should be sent to the address listed below. Claims should be submitted on a CMS 1500 or CMS 1450 form. Clean claims will be paid or denied within the timeframes required by applicable federal or state law. Kaiser Permanente Claims and Referral Department PO Box 373150 Denver, CO 80237-6970

Member Service Department - Benefit Information (303) 338-3800

To verify benefits or eligibility of a Kaiser Permanente member, contact this department. Providers can also find benefit information on the members Kaiser Permanente ID card. All co-pays or co-insurance that the member is responsible for should be collected at the time

services are provided. The department also documents, reports and facilitates the response to member complaints.

Denver/ Boulder Consultant Credentialing Requirements (719) 867-2131 opt 2 Our Credentialing Committee prior to rendering services must approve all consultants contracting with Kaiser Permanente. If you add new providers to your practice, you must contact your contract manager to have them properly credentialed.

Southern Colorado Consultant Credentialing Requirements (719) 867-2131 opt 1 Our Credentialing Committee prior to rendering services must approve all consultants contracting with Kaiser Permanente. If you add new providers to your practice, you must contact your contract manager to have them properly credentialed.

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5.2. Methods of Claims Filing

Kaiser Permanente of Colorado accepts all claims submitted by mail or electronically. Kaiser Permanente of Colorado’s Emdeon payor ID# 91617

Kaiser Permanente of Colorado’s Relay Health payor ID# Rh003 Kaiser Permanente of Colorado’s ENS payor ID# COKSR

5.2.1

Paper Claim Forms

• CMS-1500 must be used for all professional services and suppliers.

• CMS-1450 must be used by all facilities (e.g., hospitals).

• Any professional services (for example, services rendered by radiologists, ER

physicians, etc.) should be billed on CMS-1500 claim forms, unless you are

contracted under a GLOBAL rate, in which case “professional services” should not be billed separately.

Note: Effective October 2006, the center of Medicare & Medicaid Service (CMS) has revised the CMS -1500 form. The new CMS-1500 (08/05) version will accommodate the reporting of the National Provider Identifier (NPI). Kaiser Permanente began to

accept the revised form on October 1, 2006. Kaiser Permanente will only accept

(08/05) version of the CMS-1500.

The National Uniform Billing committee (NUBC) has approved the new UB-04 (CMS-1450) as the replacement for UB-92. Kaiser will begin to accept the New UB-04 on

October 1, 2006. Kaiser Permanente will only accept UB-04 (CMS-1450).

5.2.1.1 Record Authorization Number

All services that require prior authorization must have an authorization number

reflected on the claim form or a copy of the authorization form may be submitted with the claim.

CMS 1500 Form

Enter the Authorization Number (Field 23) and the Name of the Referring Provider (Field 17) on the claim form, to ensure efficient claims processing and handling. 5.2.1.2 One Member/ Provider per Claim Form

One Member per Claim Form/One Provider per claim

• Do not bill for different Members on the same claim form • Do not bill for different Providers on the same claim form.

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5.2.1.3 No Fault/ Workers’ Compensation/Other Accident

Be sure to indicate on the CMS-1500 (HCFA-1500) Claim Form in the “Is Patient’s Condition Related To” fields (Fields 10a -10c), whenever No Fault, Workers’ Compensation, or Other Accident situations apply.

5.2.1.4 Record the Name of the Provider You Are Covering For

When “covering” for another Provider, submit a CMS-1500 (HCFA-1500) claim form for these services and enter the name of the physician you are covering for in Field 19 (Reserved for Local Use).

NOTE: If a non-contracting Provider will be covering for you in your absence, please notify that individual of this requirement.

5.2.1.5 Submission of Multiple Page Claim

If due to space constraints you must use a second claim form, please write

“continuation” at the top of the second form, and attach the second claim form to the first claim with a paper clip. Enter the TOTAL CHARGE (Field 28) on the last page of your claim submission.

5.2.1.6 Entering Dates

Below is an example of how to enter dates on the CMS-1500 (HCFA-1500) Claim Form.

5.2.1.7 Multiple Dates of Services and Place of Services

• Multiple dates of services at the same location can be filed on the same claim form but must be entered on a separate line.

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• Multiple dates of service at different locations must be filed on a separate claim form.

• Same date of the service at the same location can be filed on the same claim form.

• Same date of service at different locations must be filed on a separate claim form.

5.2.1.8 Surgical and/or Obstetrical Procedures

If any surgical and/or obstetrical procedures were performed, record the ICD-9-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-9-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). When submitting the UB-04, use Field 74a-e (Principal Procedure Code and Date).

5.2.1.9 Billing Inpatient Claims That Span Different Years

When an inpatient claim spans different years (for example, the patient was admitted in December and was discharged in January of the following year), it is NOT

necessary to submit two claims for these services. Bill all services for this inpatient stay on one claim form (if possible), reflecting the correct date of admission and the correct date of discharge. Kaiser Permanente will apply the appropriate/applicable payment methodologies when processing these claims.

5.2.1.10 Interim Inpatient Bills

For inpatient services only, we will accept separately billable claims for services in an inpatient facility on a bi-weekly basis. Interim hospital billings should be submitted under the same Member account number as the initial bill submission.

DRG/Case Rate/Other Reimbursement Contracts: Facilities contracted with Kaiser

Permanente under a DRG, case-rate or ther payment methodology CANNOT submit interim inpatient bills; bills can only be submitted upon patient discharge.

Per Diem: Skilled nursing facilities contracted with Kaiser Permanente uner a “per diem” methodology may submit interim inpatient bills on a monthly basis for prolonged patient

hospitalizationa. Be sure to indicate via appropriate codes in Field 22 (Discharge Status Code) and Field 4 (Type of Bill) that this is an “interim” inpatient bill.

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5.2.1.11 Supporting Documentation for Paper Claims

Supporting documentation is only required when requested upon the denial or pending of a claim. You will receive written notice if you need to provide written documentation in order to reprocess your claim.

When billing with an unlisted CPT code, to expedite claims processing and adjudication, providers should submit supporting written documentation.

5.2.1.12 Where to Mail/Fax Paper Claims

Paper claims are accepted; however EDI (electronic) submission is preferred. No handwritten claims are accepted. Paper claims are not accepted via fax due to HIPAA regulations.

Mail all paper claims to: Denver / Boulder Region

Kaiser Permanente of Colorado Claims Administration

P.O. Box 373150 Denver, CO 80237

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Southern Colorado Region Kaiser Permanente of Colorado P.O. Box 372910

Denver, CO 80237-6910

5.2.2

Electronic Data Interchange (EDI)

Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of claims.

EDI is an electronic exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI

transactions replace the submission of paper claims. Required data elements (for example, claims data elements) are entered into the computer only ONCE - typically at the Provider’s office, or at another location where services were rendered.

Benefits of EDI Submission

1 Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated.

2 Improved Data Accuracy: Because the claims data submitted by the Provider is sent electronically to Kaiser Permanente via the Clearinghouse, data accuracy is improved, as there is no need for re-keying or re-entry of data.

3 Low Error Rate: Additionally, “up-front” edits applied to the claims data while information is being entered at the Provider’s office, and additional payer-specific edits applied to the data by the Clearinghouse before the data is transmitted to the appropriate payer for processing, increase the percentage of clean claim

submissions.

4 Bypass US Mail Delivery: The usage of envelopes and stamps is eliminated. Providers save time by bypassing the U.S. mail delivery system.

5 Standardized Transaction Formats: Industry-accepted standardized medical claim formats may reduce the number of “exceptions” currently required by multiple payers.

NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under a capitated arrangement, periodic interim payments (PIP), or other reimbursement methodology, you are still required to submit Member Encounter Data to Kaiser Permanente

electronically (preferred) or via standard claim forms (CMS-1500/08/05 or 12/90 or CMS-1450/UB-04 or UB92 as applicable), and to follow all claims completion instructions set forth in this Manual.

5.2.2.1 Electronic Claims Forms / Submissions

Professional and facility claims can be submitted electronically via the current version of:

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• 837I must be used by all facilities (e.g., hospitals).below

Supporting Documentation for EDI Claims

Currently, Kaiser Permanente Colorado does not have the capability to accept claims with electronic attachments. These types of submissions will need to be submitted via the paper process.

To Initiate Electronic Claims Submissions

Trading Partners or Trading Parties interested in implementing EDI transactions with Kaiser Permanente should contact Regional EDI Business Operations for

information via email.KP-RM.EDI.Services@kp.org.

Providers without electronic connectivity need to contact the Clearing House of choice to establish connectivity. For any additional questions contact the Colorado EDI Coordinator at 720-857-4718.

Providers with existing electronic connectivity, please use the Payer ID list below:

•

SSI 837I only– 99999-0273

1-800-880-3032

•

Envoy/NEIC/WebMD/Emdeon 837I/P– 91617—Self Funded use

94320

1-800-845-6592

•

ENS/Ingenix/OptumInsight 837I/P– COKSR

719-277-7545

•

Relay Health 837I/P-RH003

800 545 2488 or 778-6711 for new customers and

800-527-8133 for existing customers

Electronic Submission Process

1 Providers’ EDI Responsibilities: Once a Provider has entered all of the required data elements (e.g., all of the required data for a particular claim) into a their claims processing system, the Provider then electronically “sends” all of this information to a Clearinghouse for further data sorting and

distribution.

2 Clearinghouse’s EDI Responsibilities: The Clearinghouse receives

information electronically from a variety of Providers, which have chosen that particular Clearinghouse as their data sorter and distributor.

The Clearinghouse “batches” all of the information it has received from the various Providers, sorts the information, and then electronically “sends” the information to the payer that the provider has identified in the transaction for

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processing. Data content required by HIPAA Transaction Implementation Guides is the responsibility of the Provider and the Clearinghouse. The

Clearinghouse should ensure HIPAA Transaction Set Format compliance with HIPAA rules.

In addition, Clearinghouses:

• Frequently supply the required PC software to enable direct data entry in the Provider’s office.

• Edit the data which is electronically submitted to the Clearinghouse by the Provider’s office, so that the data submission will be accepted by the appropriate payer for processing.

• Transmit the data to the correct payer in a format easily understood by the payer’s computer system.

• Transmit electronic claim status reports from payers to Providers.

3 Kaiser Permanente’s EDI Responsibilities: Kaiser Permanente receives EDI information after the Provider sends it to the Clearinghouse for distribution. The data is loaded into Kaiser Permanente’s claims systems electronically and it is prepared for further processing. On the same day that Kaiser Permanente receives the EDI claims, Kaiser Permanente prepares an

electronic acknowledgement which is transmitted back to the Clearinghouse. NOTE: If a Provider is not receiving Kaiser Permanente’s electronic claim acknowledgement from the Clearinghouse, contact your billing service or the Clearinghouse and request that this be routinely forwarded to you.

HIPAA Requirements

All electronic claim submissions must adhere to all HIPAA requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) 949-9740.

• www.dhhs.gov • www.wedi.org • www.wpc-edi.com

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5.3. Claim Filing Requirements

5.3.1

Clean Claims

Kaiser Permanente considers a claim ‘clean’ when the following requirements are met:

Correct Form - Kaiser Permanente requires all professional claims to be submitted using the CMS Form 1500 and all facility claims (or appropriate ancillary services) to be submitted using the CMS Form CMS 1450 (UB04 or 92 based on CMS guidelines. Standard Coding – All fields should be completed using industry standard coding. Applicable Attachments – Attachments should be included in your submission when circumstances require additional information.

Completed Field Elements for CMS Form 1500 (08/05 or 12/90 based on CMS

guidelines) Or CMS 1450 (UB-04 or UB92 based on CMS guidelines) – All applicable data elements of CMS forms should be completed.

A claim is not considered to be “Clean” or payable if one or more of the following are missing or are in dispute:

• The format used in the completion or submission of the claim is missing required

fields or codes are not active.

• The eligibility of a member cannot be verified.

• The responsibility of another payor for all or part of the claim is not included or

sent with the claim.

• Other coverage has not been verified.

• Additional information is required for processing such as COB information,

operative report or medical notes (these will be requested upon denial or pending of claim).

• The claim was submitted fraudulently.

• Must comply with coding standards (detailed in Sections 5.36 and 5.37 of this

Manual).

NOTE: Failure to include all information will result in a delay in claim processing and payment and will be returned for any missing information. A claim missing any of the required information will not be considered a clean claim.

5.3.2

Claims Submission Timeframes

Timeframes for filing a claim:

New Claims - The standard is 90 days from the date of service, for both commercial and Medicare members.

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COB Claims - COB information must be received within 12 months of the request for commercial members and 24 months for Medicare/Medicaid Members. (If within the last three months of the year, Medicare/Medicaid Members have 27 months.) Processing of your claim may be delayed for receipt of COB information.

Claim Corrections - When a claim is received within the contractual timely filing period but is received with missing information, the provider will be required to submit a

corrected claim to Kaiser Permanente within forty five (45) calendar days from the date of the original Statement of Remittance (SOR).

5.3.3

Claims Processing Turn-Around Time

Clean claims will be processed pursuant to the timeframe specified by applicable law for Commercial Lines of Business and 30 calendar days from receipt for Senior

Advantage/Medicare Lines of Business. Refer to Section 4 of this Manual for the definition of a clean claim.

5.3.4

Proof of Timely Claims Submission

Claims submitted for consideration or reconsideration of timely filing must be reviewed with information that indicates the claim was initially submitted within the appropriate time frames outlined in Section 5.22 of this Manual. Acceptable proof of timely filing may include the following documentation and/or situations:

• EDI Transmission reports (reports from a clearinghouse i.e. Emdeon, Relay Health,

ENS)

• Remit notices

• Denial notices

*Hand-written or typed documentation is not acceptable proof of timely filing.

Corrected/Replacement Claims

Timely receipt of Corrected/Replacement claims

When a claim is received within the contractual timely filing period but has missing or incorrect information, the provider will be required to submit the requested information within forty five (45) calendar days from the date of the Kaiser Permanente request letter.

Timely receipt of claims filed for reconsideration

When provider requests reconsideration on a claim, the provider will have 45 days from the date of the original SOR to submit the additional documentation.

5.3.5

Appeal of Timely Claims Submission

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original date of denial or explanation of payment, will be allowed for reconsideration of claim processing and payment. Any claim resubmissions received for timely filing reconsideration beyond 45 days of the original date of denial or explanation of payment will be denied as untimely submitted.

5.4. Claim Adjustments/ Corrections (Required)

Claim Adjustments

We reserve the right to audit claims for adjustments and corrections to ensure services rendered are medically necessary, coding requirements are met as stated in this Manual, and payment is according to your Agreement.

Necessary adjustments may be made by offsetting against future claims to any and all claims prior to or after payment.

Periodically, Kaiser Permanente will perform audits on claims to determine if payments have been made appropriately. If our audit determines that an overpayment was made, you will be notified in writing of the amount of the overpayment and given instructions on the process and time frame for reimbursing Kaiser Permanente for the amount

overpaid.

If you do not send a check for the amount of the overpayment within the timeframe specified in your notice, future claims will be offset. Remit notices for claims that have been offset will reflect the amount deducted from the expected payment. Multiple claims may be affected until the entire balance of the overpayment is recovered.

Correcting a previously submitted claim

If your claim requires correction, you will receive a notice on the remit accompanying your rejected claim detailing the error. If corrections can be made, you should submit a corrected claim.

The timeframe for submitting a corrected claim is either detailed in the notice you receive requesting corrections, or will default to the timely filing limit if not specified. Contracted providers can submit a claim correction if he/she has the following justifications:

• Original claim submitted with incorrect diagnosis

• Original claim submitted with incorrect procedure(s)

• Original claim submitted with incorrect member

• Original claim submitted with incorrect date of service

• Original claim submitted with incorrect contract rates applied

• Authorization has been obtained

• Any other information that has been added/corrected on the original claim.

Procedures for submitting a paper claim correction to Kaiser Permanente for processing:

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• Write “CORRECTED CLAIM” in the top (blank) portion of the standard claim

form.

• Attach a copy of the corresponding page of Kaiser Permanente’s

Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip.

• Mail the corrected claim(s) to Kaiser Permanente:

Kaiser Permanente of Colorado Claims Administration

P.O. Box 373150 Denver, CO 80237

A detailed explanation of what should be adjusted and the reason(s) why it

Should be adjusted must be accompanied by supporting documentation to support the adjustment. Allow thirty (30) days from the receipt of your request to research and resolve your adjustment/correction request.

5.4.1

Incorrect Claims Payments

For an Underpayment Error:

Write or call Claims Customer Service (303-338-3800) and explain the error.

If Kaiser Permanente agrees that there has been an error, appropriate corrections will be made by Kaiser Permanente and the underpayment amount owed you will be added to/reflected in your next Kaiser Permanente reimbursement check.

For an Overpayment Error:

You have responsibility to identify and notify us of any overpayments. If you have identified an overpayment, the following options are available to you.

• Write a refund check to Kaiser Permanente for the excess amount paid to you by

Kaiser Permanente. Attach a copy of Kaiser Permanente’s Evidence of Payment to your refund check, as well as a brief note explaining the error.

NOTE: If Kaiser Permanente’s Evidence of Payment is not available, please record the Member’s Medical Record Number on the payment check you are returning.

Mail your refund check (and brief note) to:

Kaiser Permanente Health Plan of Colorado P.O. Box 373150

Denver, CO 80237

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Send the appropriate refund to Kaiser Permanente within thirty (30) days from when you confirm that you are not entitled to the payment for claims within 12 months of the date of service.

• Write or call Claims Customer Service and explain the error. Appropriate

corrections will be made and the overpayment amount will be automatically deducted from your next Kaiser Permanente reimbursement check.

If you discover an overpayment and you do not choose one of the above options, Kaiser Permanente reserves the right to offset future payments for the amount owed.

5.4.2

Rejected Claims Due to EDI Claims Error

The submitting provider is responsible for monitoring the acceptance and reject reports provided by the clearinghouse and to resolve transmission and format issues with the clearinghouse. Issues between the clearinghouse and Kaiser Permanente will be

addressed by Kaiser Permanente.

5.5. Required Identification Information

5.5.1

Federal Tax ID Number

The Federal Tax ID Number as reported on any and all claim form(s) must match the information filed with the Internal Revenue Service (IRS).

1 When completing IRS Form W-9, please note the following:

• Name: This should be the equivalent of your “entity name,” which you use to file your tax forms with the IRS.

• Sole Provider/Proprietor: List your name, as registered with the IRS.

• Group Practice/Facility: List your “group” or “facility” name, as registered with the IRS.

2 Business Name: Leave this field blank, unless you have registered with the IRS as a “Doing Business As” (DBA) entity. If you are doing business under a different name, enter that name on the IRS Form W-9.

3 Address/City, State, Zip Code: Enter the address where Kaiser Permanente should mail your IRS Form 1099.

4 Taxpayer Identification Number (TIN): The number reported in this field (either the social security number or the employer identification number) MUST be used on all claims submitted to Kaiser Permanente.

• Sole Provider/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are “doing business as” an

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entity under a different name).

• Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN).

If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your Federal Taxpayer ID Number on your claim forms, please contact the IRS help line in your area or refer to the following website:

http://www.irs.gov/Forms-&-Pubs

Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente

Attn: Provider Add Technician P.O. Box 372970 Denver, CO 80237

IMPORTANT: If your Federal Tax ID Number should change, please notify us

immediately, so that appropriate corrections can be made to Kaiser Permanente’s files.

5.5.2

Changes in Federal Tax ID Number

If your office/facility changes any pertinent information (i.e., tax identification number, phone or fax number, billing address, practice address, etc.) please mail or fax written notice, including the effective date of the change, as soon as possible, or if at all

possible, with 90 days advance notice. For changes in Federal Tax-ID numbers, please include a W-9 form with the correct information.

Kaiser Permanente Attn: Provider Add Technician

P.O. Box 372970 Denver, CO 80237-6970

5.5.3

National Provider Identification (NPI)

As of May 23, 2008, Kaiser Permanente will not be able to process electronic claims unless they contain the NPI.

If you have already obtained your NPI numbers (both Individual Type 1and/or

Organization/Group Type 2), please notify Kaiser Permanente Provider Contracting & Network Management department.

Individual (Type 1) and Organization/Group (Type 2) NPI applications and instructions

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5.6. Member Cost Share

Depending on the benefit plan, Kaiser Permanente Members may be responsible to share some cost of the services provided. Copayment, co-insurance and deductible (collectively, “Member Cost Share”) are the fees a Member is responsible to pay a Provider for certain covered services. This information varies by plan and all Providers are responsible for collecting Member Cost Share in accordance with Kaiser Permanente Member’s benefits unless explicitly stated otherwise in your Agreement.

Please verify applicable Member Cost Share at the time of service. Member Cost Share information can be obtained from:

• Member ID Card. Copayments, co-insurance and deductible information are listed on the front of the Member ID card when applicable.

5.7. Member Claims Inquiries

Members seeking information regarding claims should contact Kaiser Permanente Customer Service at 303-338-3600.

5.8. Visiting Members

Claims for members visiting from Kaiser Permanente regions other than Colorado should be submitted as you would normally and will be paid at the same rates pursuant to your

agreement.

5.9. Coding for Claims

It is the contracted provider’s responsibility to ensure that billing codes used on claims forms are current and accurate, that codes reflect the services provided, that coding is consistent with the encounter documentation and that coding is in compliance with Kaiser Permanente’s coding standards. Individual physician evaluation and management coding statistics are

routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators.

A full explanation of coding standards is provided in Section 4 of this manual. Incorrect and invalid coding may result in delays in payment or denial of payment.

5.9.1

Coding Standards

Coding – All fields should be completed using industry standard coding as outlined below. ICD-9 (soon to be ICD-10)

To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or five-digit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth digit for coding specificity.

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The U.S. Department of Health and Human Services (HHS) has set the compliance date of October 1, 2014 for the implementation of the International Classification of Diseases, 10th Edition (ICD-10), which is used in administrative health care transactions. This compliance date will apply to both diagnosis and procedure (ICD-10-CM and ICD-10-PCS) codes. CPT-4

The Physicians' Current Procedural Terminology, Fourth Edition (CPT) code set is a

systematic listing and coding of procedures and services performed by Participating Providers. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code.

If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's Web site at

www.ama-assn.org/ama/pub/category/3112.html or submit your request and supporting documentation to:

CPT Editorial Research and Development American Medical Association

515 North State Street Chicago IL 60610 HCPCS

The Healthcare Common Procedure Coding System (HCPCS) Level 2 identifies services and supplies. HCPCS Level 2 begin with letters A–V and are used to bill services such as, home medical equipment, ambulance, orthotics and prosthetics, drug codes and injections.

Revenue Code

Approved by the Health Services Cost Review Commission for a hospital located in the State of Maryland, or of the national or state uniform billing data elements specifications for a hospital not located in that State.

NDC (National Drug Codes)

Prescribed drugs, maintained and distributed by the U.S. Department of Health and Human Services

ASA (American Society of Anesthesiologists)

Anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists

DSM-IV (American Psychiatric Services)

For psychiatric services, codes distributed by the American Psychiatric Association

5.9.2

Modifiers in CPT and HCPCS

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service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book. Note CMS-1500 Submitters: Kaiser Permanente

processes up to 4 modifiers per claim line. When submitting claims, use modifiers to:

• Identify distinct or independent services performed on the same day • Reflect services provided and documented in a patient's medical record Modifiers for Professional and Technical Services

[Modifier 26, Professional Component - Certain procedures consist of a physician component and a technical component. When the physician component is reported separately, adding the Modifier 26 to the CPT procedure code identifies the service. Modifier TC, Technical Component - The modifier TC is submitted with a CPT procedure code to bill for equipment and facility charges, to indicate the technical component.

• Use with diagnostic tests; e.g. radiation therapy, radiology, and pulmonary function tests.

• Indicates the Provider performed only the technical component portion of the service.]

Modifiers Billed with Evaluation and Management (E/M) Services

[Modifier 24 is used to report an unrelated evaluation and management service performed by the same physician who performed the surgery during a postoperative period.

Modifier 25 is used to report a significant, separately identifiable evaluation and

management service performed by the same physician on the same date of service as a procedure or service. Modifier 25 can be used for significant, identifiable visits to be considered for reimbursement when substantiated in the medical records, which should be available upon request.

Modifier 57 is used when the decision to perform a major surgery happens the day before or day of the major surgery.]

Modifiers Billed with Surgical Procedures [Modifier 50 – Bilateral Procedure

Add Modifier 50 to the service line of a unilateral 5-digit CPT procedure code to indicate that a bilateral procedure was performed. Modifier 50 may be used to bill surgical

procedures at the same operative session, or to bill diagnostic and therapeutic procedures that were performed bilaterally on the same day.]

Durable Medical Equipment (DME) Modifiers Modifier RR–Rental (DME)

Add Modifier RR to the service line of a DME procedure code to indicate that equipment is a rental.

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Modifier NU–New Equipment

Add Modifier NU to the service line of a DME procedure code to indicate that equipment is a purchase.

5.9.3

Modifier Review

Kaiser Permanente reserves the right to review use of modifiers to ensure accuracy and appropriateness. Improper use of modifiers may cause claims to pend and/or the return of claims for correction.

5.9.4

Coding & Billing Validation

We perform code editing to enforce both Kaiser Permanente and nationally accepted coding and payment rules (see Section 5.37 of this Manual), and to verify the codes you submit are consistent based on the services rendered. Your claims will be subjected to McKesson code editing software (“CodeReview®”). CodeReview® assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding of procedure(s) not their medical necessity. CodeReview® provides consistent and objective claim review by accurately

applying coding criteria for all clinical areas of medicine, surgery, laboratory, pathology, radiology and anesthesia. See Section 5.41 for code editing rules.

CodeReview® may change and edit your claim, perhaps substantially, as a result of these code editing rules. When a change is made to your submitted code(s), Kaiser Permanente will provide an explanation of the reason for the change.

Possible outcomes from Code Review include:

• Accepting the code(s) as submitted.

• Changing the submitted code(s) to comply with generally accepted coding

practices that are consistent with Physicians Current Procedural Terminology (CPT), the HCPCS Code Book and recommendations made by peer specialist physicians.

• Updating outdated or invalid codes.

• Denying line items.

• Bundling or unbundling codes as appropriate.

• Denying code(s) as incidental or inherent part of the more global code billed.

• Adjusting payment.

• Seeking additional information from the physician’s office due to inconsistent

information in the claim.

Fraudulent coding will be investigated by Kaiser Permanente. In addition, individual physician evaluation and management coding statistics are routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators.

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5.9.4.1 Claims Editing Software Programs

Services must be reported in accordance with the reporting guidelines and instructions contained in the American Medical Association (“AMA”) CPT Manual, “CPT® Assistant,” and HCPCS publications.” Providers are responsible for accurately reporting the

medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate.

Claims are processed utilizing claims editing software product from McKesson Code Review/ ClaimsXten. CodeReivew/ClaimsXten includes edit rules such as incidental, bundled and mutually as well as other edits that are recognized by industry guidelines. CodeReview/ClaimsXten will be updated on a quarterly basis. In addition to adding new CPT codes, HCPCS codes, and NCCI edits, McKesson continues to add and revise content based on ongoing review of the entire knowledge base. This continuous process helps to ensure that the clinical content used in CodeReview/ClaimsXten is clinically appropriate and withstands the scrutiny of both payers and providers.

Code Review/ ClaimsXten is used to evaluate the accuracy of medical claims and their adherence to accepted CPT/HCPCS coding practices and it allows us to monitor the increasingly complex developments in medical technology and correct procedure coding used to process physician payments. American Medical Association Complete

Procedural Terminology (CPT®), CPT Assistant, coding guidelines developed from national specialty societies, CMS, National Correct Coding Initiative (“NCCI” or “CCI”), Healthcare Common Procedure Coding System (HCPCS®), American Society of Anesthesiology (“ASA”), and other standard-setting organizations for claims billing procedures are considered in developing Kaiser Permanente’s coding and

reimbursement edits and policies. 5.9.4.2 Types of edits

Procedure unbundling occurs when two (2) or more procedures are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed by a provider. In this instance, the two (2) codes may be replaced with the more appropriate code by our bundling system.

Example 1: Laboratory

Laboratory unbundling edits are applied when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should not be billed separately, but should be billed using one (1) panel coding.

Example 2: Electrocardiograms

A claim billed with the following two (2) codes together would be considered as unbundled:

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Claim Detail Line 1 - 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report.

Claim Detail Line 2 - 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

Example 2 Explanation: When CPT codes 93004 and 93010 are performed on the same day, the appropriate comprehensive procedure code would be 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.

An incidental procedure is performed at the same time as a more complex primary procedure. The incidental procedure doesn’t require significant additional physician resources and/or is clinically integral to the performance of the primary procedure. Mutually exclusive procedures are two (2) or more procedures usually not performed during the same patient encounter on the same date of service. Mutually exclusive rules may also govern different procedure code descriptions for the same type of procedure for which the physician should be submitting only one (1) procedure. Duplicate procedure editing involves duplicate procedures submitted with the same date of service or on previously submitted claim(s) or claim line(s). Duplicate line items are determined based on matches on certain key fields. Duplicate procedures include the following

When the description of the procedure contains the word “bilateral,” the procedure may be performed only once on a single date of service. When the description of a procedure code contains the phrase

“unilateral/bilateral,” the procedure may be performed only once on a single date of service.

When the description of the procedure specifies “unilateral” and there is another procedure whose description specifies “bilateral” performance of the same procedure, the unilateral procedure may not be submitted more than once on a single date of service.

When the description of one procedure specifies a “single” procedure and the description of a second procedure specifies “multiple” procedures, the single procedure may not be submitted more than once on a single date of service. The global duplicate value is the total number of times it’s clinically possible or Medically Necessary to perform a given procedure on a single date of service across all anatomic sites.

Age edits occur when the provider assigns an age-specific procedure or diagnosis code to a patient whose age is outside the designated age range.

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Gender edits occur when the provider assigns a gender-specific procedure or diagnosis code to a patient of the opposite sex.

Frequency edits occur when a procedure is billed more often than would be expected. Frequency edits occur when:

Procedure Maximum Frequency Per Day

Identifies procedure codes billed on a claim that have maximum quantities allowed within a twenty-four (24) hour period.

Deny Base Code with Quantity Greater than One (1)

Identifies situations on a claim where the base code with quantity is billed rather than the appropriate add on code(s). Add-on procedures should be submitted in addition to the primary (base code) procedure. Primary (base code) procedures are typically billed with a quantity of one (1). Additional services beyond the primary (base code) procedure should be billed as an add-on procedure code. Global Surgical Packaging identifies Evaluation & Management (E&M) codes and supplies billed on a claim within the global period. Procedure codes have a time frame associated with them which includes services and supplies associated with the

procedure. The time frames are set by both the Center of Medicare and Medicaid Services (CMS) and broadly accepted industry sources.

New Patient Code for Established Patient identifies new patient visits that are billed for established patients. The new patient procedure code may only be billed once every three (3) years.

History Editing occurs when a previously submitted historical claim that is related to current claim submission is identified. This identification/edit may result in adjustments to claims previously processed.

An example of such a historical auditing action would occur when an E/M visit is submitted on one (1) claim and then a surgery for the same service date is submitted on a different claim. If a determination that the E/M visit paid in history is included in the allowable for the surgery, an adjustment of the E/M claim will be necessary, this may result in an overpayment recovery

History editing capability are not limited to; global surgery, multiple visits per day, pre/post-operative visits, new patient visits, frequency rules, incidental, mutually exclusive and rebundle edits and maternity services

Place of Service edits identify the reporting of an inappropriate place of service for a particular procedure, either due to the descriptive verbiage of the code, or due to published CPT coding guidelines which indicate that a specific procedure is not intended to be reported in a certain setting

Deleted Procedure Code identifies a deleted or expired code billed on a claim. The Center of Medicare and Medicaid Services (CMS) does not permit reimbursement of

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AMA deleted codes when they are submitted after the deletion date and beyond the submission period.

Multiple/Duplicate Component Billing identifies when a procedure billed on a claim may be billed with a professional or technical components (i.e., with Modifiers 26 or TC) submitted. The edits ensures that the total reimbursement amount does not exceed the allowable amount for the procedure without the modifier(s). Kaiser Permanente

reserves the right to adjust claims that are paid in excess of the total.

5.9.4.3 Modifiers

In certain circumstances, it is appropriate to use modifiers to report services that warrant reimbursement separately from what would usually be expected. The use of these modifiers should not be routine.

Modifier 25 is used to indicate that on the day a procedure or preventive exam was performed, the patient’s condition required a significant, separately identifiable E/M service beyond the usual care associated with the procedure or preventive exam. Without the modifier-25 designation, the E/M code is bundled into the procedure, or preventive exam. Only append modifier 25 to E/M codes 99201-99499

Modifier 50 is used to indicate a bilateral procedure and using CMS guidelines when processing bilateral surgeries/procedures. When a procedure is not identified by its terminology as a bilateral procedure it is billed on one line with the surgical procedure code, one unit of service and modifier 50. Bilateral surgeries/procedures are considered one surgery. We will be using CMS guidelines to determine appropriateness.

If the code is reported as a bilateral procedure, and is reported with other procedure codes on the same day, then the bilateral adjustment will be applied before applying any multiple procedure rules.

Modifier 51 is used to indicate when multiple procedures are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or services(s) shall be identified by appending modifier 51 to the additional procedure or service codes(s). Modifier 51 should not be appended to designated “add-on” codes. We will be using CMS guidelines to determine appropriateness.

Modifier 52 is used to identify reduced services. Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. These services may be reviewed.

Modifier 57 is used to identify the patient encounter that resulted in the decision to perform surgery. Without the modifier, the E/M code is bundled to the surgical procedure when performed the day of or the day before a major surgical procedure

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Modifier 59 is used to identify procedures/services that aren’t normally reported together but are appropriate under the circumstances. This may include a different procedure or surgery, a different site, or a separate incision/excision, lesion or patient encounter.

Append modifier 59 to procedures or surgeries; Modifier 59 is not appropriate for supplies, DME codes, drugs or “J” codes or E/M codes

If modifier 59 is appended to inappropriate codes, it will be disregarded or denied as inappropriate use of the modifier

Modifier 80, 81, 82 or AS is used to identify assist surgeon procedures. We will be using CMS guidelines to determine appropriateness.

Multiple modifiers: Kaiser Permanente systems adjudicate using the first and second modifier on the claim line. If all modifiers are used to make payment determination, the claim will pend so that it can be manually adjudicated with all modifiers reported

5.9.5

Coding Edit Rules

Kaiser Permanente applies coding edit rules to all claims submitted. The following descriptions outline some of the major categories of our coding edit rules, some of which CodeReview/ClaimsXten® (see Section 5.40) applies automatically as part of coding and billing validation.

These rules are subject to change and may be edited from time to time. There may be situations where your contract supersedes these rules. Should you have any questions regarding your contract and code editing, please contact your Contract manager or Claims Customer Service. Major Categories of Claim Coding Errors/Inconsistencies: AMA and CMS Guidelines

CodeReview/ClaimsXten® will correct input codes without valid modifiers to more closely correspond to accepted coding practices by eliminating, replacing or flagging potential errors while accepting coding practices judged to be conventional by the American Medical Association (AMA) and the Centers for Medicare &

Medicaid Services (CMS). The CPT and HCPCS manuals explicitly detail and outline many of the rules included in

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HCPCS codes related to CPT codes

CodeReview/ClaimsXten® also evaluates the combination of HCPCS codes and CPT codes. These codes are cross walked to identify where a HCPCS code is related to one or many CPT codes, and are evaluated based on the existing CPT rules. Unnecessary or disallowed codes are then rejected.

Example: HCPCS code D7872 is defined as “diagnostic arthroscopy of the

temporomandibular joint, with or without biopsy”. D7872 is related to the CPT code 29800 “diagnostic arthroscopy of temporomandibular joint.” Since both codes have the same narrative, the CPT code should be used. If both codes are submitted for the same date of service, CodeReview denies the HCPCS code as part of the CPT code. In addition, additional rules regarding CPT and HCPCS codes will be applied, so in this example, if 90780 or 90781 (IV infusion) were also on the claim, they would be denied as part of the global services.

HCPCS codes not related to CPT codes

CodeReview® also detects situations where HCPCS codes are not related to CPT codes. Rules developed as appropriate that are the result of the review of non-CPT related HCPCS codes are part of the knowledge base supporting CodeReview® and do not conflict with the National Correct Coding Policy Initiative (NCCPI).

Example: E1050 is denied in conjunction with E1060. The description for E1050 is “fully reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests”. The description for E1060 is “fully reclining wheelchair, detachable arms, swing away detachable elevating leg rests.”

Procedure Unbundling

Procedure unbundling occurs when two or more procedure codes are used to describe a procedure performed, when a single—more comprehensive—procedure code exists that accurately describes the entire procedure performed.

Example 1: Laboratory unbundling occurs when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should NOT be billed separately, but should be billed using ONE panel code.

Example 2: Billing the following two codes together is considered “unbundling.” 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report.

93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

When 93005 and 93010 are performed on the same day the appropriate comprehensive procedure code would be 93000.

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Incidental Procedures

An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately. Separate Procedures

Procedures designated as a “separate procedure” in the CPT code book are commonly performed as an integral part of a total, larger procedure, and normally does NOT warrant separate identification. Therefore, these services are typically included as part of the “global” charges submitted for the related, larger procedure. However, when the procedure is performed as a separate, independent service not in conjunction with any normally related procedure it may be billed as a “separate procedure.” If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement.

Mutually Exclusive Procedures

Mutually exclusive procedures are two or more procedures that are usually

NOT performed at the same operative session on the same member on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedure(s), for which the physician should be submitting only ONE of the procedure codes.

Age and Gender (Sex) Conflicts

An age conflict occurs when the contracted provider bills an age-specific procedure code for a member outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a member of the opposite gender.

Example 1: The contracted provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old member.

Example 2: Code 58150 Total abdominal hysterectomy is submitted for a male member.

Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother’s contract and are excluded from the age processing rules.

The following age categories are examined for conflicts: • Newborn (age less than 1 year old)

• Pediatric (ages 1-17 years old) • Maternity (ages 12-55 years old) • Adult (ages over 14 years old)

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Obsolete/Deleted Codes

If obsolete or deleted codes cannot be cross walked to current or updated codes, claims submitted may be denied. Obsolete or deleted codes are updated each calendar year and are not accepted past the end date specified by CMS. Medicare claims with outdated codes will be subject to denial as per CMS guidelines.

Multiple/ Duplicate Component Billing

When procedures are billable for professional and technical components (i.e., with Modifiers 26 and TC), Kaiser Permanente monitors that the total amount paid for the service does not exceed what would have been paid if the procedure had been billed without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total.

Denied codes

Certain codes are always denied. To obtain a full list of these codes, please contact Claims Customer Service at 303-338-3800. Kaiser Permanente reserves the right to revise the list from time to time. In general, these codes relate to personal comfort items, non-covered services, benefit exceptions, and codes not reimbursable when billed in conjunction with Emergency services (i.e., X-ray interpretation, After-Hours codes.)

Additional circumstances where coding edits are applied are detailed in Section 5.52 of this Manual.

CodeReview/ ClaimXten® assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding of the procedure(s) not their medical necessity. When a change is made to your

submitted code(s), it will be noted in your remit.

5.10.

Medical Claims Review (Required)

Medical claims review is performed by comparing billing records with medical records to determine payment accuracy and to ensure claims are paid only for services delivered. Physician orders are carefully checked to make sure services delivered were ordered by a physician.

We perform medical claims review on an ongoing basis as a monitoring function and for the purpose of trending for aberrance. In addition, medical claims review may occur as the result of a complaint or compliance violation.

If you should be contacted regarding medical claims review, we expect you to respond within the timeframe specified in our request.

5.10.1 Major Categories of Claim Coding Errors/Inconsistencies

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Definition: Procedure unbundling occurs when two or more procedure codes are used to describe a procedure performed, when a single – more comprehensive – procedure code exists that accurately describes the entire procedure performed. [Example 1: Laboratory unbundling occurs when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should NOT be billed separately, but should be billed using ONE panel code.

Example 2: Billing the following 2 codes together is considered “unbundling.” 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report

93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

When 93005 and 93010 are performed on the same day the appropriate comprehensive procedure code would be 93000.]

5.10.1.2 Incidental Procedures

Definition: An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little

additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed

separately.

5.10.1.3 Separate Procedures

Definition: Procedures designated as a “separate procedure” in the CPT code book are commonly performed as an integral part of a total, larger procedure, and

normally do NOT warrant separate identification. Therefore, these services are typically included as part of the “global” charges submitted for the related, larger procedure.

However, when the procedure is performed as a separate, independent service not in conjunction with any normally related procedure it may be billed as a “separate procedure.” If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement.

5.10.1.4 Mutually Exclusive Procedures

Definition: Mutually exclusive procedures are two or more procedures that are usually NOT performed at the same operative session on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedure(s), for which the physician should be submitting only ONE of the procedure codes.

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5.10.1.5 Age and Gender (Sex) Conflicts

Definition: An age conflict occurs when the Provider bills an age-specific procedure code for a patient outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a patient of the opposite gender.

[Example 1: The Provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old patient.

Example 2: Code 58150 Total abdominal hysterectomy is submitted for a male patient. Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother’s contract and are excluded from the age processing rules.

The following age categories are examined for conflicts: • Newborn (age less than 1 year old)

• Pediatric (age 1-17 years old) • Maternity (age 12-55 years old) • Adult (age over 14 years old)] 5.10.1.6 Obsolete/Deleted Codes

Claims submitted with obsolete or deleted codes may be denied. Obsolete or

deleted codes are updated each calendar year and will be end dated as specified by CMS. Kaiser Permanente pays against deleted codes for as long as the code billed was valid for the date of service on the claim.

5.10.1.7 Multiple/ Duplicate Component Billing

When procedures are billable for professional and technical components (i.e. with

modifiers 26 and TC), Kaiser Permanentemonitors that the total amount paid for the

service does not exceed what would have been paid if the procedure had been billed

without the modifier(s). Kaiser Permanentereserves the right to adjust claims that

are paid in excess of the total.

5.11.

Third Party Liability (TPL)

Third Party Liability is coordinated thru Healthcare Recovery Incorporated (HRI).

P.O. BOX 37440 Louisville, KY 40233 TEL: 1-800 552-83