Provider Manual - Kaiser Permanenteinfo.kaiserpermanente.org/info_assets/cpp_cod/cod_providermanual... · Kaiser Permanente Provider Manual 3 Table of Contents ... 5.16.7.4 Antepartum

Provider Manual Billing and Payment

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 you have a question or concern about the information in this section, please call

1-888-681-7878 or 303-338-3600 .

Billing and Payment

KAISER PERMANENTE

Kaiser Permanente Provider Manual 3

Table of Contents

SECTION 5: BILLING AND PAYMENT .......................................................................... 8

5.1. WHOM TO CONTACT WITH QUESTIONS ........................................................................... 8

5.2. METHODS OF CLAIMS FILING ........................................................................................... 8

5.2.1 Paper Claim Forms ................................................................................................................. 8

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 ............................................................. 9

5.2.1.4 Record the Name of the Provider You Are Covering For ................................................... 9

5.2.1.5 Submission of Multiple Page Claim .................................................................................... 9

5.2.1.6 Entering Dates ................................................................................................................... 9

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

5.2.1.8 Surgical and/or Obstetrical Procedures ............................................................................ 10

5.2.1.9 Billing Inpatient Claims That Span Different Years ........................................................... 10

5.2.1.10 Interim Inpatient Bills ...................................................................................................... 10

5.2.1.11 Supporting Documentation for Paper Claims ................................................................. 11

5.2.1.12 Where to Mail/Fax Paper Claims .................................................................................... 11

5.2.2 Electronic Data Interchange (EDI) ...................................................................................... 11

5.2.2.1 Electronic Claims Forms / Submissions ........................................................................... 12

5.3. CLAIM FILING REQUIREMENTS ....................................................................................... 13

5.3.1 Clean Claims .......................................................................................................................... 13

5.3.2 Claims Submission Timeframes .......................................................................................... 14

5.3.3 Claims Processing Turn-Around Time .............................................................................. 14

5.3.4 Proof of Timely Claims Submission ................................................................................... 14

5.3.5 Appeal of Timely Claims Submission ................................................................................ 15

5.4. CLAIM ADJUSTMENTS/ CORRECTIONS (REQUIRED) ...................................................... 15

KAISER PERMANENTE


5.4.1 Incorrect Claims Payments .................................................................................................. 16

5.4.2 Rejected Claims Due to EDI Claims Error ......................................................................... 17

5.5. REQUIRED IDENTIFICATION INFORMATION ................................................................... 17

5.5.1 Federal Tax ID Number ....................................................................................................... 17

5.5.2 Changes in Federal Tax ID Number ................................................................................... 18

5.5.3 National Provider Identification (NPI) .............................................................................. 19

5.6. MEMBER COST SHARE ..................................................................................................... 19

5.7. MEMBER CLAIMS INQUIRIES ........................................................................................... 19

5.8. VISITING MEMBERS .......................................................................................................... 19

5.9. CODING FOR CLAIMS ....................................................................................................... 19

5.9.1 Coding Standards ................................................................................................................. 20

5.9.2 Modifiers in CPT and HCPCS ............................................................................................. 21

5.9.3 Modifier Review .................................................................................................................... 22

5.9.4 Coding & Billing Validation ................................................................................................ 22

5.9.4.1 Claims Editing Software Programs ................................................................................... 23

5.9.4.2 Types of edits ................................................................................................................... 23

5.9.4.3 Modifiers ........................................................................................................................... 26

5.9.5 Coding Edit Rules ................................................................................................................. 27

5.10. MEDICAL CLAIMS REVIEW (REQUIRED) ....................................................................... 30

5.10.1 Major Categories of Claim Coding Errors/Inconsistencies ............................................. 31

5.10.1.1 Procedure Unbundling .................................................................................................... 31

5.10.1.2 Incidental Procedures ..................................................................................................... 31

5.10.1.3 Separate Procedures ..................................................................................................... 31

5.10.1.4 Mutually Exclusive Procedures ...................................................................................... 31

5.10.1.5 Age and Gender (Sex) Conflicts ..................................................................................... 31

5.10.1.6 Obsolete/Deleted Codes ................................................................................................ 32

KAISER PERMANENTE


5.10.1.7 Multiple/ Duplicate Component Billing ............................................................................ 32

5.11. THIRD PARTY LIABILITY (TPL) ....................................................................................... 32

5.12. WORKERS’ COMPENSATION ............................................................................................ 32

5.13. THIRD PARTY ADMINISTRATOR (TPA) (REQUIRED) .................................................... 32

5.14. PROVIDER CLAIMS APPEALS (REQUIRED) .................................................................... 33

5.14.1 Provider Claim Payment Appeals Process ........................................................................ 33

5.15. CLAIM FORM EXAMPLES AND INSTRUCTIONS ............................................................... 33

5.15.1 CMS-1500 (08/05) FIELD DESCRIPTIONS ........................................................................ 33

5.15.2 CMS-1450 (UB-04) Field Descriptions ................................................................................ 42

5.16. BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ......................... 47

5.16.1 Capitation Payments ............................................................................................................ 47

5.16.2 Evaluation Management (E/M) Services ............................................................................ 48

5.16.2.1 Inpatient E/M Services: .................................................................................................. 48

5.16.2.2 Surgical Procedure that Include E/M Services: .............................................................. 49

5.16.2.3 Preventive Medicine Services: ....................................................................................... 53

5.16.3 Emergency Rooms ................................................................................................................ 54

5.16.3.1 Two Physicians Involved in Admitting a Patient from the ER ......................................... 54

5.16.3.2 “Emergency” in the Office Setting................................................................................... 54

5.16.3.3 “Non-Emergency” Services Provided in the Emergency Department ............................. 54

5.16.3.4 Emergency Room and Urgent Care Services Submitted on a UB-92 ............................ 55

5.16.4 Critical Care Services ............................................................................................................ 55

5.16.4.1 Patient Located in a Critical Care Unit Not Receiving Critical Care Services ................. 55

5.16.5 Observation Services ............................................................................................................ 55

5.16.6 Injection/ Immunizations ..................................................................................................... 55

5.16.6.1 Vaccine Immunizations .................................................................................................. 55

5.16.6.2 Allergy Immunotherapy .................................................................................................. 55

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5.16.7 Obstetrical Services ............................................................................................................... 56

5.16.7.1 Admissions for False Labor ............................................................................................ 56

5.16.7.2 Anesthesia Services Provided with Deliveries ................................................................ 56

5.16.7.3 Multiple Physicians Provide Different Components of the Obstetrical Care ................... 57

5.16.7.4 Antepartum Care ............................................................................................................ 57

5.16.8 Newborn Services ................................................................................................................. 57

5.16.8.1 Newborn Care When Baby Is Discharged with Mother .................................................. 57

5.16.8.2 Newborn Care When Baby is Discharged without Mother .............................................. 58

5.16.8.3 Boarder Babies Who Stay Beyond Their Mother’s Discharge Date ............................... 58

5.16.8.4 Mother who stays beyond their baby discharge date. .................................................... 59

5.16.9 Surgery ................................................................................................................................... 59

5.16.9.1 Global Period / Surgical Package ................................................................................... 59

5.16.9.2 Endoscopic Procedures Included in the Surgical Package ............................................ 63

5.16.9.3 Anesthesia Procedures Included in the Surgical Package ............................................. 64

5.16.9.4 Topical/Local/Digital Block Anesthesia Included in the Surgical Package ...................... 64

5.16.9.5 Preoperative Care/Services Included in the Surgical Package ...................................... 64

5.16.9.6 Preoperative Care/Services Excluded from the Surgical Package ................................. 65

5.16.9.7 Postoperative Follow-Up Care Included in the Surgical Package .................................. 65

5.16.9.8 Postoperative Follow-Up Care Excluded from the Surgical Package ............................. 65

5.16.9.9 Same-Day Services Excluded from the Surgical Package ............................................. 66

5.16.9.10 Assistant Surgeon ........................................................................................................ 66

5.16.9.11 Co-Surgery (Two Surgeons) ........................................................................................ 67

5.16.9.12 Team Surgery .............................................................................................................. 67

5.16.9.13 Duplicate / Bilateral Procedures ................................................................................... 67

5.16.9.14 Multiple Surgery Reimbursement for Professional and Facility Claims ........................ 68

5.16.9.15 Exploratory/Diagnostic Procedures .............................................................................. 68

5.16.10 Cardiac Procedures ............................................................................................................... 68

5.16.10.1 Cardiac Catheterization Billing ..................................................................................... 68

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5.16.10.2 Electrophysiologic Studies (EPS), Cardiac Mapping and Ablations ............................. 69

5.16.10.3 EPS and Cardiac Catheterization ................................................................................. 70

5.16.10.4 Cardiac Rehabilitation .................................................................................................. 70

5.16.11 Transplants ............................................................................................................................ 70

5.16.12 Anesthesia .............................................................................................................................. 71

5.16.13 Behavioral Health Services .................................................................................................. 72

5.16.14 Durable Medical Equipment ............................................................................................... 73

5.16.15 Laboratory Procedures ......................................................................................................... 73

5.16.16 Radiology Services ................................................................................................................ 74

5.16.17 Radiation Treatment ............................................................................................................. 75

5.16.18 Interventional Radiology ..................................................................................................... 76

5.16.19 Therapy: Physical/ Occupational/Speech (P.O.S.) ........................................................... 76

5.17. COORDINATION OF BENEFITS (COB) (REQUIRED) ....................................................... 78

5.17.1 How to Determine the Primary Payor ............................................................................... 78

5.17.2 Description of COB Payment Methodologies ................................................................... 79

5.17.3 COB Claims Submission Requirements and Procedures ................................................ 79

5.17.4 Members Enrolled in Two Kaiser Permanente Plans....................................................... 79

5.17.5 COB Claims Submission Timeframes ................................................................................ 79

5.17.6 COB FIELDS ON THE UB-92 and UB-04 CLAIM FORM ............................................... 80

5.17.7 COB FIELDS ON THE CMS-1500 (HCFA-1500) CLAIM FORM ................................... 82

5.18. EXPLANATION OF PAYMENT (EOP) (REQUIRED) .......................................................... 85


Section 5: Billing and Payment


It is your responsibility to submit itemized claims for services provided to 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. Health Plan agrees to implement any new or revised CMS Fee Schedule within 45 calendar days after the CMS File Publish Date or CMS Implementation Date, whichever is later.

5.1. Whom to Contact with Questions

Central Pre-authorization Department (303) 636-3131 or (877) 895-2705, 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 or (800) 632-9700 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 or (800) 632-9700 Provides benefits or eligibility of a Kaiser Permanente member. Providers can also find benefit information on Kaiser Permanente ID cards. All member cost share should be collected at the time services are provided. This department also documents, reports and facilitates the response to member complaints. Provider Credentialing Requirements (866) 866-3951 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.

5.2. Methods of Claims Filing

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). Note: Effective April 1, 2014, the Center of Medicare & Medicaid Service (CMS) has revised the CMS -1500 form.

5.2.1.1 Record Authorization Number

All services that require prior authorization must have an authorization number reflected on the claim form.

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.

Separate claim forms must be completed for each Member and for each Provider

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.

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 or a case-rate 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 hospitalization. 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.

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 Paper Claims

Paper claims are accepted; however EDI (electronic) submission is preferred. Paper claims are not accepted via fax due to HIPAA regulations. Mail all paper claims to: Kaiser Permanente of Colorado Claims Administration P.O. Box 373150 Denver, CO 80237

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

Kaiser Permanente of Colorado accepts all claims submitted by mail or electronically.

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

837P must be used for all professional services and suppliers.

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 protected].

mailto:[email protected]



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 800-778-6711 for new customers and 800-527-8133 for existing customers

5.3. Claim Filing Requirements

5.3.1 Clean Claims

Kaiser Permanente follows all state and Federal clean claim requirements. Please refer to 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 o r 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. 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. 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 ofyour 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.

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 5.3.2 of this Manual. Acceptable proof of timely filing may include the following documentation and/or situations: EDI Transmission reports) 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

Resubmitted claims along with proof of initial timely filing received within 45 days of the 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 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 via paper 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:

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

Attach a copy of the corresponding page of Kaiser Permanente’s Statement of Remittance (SOR) 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) 338-3600 or (800) 632-9700) 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 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 SOR to your refund check, as well as a brief note explaining the error.

NOTE: If Kaiser Permanente’s SOR 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 Attn: Refund Recovery Department 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 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 Contracting 10350 E. Dakota Avenue

Denver, CO 80247

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.

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



Kaiser Permanente Attn: Provider Contracting 10350 E. Dakota Avenue

Denver, CO 80247

5.5.3 National Provider Identification (NPI)

Kaiser Permanente will not be able to process electronic claims unless they contain the NPI. Individual (Type 1) and Organization/Group (Type 2) NPI applications and instructions can be accessed at: https://nppes.cms.hhs.gov.

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. 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. Please contact Member Services to obtain a visiting member identification number at 303-338-3800 or 800-632-9700.

5.9. Coding for Claims

Contracted providers are responsible to ensure that billing codes used on claims forms are current and accurate. 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.

https://nppes.cms.hhs.gov/



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.

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

Modifiers submitted with an appropriate procedure code further define and/or explain a 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. 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.

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:

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.

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 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,

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 be held for manual adjudication and review.

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® 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



closely correspond to accepted coding practices by 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 CodeReview/ClaimsXten®. 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. 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) 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.) 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.

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

5.10.1.1 Procedure Unbundling

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.

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 upays 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 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.

5.11. Third Party Liability (TPL)

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

P.O. BOX 37440

Louisville, KY 40233

TEL: 1-800 552-8314

Fax: (502) 454-1137

Hours of Operations

8:30 a.m. to 5:00 p.m. Monday-Friday (Eastern Time)

5.12. Workers’ Compensation

Workers’ Compensation claims are not covered by Kaiser Permanente. We will deny all claims related to Workers’ Compensation.

5.13. Third Party Administrator (TPA) (Required)

Ground Ambulance is paid by a TPA for all lines of business. All Ground Ambulance claims should be mailed to the below address: Employers Mutual 9716 San Jose Blvd. Jacksonville, FL 32257-5436



5.14. Provider Claims Appeals (Required)

Refer to Section 4 of this Manual for the information on provider claims appeals.

5.14.1 Provider Claim Payment Appeals Process

If your office/facility has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact Claims Customer Service at 303-338-3800. Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone. If your issue cannot be resolved through this initial contact, you have the right to appeal. See Section 6 of this Manual for a full explanation of this process. For information on self-funded claim disputes or appeals, call 1-877-883-6698. In most cases, they will be able to answer and resolve any issues you may have. For further information, please refer to the Self-Funded Program Provider Manual.

5.15. Claim Form Examples and Instructions

5.15.1 CMS-1500

The fields identified in the table below as “Required” must be completed when submitting a CMS-1500 (08/05) claim form to Kaiser Permanente for processing: Note: The required fields for submission shown below are required by Kaiser Permanente but not necessarily required by CMS or other payers. For Medicare Members, please refer to Medicare Billing Requirements for appropriate field requirements and instructions/examples.

FIELD NUMBER

FIELD NAME REQUIRED FIELDS

FOR CLAIM SUBMISSIONS

INSTRUCTIONS/EXAMPLES

1

MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER

Not Required Check the type of health insurance coverage applicable to this claim by checking the appropriate box.

1a

INSURED’S I.D. NUMBER Required Enter the subscriber’s plan identification number.

2

PATIENT’S NAME Required Enter the patient’s name. When submitting newborn claims, enter the newborn’s first



FIELD NUMBER




and last name.

3

PATIENT’S BIRTH DATE AND SEX

Required Enter the patient’s date of birth and gender. The date of birth must include the month, day and FOUR DIGITS for

the year (MM/DD/YYYY). Example: 01/05/2006

4

INSURED’S NAME

Required Enter the name of the insured (Last Name, First Name, and Middle Initial), unless the insured and the patient are

the same—then the word “SAME” may be entered.

5

PATIENT’S ADDRESS Required Enter the patient’s mailing address and telephone number. On the first line, enter the STREET ADDRESS; the second line is for the CITY and STATE; the third line is for the ZIP CODE and PHONE NUMBER.

6

PATIENT’S RELATIONSHIP TO INSURED

Required Check the appropriate box for the patient’s relationship to the insured.

7

INSURED’S ADDRESS Required if Applicable

Enter the insured’s address (STREET ADDRESS, CITY, STATE, and ZIP CODE) and telephone number. When

the address is the same as the patient’s—the word

“SAME” may be entered.

8

Reserved for NUCC Use Not required

9

OTHER INSURED’S NAME

Required if Applicable

When additional insurance coverage exists, enter the last name, first name and middle initial of the insured.

9a OTHER INSURED’S POLICY OR

GROUP NUMBER Required if Applicable

Enter the policy and/or group number of the insured

individual named in Field 9 (Other Insured’s Name) above. NOTE: For each entry in Field 9A, there must be a corresponding entry in Field 9d.

9b RESERVED FOR NUCC USE Required if Applicable

9c RESERVED FOR NUCC USE Required if Applicable

9d INSURANCE PLAN NAME OR PROGRAM NAME


Enter the name of the “other” insured’s INSURANCE PLAN or program.

10a-c IS PATIENT CONDITION RELATED TO

Required Check “Yes” or “No” to indicate whether

employment, auto liability, or other accident

involvement applies to one or more of the services described in field 24.

NOTE: If “yes” there must be a corresponding entry in Field 14 (Date of Current Illness/Injury). Place (State) - enter the State postal code.



FIELD NUMBER




10d

CLAIM CODES Not Required Leave blank.

11

INSURED’S POLICY NUMBER OR FECA NUMBER

Not Required If there is insurance primary to Medicare, enter the insured’s policy or group number.

11a

INSURED’S DATE OF BIRTH

Not Required Enter the insured’s date of birth and sex, if different from Field 3. The date of birth must include the month, day, and FOUR digits for the year (MM/DD/YYYY). Example: 01/05/2006

11b

OTHER CLAIM ID Not Required Leave blank

11c

INSURANCE PLAN OR PROGRAM NAME

Not Required Enter the insurance plan or program name.

11d

IS THERE ANOTHER HEALTH BENEFIT PLAN?

Required Check “yes” or “no” to indicate if there is another health benefit plan. For example, the patient may be covered under insurance held by a spouse, parent, or some other person. If “yes” then fields 9 and 9a-d must be completed.

12

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

Not Required Have the patient or an authorized representative SIGN and DATE this block, unless the signature is on file. If the patient’s representative signs, then the relationship to the patient must be indicated.

13

INSURED’S OR AUTHORIZED PERSON’S SIGNATURE

Not Required Have the patient or an authorized representative SIGN this block, unless the signature is on file.

14

DATE OF CURRENT ILLNESS, INJURY, PREGNANCY


Enter the date of the current illness or injury. If pregnancy, enter the date of the patient’s last menstrual period. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY).

Example: 01/05/2006

15

IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS

Not Required Enter the previous date the patient had a similar illness, if applicable. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY).



FIELD NUMBER




Example: 01/05/2006

16

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

Not Required Enter the “from” and “to” dates that the patient is unable to work. The dates must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2003

17

NAME OF REFERRING PHYSICIAN OR OTHER SOURCE


Enter the FIRST and LAST NAME of the referring or ordering physician.

17a

OTHER ID # Not Required In the shaded area, enter the non-NPI ID number of the physician whose name is listed in Field 17. Enter the qualifier identifying the number in the field to the right of 17a. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number EI - Employer’s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy

17b NPI NUMBER Required In the non-shaded area enter the NPI

number of the referring provider

18

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

19

ADDITIONAL CLAIM INFORMATION

Not Required

Leave Blank

20 OUTSIDE LAB CHARGES Not Required 21

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Required Enter the diagnosis/condition of the patient, indicated by an ICD-9-CM code number. Enter up to 12 diagnostic codes, in PRIORITY order (primary, secondary condition).

22

RESUBMISSION CODE Not Required



FIELD NUMBER




23

PRIOR AUTHORIZATION NUMBER

Required Enter the prior authorization number for those procedures requiring prior approval.

24 a-j SUPPLEMENTAL INFORMATION SUPPLEMENTAL INFORMATION, con’t.

Required Supplemental information can only be entered with a corresponding, completed service line. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. When reporting additional anesthesia services information (e.g., begin and end times), narrative description of an unspecified code, NDC, VP – HIBCC codes, OZ – GTIN codes or contract rate, enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not enter a space, hyphen, or other separator between the qualifier and the number/code/information. The following qualifiers are to be used when reporting these services. 7 - Anesthesia information ZZ - Narrative description of unspecified code N4 - National Drug Codes (NDC) VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ - Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN) CTR - Contract rate

24a

DATE(S) OF SERVICE Required Enter the month, day, and year (MM/DD/YY) for each procedure, service, or supply. Services must be entered chronologically (starting with the oldest date first).

For each service date listed/billed, the following fields must also be entered: Units, Charges/Amount/Fee, Place of Service, Procedure Code, and corresponding Diagnosis Code. IMPORTANT: Do not submit a claim with a future date of service. Claims can only be submitted once the service has been rendered (for example: durable medical equipment).



FIELD NUMBER




24b

PLACE OF SERVICE

Required Enter the place of service code for each item used or service performed. (see page 38 for list of common codes.)

24c

EMG

Not Required Enter Y for “YES” or leave blank if “NO” to indicate an EMERGENCY as defined in the electronic 837 Professional 4010A1 implementation guide.

24d PROCEDURES, SERVICES, OR

SUPPLIES: CPT/HCPCS, MODIFIER

Required Enter the CPT/HCPCS codes and MODIFIERS (if applicable) reflecting the procedures performed, services rendered, or supplies used.

IMPORTANT: Enter the anesthesia time, reported

as the “beginning” and “end” times of anesthesia in military time above the appropriate procedure code.

24e

DIAGNOSIS POINTER

Required Enter the diagnosis code reference number (pointer) as it relates the date of service and the

procedures shown in Field 21, When multiple services are performed, the primary reference number for each service should be listed first, and other applicable services should follow. The reference number(s) should be a 1, or a 2, or a 3, or a 4; or multiple numbers as explained.

IMPORTANT: (ICD-9-CM diagnosis codes must be

entered in Item Number 21 only. Do not enter them in 24E.)

24f

$ CHARGES Required Enter the FULL CHARGE for each listed service.

Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, co-pays etc). Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number.

24g

DAYS OR UNITS Required Enter the number of days or units in this block. (For

example: units of supplies, etc.) When entering the NDC units in addition to the HCPCS units, enter the applicable NDC ‘units’ qualifier and related units in the shaded line. The following qualifiers are to be used: F2 - International Unit ML - Milliliter GR - Gram UN Unit

24h

EPSDT FAMILY PLAN Not Required



FIELD NUMBER




24i ID. QUAL Required Enter in the shaded area of 24I the qualifier identifying if the number is a non-NPI. The Other ID# of the rendering provider is reported in 24J in the shaded area. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number EI - Employer’s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy

24j RENDERING PROVIDER ID # Required Enter the non-NPI ID number in the shaded area of the

field. Enter the NPI number in the non-shaded area of the field. Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.

25

FEDERAL TAX ID NUMBER

Required Enter the physician/supplier federal tax I.D. number or

Social Security number. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.

IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS.

26

PATIENT’S ACCOUNT NO.

Required Enter the Members account number assigned by the Provider’s/provider’s accounting system.

IMPORTANT: This field aids in patient identification

by the Provider/Provider.

27

ACCEPT ASSIGNMENT

Not Required

28

TOTAL CHARGE Required Enter the total charges for the services rendered (total of all the charges listed in Field 24f).

29

AMOUNT PAID Required if Applicable

Enter the amount paid (i.e., Member copayments or other insurance payments) to date in this field for the services billed.



FIELD NUMBER




30

BALANCE DUE Not Required Enter the balance due (total charges less amount paid).

31

SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

Required Enter the signature of the physician/supplier or his/her representative, and the date the form was signed. For claims submitted electronically, include a computer printed name as the signature of the health care Provider or person entitled to reimbursement.

32

SERVICE FACILITY LOCATION INFORMATION


The name and address of the facility where services were rendered (if other than patient’s home or physician’s office). Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code Do not use commas, periods, or other punctuation in the address (e.g., “123 N Main Street 101” instead of “123 N. Main Street, #101”). Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen.

32a NPI # Required Enter the NPI number of the service facility.

32b OTHER ID # Required Enter the two digit qualifier identifying the non-NPI

number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

33

BILLING PROVIDER INFO & PH #

Required Enter the name, address and phone number of the billing entity.

33a NPI # Required Enter the NPI number of the service facility location in 32a.

33b OTHER ID # Required Enter the two digit qualifier identifying the non-NPI

number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

If available, please enter your provider or unique vendor number.



KAISER PERMANENTE

- FOR REFERENCE ONLY

5.15.2 CMS-1450 (UB-04) Field Descriptions

The fields identified in the table below as “Required” must be completed when submitting a CMS-1450 (UB-04) claim form to Kaiser Permanente for processing. Please Note: The fields required for submission below are required by Kaiser Permanente but not necessarily by CMS or other payers. For Medicare members, please refer to Medicare’s billing requirements for appropriate field requirements and instructions or examples.

FIELD NUMBER




1 PROVIDER NAME and ADDRESS

Required Enter the name and address of the hospital or person who rendered the services being billed.

2 PAY-TO NAME, ADDRESS, CITY/STATE, ID #

Required Enter the name and address of the hospital or person to receive the reimbursement.

3a PATIENT CONTROL NUMBER

Required Enter the member’s control number.

IMPORTANT: This field aids in patient identification

by the Provider/Provider. 3b MEDICAL RECORD

NUMBER

Not Required Enter the number assigned to the patient’s medical/health record by the provider.

4 TYPE OF BILL

Required Enter the appropriate code to identify the specific type of bill being submitted. This code is required for the correct identification of inpatient vs. outpatient claims, voids, etc.

5 FEDERAL TAX NUMBER

Required Enter the federal tax ID of the hospital or person entitled to reimbursement.

6 STATEMENT COVERS PERIOD

Required Enter the beginning and ending date of service included in the claim.

7 BLANK Not Required Leave blank. 8 PATIENT NAME Required Enter the member’s name. 9 PATIENT ADDRESS Required Enter the member’s address.

10 PATIENT BIRTH DATE Required Enter the member’s birth date.

11 PATIENT SEX Required Enter the member’s gender. 12 ADMISSION DATE Required For inpatient claims only, enter the date of admission.

13 ADMISSION HOUR Required For either inpatient OR outpatient care, enter the 2-digit code for the hour during which the member was admitted or seen.

14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency, urgent, elective, and newborn).

15 ADMISSION SOURCE Required Enter the source of the admission type code.

16 DISCHARGE HOUR (DHR)


Enter the two-digit code for the hour during which the member was discharged.

17 PATIENT STATUS Required Enter the discharge status code. 18-28

CONDITION CODES Required if Applicable

Enter any applicable codes which identify conditions relating to the claim that may affect claims processing.

29 ACCIDENT (ACDT) STATE

Not Required Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment.

KAISER PERMANENTE


FIELD NUMBER




30 BLANK Not Required Leave blank.

31-34

OCCURRENCE CODES AND DATES


Enter the code and the associated date defining a significant event relating to this bill that may affect claims processing.

35-36

OCCURRENCE SPAN CODES AND DATES


Enter the occurrence span code and associated dates defining a significant event relating to this bill that may affect claims processing.


38 RESPONSIBLE PARTY Not Required Enter the responsible party name and address.

39-41

VALUE CODES and AMOUNT


Enter the code and related amount/value which is necessary to process the claim.

42 REVENUE CODE Required Identify the specific accommodation, ancillary service, or billing calculation, by assigning an appropriate revenue code.

43

REVENUE DESCRIPTION

Not Required Enter the revenue description.

44 PROCEDURE CODE AND MODIFIER

Required For ALL outpatient claims, enter BOTH a revenue code in Field 42 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field.

45

SERVICE DATE

Required

Outpatient Series Bills: A service date must be entered for all outpatient series bills whenever the “from” and “through” dates in Field 6 (Statement Covers Period: From/Through) are not the same. Submissions that are received without the required service date(s) will be rejected with a request for itemization. Multiple/Different Dates of Service: Multiple/different dates of service can be listed on ONE claim form. List each date on a separate line on the form, along with the corresponding revenue code (Field 42), procedure code (Field 44), and total charges (Field 47).

46 UNITS OF SERVICE Required The units of service.

47 TOTAL CHARGES Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field 6.


48 NON COVERED CHARGES

Not Required Enter any non-covered charges.

KAISER PERMANENTE


FIELD NUMBER




50

PAYER NAME

Required Enter (in appropriate ORDER on lines A, B, and C) the NAME and NUMBER of each payer organization from whom you are expecting payment towards the claim.

51 HEALTH PLAN ID Required Enter the provider number.

52

RELEASE OF INFORMATION (RLS INFO)

Not Required Enter the release of information certification number

53

ASSIGNMENT OF BENEFITS (ASG BEN)


Enter the assignment of benefits certification number.

54a-c

PRIOR PAYMENTS Required if Applicable

If payment has already been received toward the claim by one of the payers listed in Field 50 (Payer) prior to the billing date, enter the amounts here.

55 ESTIMATED AMOUNT DUE

Not Required Enter the estimated amount due.

56

NATIONAL PROVIDER IDENTIFIER (NPI)

Required Enter the service provider’s National Provider Identifier (NPI).

57 OTHER PROVIDER ID Required Enter the service provider’s Kaiser-assigned provider ID.

58

INSURED’S NAME

Required Enter the subscriber’s name.

59

PATIENT’S RELATION TO INSURED


Enter the member’s relationship to the subscriber.

60 INSURED’S UNIQUE ID Required Enter the insured person’s unique individual member identification number (medical/health record number), as assigned by Kaiser.

61

INSURED’S GROUP NAME


Enter the insured’s group name.

62

INSURED’S GROUP NUMBER


Enter the insured’s group number as shown on the identification card. For Prepaid Services claims enter “PPS”.

63

TREATMENT AUTHORIZATION CODE


For ALL inpatient and outpatient claims, enter the referral number.

64 DOCUMENT CONTROL NUMBER

Not Required Enter the document control number related to the member or the claim.

65

EMPLOYER NAME Required if Applicable

Enter the employer’s name.

66 DX VERSION QUALIFIER

Not Required Indicate the type of diagnosis codes being reported.

Note: At the time of printing, Kaiser only accepts ICD-9-CM diagnosis codes on the UB-04.

67

PRINCIPAL DIAGNOSIS CODE

Required Enter the principal diagnosis code, on all inpatient and outpatient claims.

67 A-Q

OTHER DIAGNOSES CODES


Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail.


69

ADMITTING DIAGNOSIS

Required Enter the admitting diagnosis code on all inpatient claims.

70 (a-c)

REASON FOR VISIT (PATIENT REASON DX)

Not Required Enter the diagnosis codes indicating the patient’s reason for outpatient visit at the time of registration.

KAISER PERMANENTE


FIELD NUMBER




71 PPS CODE Required if Applicable

Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology.

72

EXTERNAL CAUSE OF INJURY CODE (ECI)


Enter an ICD-9-CM “E-code” in this field (if applicable).

73 BLANK Not required Leave blank.

74

PRINCIPAL PROCEDURE CODE AND DATE


Enter the ICD-9-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable).

74 (a–e)

OTHER PROCEDURE CODES AND DATES


Enter other ICD-9-CM procedure CODE(S) and DATE(S) on all inpatient AND outpatient claims (in fields “A” through “E”) for any additional surgical and/or obstetrical procedures which were performed (if applicable).

75 BLANK Not required Leave blank.

76

ATTENDING PHYSICIAN / NPI / QUAL / ID

Required Enter the National Provider Identifier (NPI) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services.

Inpatient Claims—Attending Physician Enter the full name (first and last name) of the physician who is responsible for the care of the patient. Outpatient Claims—Referring Physician For ALL outpatient claims, enter the full name (first and last name) of the physician who referred the Member for the outpatient services billed on the claim.

77

OPERATING PHYSICIAN / NPI/ QUAL/ ID

Required If Applicable

Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure.

78-79

OTHER PHYSICIAN/ NPI/ QUAL/ ID


Enter the National Provider Identifier (NPI) and name of any other physicians.

80 REMARKS

Not Required Special annotations may be entered in this field.

81 CODE-CODE Not required Enter the code qualifier and additional code, such as martial status, taxonomy, or ethnicity codes, as may be appropriate.

KAISER PERMANENTE




5.16. Billing Requirements and Instruction for Specific Services

Instructions on billing for specific services can also be obtained by contacting Claims Customer Service at 303-338-3800. Certain billing requirements are detailed below. You should always bill for the services we have contracted with you to perform according to the terms of your contract.

5.16.1 Capitation Payments

Contracted providers with a capitated contract will still need to bill for services. Kaiser Permanente requires the monthly submission of encounter data and utilization information. This information is used to determine the volume and the types of services your office provides, and will be used to determine future contract rates. Follow the steps below to submit monthly utilization information: Providers will submit a CMS 1500 (HCFA 1500) Form, or other format indicated by Agreement. All utilization information submitted must include: Patient Name Patient Identification Number/Medical Record Number Provider’s Name Tax Identification Number Date of the Bill Date(s) of Service Current CPT-4 Codes ICD 9 – CM Diagnosis Code Billed Charges Authorization Number Narrative description of charges if billing an unlisted code. Submit all utilization information to: Kaiser Permanente Claims Administration/CO P.O. Box 373150 Denver, CO 80237 NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under a 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/HCFA-1500 or CMS-1450/UB-04 as applicable), and to follow all claims completion instructions set forth in this Manual.



5.16.2 Evaluation Management (E/M) Services

For Hospital Admissions: Do not bill E/M services (an office visit, hospital observation service, nursing facility visit, etc.) that occur on the same date as a hospital admission on the same claim form. All E/M services provided by the physician in conjunction with a member’s admission are considered part of the initial hospital care when provided on the same date as the hospital admission. Example: Do not bill emergency department E/M codes when the member is admitted directly from the ER. Admissions “For Observation”: If a member is admitted for observation following the performance of a major/minor “surgical package” procedure, do not report hospital observation service codes, as all post-operative E/M services are included as part of the global surgical package. Outpatient E/M Services: Preventive Medicine Services: Preventive medicine codes, not office evaluation/management codes, should be used to report the routine evaluation and management of adults and children, in the absence of member complaints. For example, preventive medicine codes should be used for: • Well-baby check-ups • “Routine” pediatric visits • “Routine” annual gynecological exams Preventive medicine visits include a comprehensive history and physical, identification of risk factors, and the ordering of lab/diagnostic tests as appropriate. Immunizations given during a preventive medicine visit may be billed separately.

5.16.2.1 Inpatient E/M Services:

For Hospital Admissions: Do not bill E/M services (an office visit, hospital observation service, nursing facility visit, etc.) that occur on the same date as a hospital admission on the same claim form. All E/M services provided by the physician in conjunction with a member’s admission are considered part of the initial hospital care when provided on the same date as the hospital admission. Example: Do not bill emergency department E/M codes when the member



is admitted directly from the ER. Admissions “For Observation”: If a member is admitted for observation following the performance of a major/minor “surgical package” procedure, do not report hospital observation service codes, as all post-operative E/M services are included as part of the global surgical package.

5.16.2.2 Surgical Procedure that Include E/M Services:

E/M Services provided on the SAME DAY as a Surgical or Endoscopic Procedure Reimbursement does NOT generally apply for a pre or post-operative E/M visit provided on the same day as major/minor surgery or an endoscopic procedure, unless Kaiser Permanente’s agrees that there was a significant, separately identifiable E/M service provided in addition to the procedure. In these instances, the provider must bill for the E/M visit using modifier 25.

Global Period/Surgical Package Surgical Package: The American Medical Association (AMA) defines the surgical package as including:

Pre-operative visit/services, in or out of the hospital, beginning with the day before surgery for major surgeries and the day of the surgery for minor surgeries. This includes one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical), subsequent to the decision for surgery.

All intra-operative procedures that are normally a necessary part of the surgery.

Any local or topical anesthesia, including local infiltration, metacarpal /metatarsal/digital block, or topical anesthesia.

Any digital nerve blocks.

All normal, uncomplicated post-operative care and visits. This includes immediate post-operative care, including dictating operative notes, evaluating the member in the post-anesthesia recovery area, talking with the family and other physicians, and writing orders.

Post-surgical pain management.

Supplies.

Miscellaneous services such as incision care, dressing changes, removal of sutures.

Staples, lines, wires, casts, drains, catheters, etc. Endoscopic Procedures Included in the Surgical Package For endoscopic procedures, the surgical package includes:

The physician’s visit/services on the day of the procedure

The endoscopic procedure



There is NO post-operative period for endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope. Anesthesia Procedures Included in the Surgical Package Anesthesia is considered separate and distinct from surgery if administered by an anesthesiologist or CRNA. When administered by a surgeon (i.e., regional block, local anesthesia), anesthesia is considered part of the surgical package. CPT guidelines for anesthesia procedures include the following services:

pre- and postoperative visits

anesthesia care during the procedure

administration of fluids and/or blood

usual monitoring service (i.e., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry)

Based on this definition, the following services are found incidental to anesthesia services:

Administration of fluids and/or blood

Intra-operative monitoring and supportive services Topical/Local/Digital Block Anesthesia Included in the Surgical Package When anesthesia is provided for a procedure, the guidelines state that “local infiltration, metacarpal/digital block, or topical anesthesia…” is included as part of the operation. Kaiser Permanente reviews all claims and denies topical or local anesthesia, performed by the surgeon, whenever it is billed with a surgical procedure. Example: Injection of anesthetic agent, other peripheral nerve or branch is denied when billed with the procedure code excision of pilonidal cyst or sinus, simple. Preoperative Care/Services Included in the Surgical Package Preoperative visits are not separately reimbursable services when performed within the assigned global period by the physician or a partner of the same specialty, as indicated here: For major procedures, visits on the day before and on the day of the procedure are included in the global period. This rule applies to an evaluation/management (E/M) service in a variety of member care settings, including the office, home, emergency department, or hospital. For minor procedures, all pre-operative visits/services performed on the day of the procedure are included in the global fee, except for E/M visits as described below.



NOTE: For E/M visits to be considered for reimbursement, they must be “significant and separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.” The provider must bill for these E/M services using Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” Preoperative Care/Services Excluded from the Surgical Package The initial consultation by the physicians to determine the need for surgery or procedure is excluded from the surgical package and is separately reimbursable. NOTE: Initial hospital and initial observation codes are not recognized as initial evaluation codes. Postoperative Follow-Up Care Included in the Surgical Package The surgical package typically includes all normal and uncomplicated follow-up care as part of the reimbursement for the surgical procedure. Postoperative Follow-Up Care Excluded from the Surgical Package The following postoperative services are excluded from the surgical package and are separately reimbursable:

Postoperative visits by the operating surgeon unrelated to the diagnosis for which the procedure was performed. (Use Modifier 24 to claim separate reimbursement for those visits.)

Services of other physicians not providing surgical package services

Visits by the operating surgeon that are unrelated to the diagnosis for which the procedure was performed. (Use Modifier 24 during the postoperative period. Use Modifier 25 for the day of the procedure.)

Diagnostic tests and procedures (including lab tests and X-rays)

E/M services that result in the decision to perform a major procedure when submitted with a Modifier 57.

Modifier 57 When the decision to perform a major surgery occurs on the day before or day of the major surgery, append Modifier 57 (E/M service resulting in the initial decision to perform a major surgery). Example: A physician is consulted to determine if a member needs surgery for abdominal pain. The consult confirms that the member has a ruptured appendix and immediate surgery is performed on this day. The E/M service is billed with Modifier 57 and the surgery is billed without a modifier.



Same-Day Services Excluded from the Surgical Package Same-day services are excluded from the surgical package and are separately reimbursable, as follows:


E/M services performed by the physician that are “significant and separately identifiable.” If provided on the same day of service, these may be submitted with Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….” Post-payment audits may be performed to validate claims.

Assistant Surgeons Kaiser Permanente reviews all “assistant surgeon” claims to determine the medical necessity of the assistant surgeon’s services. PLEASE NOTE:

All assistant surgeons should bill FULL charges. Any necessary payment reductions are made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, copayments, etc.).

Modifier 80, 81 or 82 should be used to report “assistant surgeon” services.

Reimbursement for “assistant surgeon” services is limited to services determined to be medically necessary.

Reimbursement for “assistant surgeon” services is subject to all incidental, mutually exclusive, and multiple surgery guidelines.

Reimbursement for a NON-PHYSICIAN assisting at surgery is set at a lower reimbursement rate than for a PHYSICIAN assistant at surgery. All reimbursements are subject to the guidelines stated above.

Co-Surgery (Two Surgeons) Under certain circumstances, the skills of two surgeons (usually with different skill sets) may be required in the management of a specific surgical procedure. To bill for these procedures (as a co-surgeon), use Modifier 62. Supporting documentation must be attached to the claim, explaining the need for each physician’s involvement with the case. Before reimbursement is considered, Kaiser Permanente must agree that it was medically necessary for both surgeons to be involved with the case. Team Surgery When highly complex procedures are carried out under the “surgical team” concept, use Modifier 66 to report these services. Adequate supporting documentation must be submitted with the claim, to allow Kaiser Permanente to review the case and determine medical necessity and appropriate reimbursement.



Duplicate/Bilateral Procedures CPT code states “bilateral”: If the description of the duplicate code on a claim contains the phrase “bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Excision of hydrocele; bilateral is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate. CPT code states “unilateral/bilateral”: If the description of the duplicate code on a claim contains the phrase “unilateral/ bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate. Kaiser Permanente performs code replacements, if appropriate, when one procedure code specifies a SINGLE service, but another procedure code is available for identifying MULTIPLE services. Exploratory/Diagnostic Procedures According to accepted industry coding practices, when an exploratory or diagnostic procedure is billed with a major surgical procedure in the same incision site, only the major surgery is reimbursed. Example: Since an exploratory laparotomy is a diagnostic procedure and the method of approach is into the abdominal cavity, Kaiser Permanente identifies an exploratory laparotomy as incidental to a number of invasive abdominal procedures when performed during the same operative session.

5.16.2.3 Preventive Medicine Services:

Preventive medicine codes (99381-99397), NOT office evaluation/management codes, should be used to report the routine evaluation and management of adults and children, in the absence of patient complaints. For example, preventive medicine codes should be used for:

Well baby check-ups

“Routine” pediatric visits

“Routine” annual gynecological exams

Preventive medicine visits include a comprehensive history and physical, identification of risk factors, and the ordering of lab/diagnostic tests as appropriate. Immunizations (90700-90749) given during a preventive



medicine visit may be billed separately.

5.16.3 Emergency Rooms

Two Physicians Involved in Admitting a Member from the ER: If an “emergency department” physician and an “attending” physician are involved in admitting a member from the ER, the ER physician should bill for services using the emergency department E/M codes, and the attending physician should bill for services using the INITIAL hospital visit codes. Physicians cannot bill for both the ER services rendered and the hospital admission in this circumstance. “Emergency” in the Office Setting The emergency department E/M visit should ONLY be used if the member is seen in the emergency department. For urgent or emergency services provided in the office setting, use office visit codes. “Non-Emergency” Services Provided in the Emergency Department Emergency department E/M visit codes should be used for E/M services provided in the emergency department, even if these were “nonemergency” services. The only requirement for using “emergency department” codes is that the member must be registered in the emergency department. Office visit E/M codes should be used if the member was seen in the ER as a convenience to the physician and/or member, but the member is not registered in the emergency department.

5.16.3.1 Two Physicians Involved in Admitting a Patient from the ER

If an “emergency department” physician and an “attending” physician are involved in admitting a patient from the ER, the ER physician should bill for services using the emergency department E/M codes, and the attending physician should bill for services using the INITIAL hospital visit codes. Physicians cannot bill for both the ER services rendered and the hospital admission in this circumstance.

5.16.3.2 “Emergency” in the Office Setting

The emergency department E/M visit should ONLY be used if the patient is seen in the emergency department. For urgent or emergency services provided in the office setting, use code 99058 (Office services provided on an emergency basis) in addition to the appropriate E/M office visit code.

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

Emergency department E/M visit codes should be used for E/M services provided in the emergency department, even if these were “non-emergency” services. The only requirement for using “emergency department” codes is



that the patient must be registered in the emergency department. Office visit E/M codes should be used if the patient was seen in the ER as a convenience to the physician and/or patient, but the patient is not registered in the emergency department.

5.16.3.4 Emergency Room and Urgent Care Services Submitted on a UB-04

When submitting claims for services rendered in the emergency room or in an urgent care facility, the following information must be included on the claim to assure payment:

Emergency Services: Revenue Code 450 is required in FL (field) 42, and a procedure code (CPT) or HCPCS code is required in FL 44.

Urgent Services: Revenue Code 456, 516, or 526 is required in FL 42, and a procedure code (CPT) or HCPCS code is required in FL 44.

5.16.4 Critical Care Services

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

Member Located in a Critical Care Unit NOT Receiving Critical Care Services If a member has been stabilized, and is NOT receiving intensive “lifesaving” critical care services in the Critical Care Unit, subsequent hospital care codes are to be used to report any E/M services provided to the member. Critical care codes should not be used in this circumstance.

5.16.5 Observation Services

Use hospital observation E/M codes to report E/M services rendered.

5.16.6 Injection/ Immunizations

5.16.6.1 Vaccine Immunizations

Report the codes 90465 through 90468 only when the physician is present and provides face-to-face counseling of the member and family during the administration of a vaccine. Immunizations should be billed with both an Immunization Administration Code and the code that identifies the vaccine product. E/M visit codes should not be billed in conjunction with immunizations unless there is a significantly, separately identifiable evaluation and management service. In these cases the E/M service should be billed with Modifier 25.

5.16.6.2 Allergy Immunotherapy



E/M visits should NOT generally be billed on the same day as an allergen injection code. The allergen immunotherapy codes include the necessary professional services. Nursing services for observation and medical instruction are included as an integral part of administering extracts or antigens. Office visit codes may be used in addition to allergen immunotherapy, if and only if, other identifiable services are provided at that time. Modifier 25 must be used. Office visit copayments are only applicable when an office visit code is appropriately billed.

E/M visits should NOT generally be billed on the same day as an allergen injection code (95115-95199). The allergen immunotherapy codes include the necessary professional services. Nursing services for observation and medical instruction are included as an integral part of administering extracts or antigens.

Office visit codes may be used in addition to allergen immunotherapy, if and only if, other identifiable services are provided at that time. Modifier 25 must be used. Office visit copays are only applicable when an office visit code is appropriately billed.

Correct Usage of Allergy Immunotherapy Codes:

CODE RANGE: Use These Codes When:

95115-95117 The injection is administered ONLY (the patient brings in the serum)

95120-95134 The provider prepares the serum and administers the injection

95144-95170 The provider prepares the serum ONLY

5.16.7 Obstetrical Services

5.16.7.1 Admissions for False Labor

When a member is admitted directly to a labor room, use the Labor Room Revenue Codes. Rarely, a member is admitted “for observation” due to labor pains, but is then discharged the same or next day due to false labor. In this event use hospital observation E/M codes to report E/M services rendered.

5.16.7.2 Anesthesia Services Provided with Deliveries

The surgery guidelines in CPT describe a “surgical package” concept pertaining to surgical procedures. When anesthesia is provided for a procedure, the guidelines state that “local infiltration, metacarpal/digital block, or topical anesthesia...” is included as part of the operation.



5.16.7.3 Multiple Physicians Provide Different Components of the Obstetrical Care

NOTE: This does NOT apply to multiple providers within ONE obstetrical group practice. Obstetrical services provided by multiple physicians within one group practice are billed as if the services were provided by ONE physician, using obstetrical “global package” codes. When different physicians provide different components of obstetrical care, each physician should bill for services using CPT code(s) describing component the physician provided (i.e., “postpartum care only”). Additionally, physicians should note in their records when, and at what stage in the pregnancy, the member transferred into or from their practice.

5.16.7.4 Antepartum Care

There are two ways to submit claims for antepartum care:

Obstetrical “Global Package” Codes: When services are provided by one physician/obstetrical group resulting in a birth/delivery, submit the claim with the global code that includes antepartum care, delivery, and postpartum care services.

Antepartum care only: When submitting a claim for antepartum care only, use appropriate antepartum codes. End date is required when antepartum care is submitted separately. Enter the end date of service on the CMS-1500 Form.

IMPORTANT: The sum of all allowances for all physicians who furnish different components of the obstetrical care cannot exceed the total amount of the allowance that would have been paid to a SINGLE physician for furnishing the total obstetrical “global package.”

5.16.8 Newborn Services

5.16.8.1 Newborn Care When Baby Is Discharged with Mother

For all babies who are discharged home with their mothers, newborn care is reimbursed at the same level, even if the baby spent time in the NICU or other specialty unit. For all babies who are discharged home with their mothers, Kaiser Permanente assigns the same inpatient length of stay (LOS) to both the mother and newborn. The LOS is typically set at two (2) days for an uncomplicated vaginal delivery and four (4) days for a cesarean section



delivery. The hospital authorization number assigned to the mother should be used when billing for the delivery and routine healthy newborn charges.

Facility Claims: Charges for both the mother and baby should be included on one claim with the mother’s identification number as the member.

Professional Claims: Use the code identifying the setting for the initial newborn history and physical. This code should be billed with the mother’s identification number. For additional well-baby visits, use codes 99238, 99239, and 99433.

Circumcision is billed under the mother’s identification numbers.

Mother not a Member: If the mother is not covered under Kaiser Permanente and the child is covered by Kaiser Permanente under the father, bill under the child’s name and identification number.

The child’s identification number is established by Kaiser Permanente when the father’s employer adds the child under the father’s insurance benefit.

The child’s stay must be authorized by Kaiser Permanente .

5.16.8.2 Newborn Care When Baby is Discharged without Mother

Hospital charges for delivery charges should be billed according to the services rendered during the in-hospital confinement.

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

Definition: A boarder baby is a newborn whose length of stay (LOS) extends beyond the mother’s date of discharge.

For boarder babies, authorizations are issued retroactively, effective as of the newborn’s date of birth. Boarder babies are issued a separate authorization number at the time the mother is discharged. Covered care for a boarder baby is extended to include additional professional services deemed medically necessary. These services may consist of visits by the newborn’s PCP or attending physician, consultations by specialists, and other professional services (such as radiology interpretations).

Boarder baby claims must be submitted with the baby’s identification number and cannot be paid until the baby is added to the contract by the employer group. When newborn reimbursement is made on a per-diem basis, each day from the boarder baby's date of birth will be reimbursed.



Boarder Babies Who Stay Beyond Their Mother’s Discharge Date

A boarder baby is a newborn whose length of stay (LOS) extends beyond the mother’s date of discharge.

For boarder babies, authorizations are issued retroactively, effective as of the newborn’s date of birth. Boarder babies are issued a separate authorization number at the time the mother is discharged. Covered care for a boarder baby is extended to include additional professional services deemed medically necessary. These services may consist of visits by the newborn’s PCP or attending physician, consultations by specialists, and other professional services (such as radiology interpretations).

Boarder baby claims must be submitted with the baby’s identification number and cannot be paid until the baby is added to the contract by the employer group. When newborn reimbursement is made on a per-diem

5.16.8.4 Mother who stays beyond their baby discharge date.

Hospital charges for delivery charges should be billed according to the services rendered during the in-hospital confinement.

5.16.9 Surgery

5.16.9.1 Global Period / Surgical Package

Surgical Package: The American Medical Association (AMA) defines the surgical package as including:

Pre-operative visit/services, in or out of the hospital, beginning with the day before surgery for major surgeries and the day of the surgery for minor surgeries. This includes one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical), subsequent to the decision for surgery.

All intra-operative procedures that are normally a necessary part of the surgery.

Any local or topical anesthesia, including local infiltration, metacarpal /metatarsal/digital block, or topical anesthesia.

Any digital nerve blocks.

All normal, uncomplicated post-operative care and visits. This includes immediate post-operative care, including dictating operative notes, evaluating the member in the post-anesthesia recovery area, talking with the family and other physicians, and writing orders.

Post-surgical pain management.

Supplies.

Miscellaneous services such as incision care, dressing changes, removal of sutures.

Staples, lines, wires, casts, drains, catheters, etc.



Endoscopic Procedures Included in the Surgical Package For endoscopic procedures, the surgical package includes:


The endoscopic procedure There is NO post-operative period for endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope Anesthesia Procedures Included in the Surgical Package Anesthesia is considered separate and distinct from surgery if administered by an anesthesiologist or CRNA. When administered by a surgeon (i.e., regional block, local anesthesia), anesthesia is considered part of the surgical package. CPT guidelines for anesthesia procedures include the following services:




usual monitoring service (i.e ., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) Based on this definition, the following services are found incidental to anesthesia services:


Intra-operative monitoring and supportive services Topical/Local/Digital Block Anesthesia Included in the Surgical Package When anesthesia is provided for a procedure, the guidelines state that “local infiltration, metacarpal/digital block, or topical anesthesia…” is included as part of the operation. Kaiser Permanente reviews all claims and denies topical or local anesthesia, performed by the surgeon, whenever it is billed with a surgical procedure. Example: Injection of anesthetic agent, other peripheral nerve or branch is denied when billed with the procedure code excision of pilonidal cyst or sinus, simple. Preoperative Care/Services Included in the Surgical Package Preoperative visits are not separately reimbursable services when performed within the assigned global period by the physician or a partner of the same specialty, as indicated here: For major procedures, visits on the day before and on the day of the procedure are included in the global period. This rule applies to an evaluation/management (E/M) service in a variety of member care settings, including the office, home, emergency department, or hospital.



For minor procedures, all pre-operative visits/services performed on the day of the procedure are included in the global fee, except for E/M visits as described below. NOTE: For E/M visits to be considered for reimbursement, they must be “significant and separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.” The provider must bill for these E/M services using Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” Preoperative Care/Services Excluded from the Surgical Package The initial consultation by the physicians to determine the need for surgery or procedure is excluded from the surgical package and is separately reimbursable. NOTE: Initial hospital and initial observation codes are not recognized as initial evaluation codes. Postoperative Follow-Up Care Included in the Surgical Package The surgical package typically includes all normal and uncomplicated follow-up care as part of the reimbursement for the surgical procedure. Postoperative Follow-Up Care Excluded from the Surgical Package The following postoperative services are excluded from the surgical package and are separately reimbursable:





E/M services that result in the decision to perform a major procedure when submitted with a Modifier 57. Modifier 57 When the decision to perform a major surgery occurs on the day before or day of the major surgery, append Modifier 57 (E/M service resulting in the initial decision to perform a major surgery). Example: A physician is consulted to determine if a member needs surgery



for abdominal pain. The consult confirms that the member has a ruptured appendix and immediate surgery is performed on this day. The E/M service is billed with Modifier 57 and the surgery is billed without a modifier. Same-Day Services Excluded from the Surgical Package Same-day services are excluded from the surgical package and are separately reimbursable, as follows:


E/M services performed by the physician that are “significant and separately identifiable.” If provided on the same day of service, these may be submitted with Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….” Post-payment audits may be performed to validate claims. Assistant Surgeons Kaiser Permanente reviews all “assistant surgeon” claims to determine the medical necessity of the assistant surgeon’s services. PLEASE NOTE:


Modifier 80, 81 or 82 should be used to report “assistant surgeon” services.



Reimbursement for a NON-PHYSICIAN assisting at surgery is set at a lower reimbursement rate than for a PHYSICIAN assistant at surgery. All reimbursements are subject to the guidelines stated above. Co-Surgery (Two Surgeons) Under certain circumstances, the skills of two surgeons (usually with different skill sets) may be required in the management of a specific surgical procedure. To bill for these procedures (as a co-surgeon), use Modifier 62. Supporting documentation must be attached to the claim, explaining the need for each physician’s involvement with the case. Before reimbursement is considered, Kaiser Permanente must agree that it was medically necessary for both surgeons to be involved with the case.



Team Surgery When highly complex procedures are carried out under the “surgical team” concept, use Modifier 66 to report these services. Adequate supporting documentation must be submitted with the claim, to allow Kaiser Permanente to review the case and determine medical necessity and appropriate reimbursement. Duplicate/Bilateral Procedures CPT code states “bilateral”: If the description of the duplicate code on a claim contains the phrase “bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Excision of hydrocele; bilateral is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate. CPT code states “unilateral/bilateral”: If the description of the duplicate code on a claim contains the phrase “unilateral/ bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate. Kaiser Permanente performs code replacements, if appropriate, when one procedure code specifies a SINGLE service, but another procedure code is available for identifying MULTIPLE services. Exploratory/Diagnostic Procedures According to accepted industry coding practices, when an exploratory or diagnostic procedure is billed with a major surgical procedure in the same incision site, only the major surgery is reimbursed. Example: Since an exploratory laparotomy is a diagnostic procedure and the method of approach is into the abdominal cavity, Kaiser Permanente identifies an exploratory laparotomy as incidental to a number of invasive abdominal procedures when performed during the same operative session.

5.16.9.2 Endoscopic Procedures Included in the Surgical Package

For endoscopic procedures, the surgical package includes:


The endoscopic procedure



There is NO post-operative period for endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope.

5.16.9.3 Anesthesia Procedures Included in the Surgical Package

Anesthesia is considered separate and distinct from surgery if administered by an anesthesiologist or CRNA. When administered by a surgeon (i.e., regional block, local anesthesia), anesthesia is considered part of the surgical package. CPT guidelines for anesthesia procedures include the following services:






Intra-operative monitoring and supportive services

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

When anesthesia is provided for a procedure, the guidelines state that “local infiltration, metacarpal/digital block, or topical anesthesia…” is included as part of the operation. Kaiser Permanente reviews all claims and denies topical or local anesthesia, performed by the surgeon, whenever it is billed with a surgical procedure. Example: Injection of anesthetic agent, other peripheral nerve or branch is denied when billed with the procedure code excision of pilonidal cyst or sinus, simple.

5.16.9.5 Preoperative Care/Services Included in the Surgical Package

Preoperative visits are not separately reimbursable services when performed within the assigned global period by the physician or a partner of the same specialty, as indicated here:

For major procedures, visits on the day before and on the day of the procedure are included in the global period. This rule applies to an evaluation/management (E/M) service in a variety of patient care settings,



including the office, home, emergency department, or hospital.

Note: Services rendered by physicians and other health care professionals of the same specialty with the same group with the same federal tax identification number are considered as having been performed by the same physician providing global period services.

For minor procedures, all pre-operative visits/services performed on the day of the procedure are included in the global fee, except for E/M visits as described below.

Note: For E/M visits to be considered for reimbursement, they must be “significant and separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.” The provider must bill for these E/M services using Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”

5.16.9.6 Preoperative Care/Services Excluded from the Surgical Package

The initial consultation by the physicians to determine the need for surgery or procedure is excluded from the surgical package and is separately reimbursable. NOTE: Initial hospital and initial observation codes are not recognized as initial evaluation codes.

5.16.9.7 Postoperative Follow-Up Care Included in the Surgical Package

The surgical package typically includes all normal and uncomplicated follow-up care as part of the reimbursement for the surgical procedure.

5.16.9.8 Postoperative Follow-Up Care Excluded from the Surgical Package

Example: A physician is consulted to determine if a patient needs surgery for abdominal pain. The consult confirms that the patient has a ruptured appendix and immediate surgery is performed on this day. The E/M service is b Postoperative Follow-Up Care Excluded from the Surgical Package The following postoperative services are excluded from the surgical package and are separately reimbursable:







E/M services that result in the decision to perform a major procedure when submitted with a Modifier 57. Modifier 57 When the decision to perform a major surgery occurs on the day before or day of the major surgery, append Modifier 57 (E/M service resulting in the initial decision to perform a major surgery). Example: A physician is consulted to determine if a member needs surgery for abdominal pain. The consult confirms that the member has a ruptured appendix and immediate surgery is performed on this day. The E/M service is billed with Modifier 57 and the surgery is billed without a modifier.

5.16.9.9 Same-Day Services Excluded from the Surgical Package

Same-day services are excluded from the surgical package and are separately reimbursable, as follows:


E/M services performed by the physician that are “significant and separately identifiable.” If provided on the same day of service, these may be submitted with Modifier 25. Modifier 25 can be used for significant, identifiable visits when substantiated in the medical records, which should be available on request. “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….” Post-payment audits may be performed to validate claims.

5.16.9.10 Assistant Surgeon

Reimbursement for a NON-PHYSICIAN assisting at surgery is set at a lower reimbursement rate than for a PHYSICIAN assistant at surgery. Kaiser Permanente reviews all “assistant surgeon” claims to determine the medical necessity of the assistant surgeon’s services.

PLEASE NOTE:


Modifier 80, 81, or 82 should be used to report “assistant surgeon”



services.



Reimbursement for a NON-PHYSICIAN assisting at surgery is set at a lower reimbursement rate than for a PHYSICIAN assistant at surgery. All reimbursements are subject to the guidelines stated above.

5.16.9.11 Co-Surgery (Two Surgeons)

Under certain circumstances, the skills of two surgeons (usually with different skill sets) may be required in the management of a specific surgical procedure. To bill for these procedures (as a co-surgeon), use Modifier 62. Supporting documentation must be attached to the claim, explaining the need for each physician’s involvement with the case. Before reimbursement is considered, Kaiser Permanente must agree that it was medically necessary for both surgeons to be involved with the case.

5.16.9.12 Team Surgery

When highly complex procedures are carried out under the “surgical team” concept, use modifier 66 to report these services. Adequate supporting documentation must be submitted with the claim, to allow Kaiser Permanente to review the case and determine medical necessity and appropriate reimbursement.

5.16.9.13 Duplicate / Bilateral Procedures

CPT code states “bilateral”: If the description of the duplicate code on a claim contains the phrase “bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Excision of hydrocele; bilateral is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate. CPT code states “unilateral/bilateral”: If the description of the duplicate code on a claim contains the phrase “unilateral/ bilateral,” Kaiser Permanente reimburses the provider for the procedure ONLY ONCE on a single date of service. Example: Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) is reimbursed only once; any occurrence of this code submitted beyond the first is denied as duplicate.



Kaiser Permanente performs code replacements, if appropriate, when one procedure code specifies a SINGLE service, but another procedure code is available for identifying MULTIPLE services.

5.16.9.14 Multiple Surgery Reimbursement for Professional and Facility Claims

Kaiser Permanente’s policy for reimbursement of multiple procedures is defined below unless it is otherwise specified in your provider contract.

Claims with multiple procedures performed during the same operative session are reimbursed as follows:

1st procedure: (report the highest cost valued code as the 1st procedure) 100% of the contracted rate.

2nd procedure: 50% of the contracted rate

3rd and subsequent procedures: 25% of the contracted rate

Certain codes identified in the Current Procedural Terminology (CPT) codebook, such as add-on codes and codes exempt from modifier 51, and are exempt from these multiple procedure rules and these reimbursement rates.

5.16.9.15 Exploratory/Diagnostic Procedures

According to accepted industry coding practices, when an exploratory or diagnostic procedure is billed with a major surgical procedure in the same incision site, only the major surgery is reimbursed.

Example: Since an exploratory laparotomy (49000) is a diagnostic procedure and the method of approach is into the abdominal cavity, Kaiser Permanente identifies an exploratory laparotomy as incidental to a number of invasive abdominal procedures when performed during the same operative session.

5.16.10 Cardiac Procedures

5.16.10.1 Cardiac Catheterization Billing

According to the AMA, three procedure codes should be billed for a cardiac catheterization procedure. They are:

Catheter code (93501-93533)

Injection code (93539-93545)

Supervisory code (93555-93556)

Example: The following procedure codes may be billed together, and separate reimbursement occurs:

93526 Combined right heart catheterization and retrograde left heart



catheterization

93545 Injection procedure during cardiac catheterization for selective coronary angiography

93555 Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization, ventricular and/or arterial angiography.

1. Pacemaker Leads Performed with Cardiac Catheterization

Placement of temporary pacemaker leads (procedures 33210, 33211) during cardiac catheterization is not routinely indicated and usually occurs in less than 5 percent of all cases. These procedures are considered incidental to all cardiac catheterization procedures. If a pacemaker lead is necessary, a review of the operative note is required. Separate reimbursement may be indicated if placement is not prophylactic (e.g., preexisting left bundle block during a planned right heart catheterization requiring the placement of a temporary pacemaker lead).

2. Cardiac Catheterization and Percutaneous Transluminal Coronary Angioplasty (PTCA)

If, during the course of performing a diagnostic cardiac catheterization, the physician discovers a significant blockage, the physician may elect to perform a therapeutic percutaneous transluminal coronary angioplasty (PTCA) procedure. PTCA is generally regarded as a more involved procedure, requiring one to two years of specialized training beyond the training required to perform cardiac catheterizations. When cardiac catheterizations and PTCA procedures are performed together, they are considered to be additive and can be billed separately.

Example: Left heart catheterization (93510) may be billed with the procedure Percutaneous transluminal coronary balloon angioplasty/PTCA/; single vessel (92982).

3. Thrombolysis performed with percutaneous transluminal coronary angioplasty (PTCA)

Kaiser Permanente denies thrombolysis as incidental when performed during PTCA.

5.16.10.2 Electrophysiologic Studies (EPS), Cardiac Mapping and Ablations

The electrophysiologic study (EPS) consists of a systematic analysis of cardiac dysrythmias by recording and measuring (mapping) a variety of electrophysiologic events with the patient in the basal (resting) state and by evaluating the patient’s response to programmed electrical stimulation (procedure codes 93600-93624).



Cardiac ablation (procedure codes 93650-93652) is performed to destroy an overactive A-V node, atrial foci or ventricular tachycardia.

The clinical management of a dysrhythmic patient typically includes performance of the EPS (e.g., 93621), followed by mapping (e.g., 93609), and then by ablation (e.g., 93650) on the same date of service. This process assures that the ablative site is treated, whereas this same site may be more difficult to locate if performed on a different date of service.

KAISER PERMANENTE allows separate reimbursement for these procedures when performed on a single date of service.

5.16.10.3 EPS and Cardiac Catheterization

When EPS procedures and Cardiac Catheterization are the only procedures reported, they are not considered separate and/or distinct procedures. A cardiac catheterization must be performed before the EPS studies can commence. Therefore, Kaiser Permanente rebundles EPS procedures and cardiac catheterization procedures.

Example: If the following codes are billed together:

93620 Electrophysiologic study

93527 Right heart catheterization and transeptal left heart catheterization

93527 is denied as rebundled to 93620.

5.16.10.4 Cardiac Rehabilitation

Reimbursement for cardiac rehabilitation is provided as a comprehensive fee and includes therapeutic exercise, cardiac education, and ECG monitoring, counseling, and risk factor modification. These services should not be billed separately. Phase III services are not covered.

Appropriate Coding for Cardiac Rehabilitation CPT Code Description

93797 Outpatient Cardiac Rehabilitation without ECG monitoring

93798 Outpatient Cardiac Rehabilitation with continuous ECG monitoring

5.16.11 Transplants

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:





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 5.3.6 and 5.3.7 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.

5.16.12 Anesthesia

Anesthesia is considered separate and distinct from surgery if administered by an anesthesiologist or CRNA. When administered by a surgeon (i.e., regional block, local anesthesia), anesthesia is considered part of the surgical package. CPT guidelines for anesthesia procedures include the following services:








Intra-operative monitoring and supportive services

5.16.13 Behavioral Health Services

















5.16.14 Durable Medical Equipment















5.16.15 Laboratory Procedures

Laboratory services include laboratory tests and procedures performed in a provider’s office, a hospital pathology department, an ambulatory care center, or an independent pathology center. Please note that your



contract may require you to send most labs to a Kaiser Permanente contracted vendor or all labs to a Kaiser Permanente facility. Kaiser Permanente has adopted standard payment rules for reimbursing providers for blood draws and specimen handling. Kaiser Permanente will not reimburse providers for blood draws when the provider performs the test. No additional reimbursement for performing the blood draw is allowed when a provider is to be reimbursed for completing the laboratory test. Draw fees are included and are inherent in the lab test reimbursement. When the provider only supplies blood draw services, Kaiser Permanente will pay a minimal draw fee. We will not pay providers for specimen collections. These are typically performed for tests done in a provider’s location. Specimen collection fees are included and are inherent in the test reimbursement. Billing for laboratory services may be for the complete service, the professional component of the service, or the technical component of the service, as defined below. Professional component: Charges for the professional component of a laboratory service are for the reading and interpretation of the test results. Kaiser Permanente reimburses the professional component only when a pathologist performs the interpretation. When billing for interpretation services, indicate the professional component by adding Modifier 26 to the CPT procedure code. Technical component: Charges for the technical component of the pathology service are for use of the facility charges associated with the test. Technical Component charges are generally submitted by imaging centers that do not have pathologist on staff. When billing for technical component services, add Modifier “TC” to the CPT procedure code. Facility claims CMS- 1450 (UB-04)assume the technical component only.

5.16.16 Radiology Services

Radiology services include procedures performed in a provider’s office, a hospital radiology department or a freestanding radiology center. Please note that your contract may require you to send most radiology to a Kaiser Permanente contracted vendor or all radiology to a Kaiser Permanente facility.



Radiology Components Radiology services include radiological tests and procedures performed in a provider’s office, a hospital radiology department, an ambulatory care center, or an independent radiology center. Billing for radiology services may be for the complete service, the professional component of the service, or the technical component of the service, as defined below. Professional component: Charges for the professional component of a radiology service are for the reading and interpretation of the test results. Kaiser Permanente reimburses the professional component only when a radiologist performs the interpretation. When billing for interpretation services, indicate the professional component by adding Modifier 26 to the CPT procedure code. Technical component: Charges for the technical component of the radiology service are for use of the equipment, overhead, and facility charges associated with the test. Technical Component charges are generally submitted by imaging centers that do not have radiologist on staff. When billing for technical component services, add Modifier “TC” to the CPT procedure code. Facility claims CMS-1450 (UB-04) assume the technical component only. Full component: Charges for the full component of the radiology service are billed when the same provider performs the technical component and the professional component. Full component charges are often submitted by radiology centers or imaging centers that provide the total service. When billing for the full component, bill the CPT code ALONE without modifiers.

5.16.17 Radiation Treatment

For radiation treatment management, the following CPT codes apply:

77427 – Radiation treatment management, five treatments

77431 – Radiation therapy management with complete course of therapy consisting of one or two fractions only

The reimbursement for code 77427 is based on five treatments/fractions per week and must be billed accordingly. For the purposes of billing for code 77427, providers should still indicate the date span that these services were provided in Block 24A on the HCFA-1500, but should enter only a unit of “1” in Block 24G for each block of five treatments per week. Providers should use code 77427 both when the entire course of treatment consists of four or five fractions and when there are three or four fractions beyond the first five. When there are only one or two fractions beyond the first five, they are not reported separately.



5.16.18 Interventional Radiology

These procedures usually consist of an invasive or surgical procedure AND radiological supervision and interpretation.

If a single physician performs this service, use codes from the surgery section in combination with “supervision and interpretation” codes from radiology.

When two physicians (usually a radiologist and a clinician) perform an invasive radiological procedure (for example, an injection, needle biopsy, arthrocentesis, angioplasty, etc.), the clinician should bill the appropriate surgical code and the radiologist should bill the appropriate radiology supervision and interpretation code.

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

KAISER PERMANENTE uses the following guidelines when processing physical, occupational, and speech therapy (PT/OT/ST) claims:

For Providers Participating in the Physical Therapy Provider Network (PTPN) and Those with Similar Agreements

For PTPN providers, PT/OT/ST services will be reimbursed on a per-visit basis (limited to one visit per day per discipline), according to the terms of the provider agreement.

For All Other Providers

Evaluations (97001-97004) are to be reported only one time per date of service.

Supervised Modalities (97010-97028, 97799) are to be reported only one time per date of service, even if applied to more than one body area. More than one modality can be billed in a day.

Example: 97010 (hot or cold packs) and 97014 (electrical stimulation unattended) can be reported per American Medical Association CPT guidelines.

Constant Attention Modalities (97032-97039) are reported in 15-minute increments. More than 30 minutes of these types of services are not considered medically necessary, therefore, more than 2 submissions of these codes on a single date of service are denied.

Iontophoresis, the application of an electrical current into the tissues to enhance the delivery of ionized medications, is a covered benefit when performed as a physical therapy modality. Claims should be submitted with CPT code 97033 – Application of a modality to one or more areas; iontophoresis.

Therapeutic Procedures (97110-97140, 97504-97530) are reported in 15-minute increments. More than one hour of these types of services is not



considered medically necessary; therefore, more than four submissions of these codes are denied.



5.17. Coordination of Benefits (COB) (Required)

Coordination of Benefits (COB) is a method for determining the order in which benefits are paid and the amounts which are payable when a Member is covered under more than one plan. It is intended to prevent duplication of benefits when an individual is covered by multiple plans providing benefits or services for medical or other care and treatment.

Kaiser Permanente Providers are responsible for determining the primary payer and for billing the appropriate party. If Kaiser Permanente is not the primary carrier, an EOB is required with the claim submission.

5.17.1 How to Determine the Primary Payor

Children: The benefits of the plan that covers an individual as an employee, Member or subscriber other than as a dependent are determined before those of a plan that covers the individual as a dependent. When both parents cover a child, the “birthday rule” applies— the payer for the parent whose birthday falls earlier in the calendar year (month and day) is the primary payer. When determining the primary payer for a child of separated or divorced parents, inquire about the court agreement or decree. In the absence of a divorce decree/court order stipulating parental healthcare responsibilities for a dependent child, insurance benefits for that child are applied according to the following order: Insurance carried by the Natural parent with custody pays first Step-parent with custody pays next Natural parent without custody pays next Step-parent without custody pays last If the parents have joint custody of the dependent child, then benefits are applied according to the birthday rule referenced above. Medicare Members: Kaiser Permanente is generally primary for working Medicare-eligible Members when the CMS Working Aged regulation applies. Medicare is generally primary for retired Medicare Members over age 65, and for employee group health plan (EGHP) Members with End Stage Renal Disease (ESRD) for the first 30 months of dialysis treatment. This does not apply to direct pay Members. Workers’ Compensation: In cases of work-related injuries, Workers Compensation is primary unless coverage for the injury has been denied.



Motor Vehicle Accidents: In cases of services for injuries sustained in motor vehicle accidents, Kaiser Permanente will request auto carrier’s payment and coordinate coverage as appropriate.

5.17.2 Description of COB Payment Methodologies

Kaiser Permanente Coordination of Benefits allows benefits from multiple carriers to be added together so that the Member receives the full benefits from their primary carrier and the secondary carrier pays their entire benefit up to 100 percent of allowed charges. When Kaiser Permanente has been determined as the secondary payor, Kaiser Permanente pays the member’s responsibility based on what the primary carrier paid. Kaiser Permanente will never pay more as a secondary carrier than the amount that would have been paid if Kaiser Permanente were the primary carrier. Benefit carve-out calculations are based on whether or not the contracted provider accepts Medicare assignment for the provider contract corresponding to the claim. Medicare assignment means the provider has agreed to accept the Medicare allowed amount as payment.

5.17.3 COB Claims Submission Requirements and Procedures

Whenever Kaiser Permanente is the SECONDARY payor, claims should be submitted on one of the standard claim formats. Send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Explanation of Medicare Benefits (EOMB)/Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient claims processing/adjudication. Kaiser Permanente cannot process a claim without an EOB or EOMB/MSN from the primary carrier. Complete the following fields:

CMS-1500 claim form: Field 29 (Amount Paid)

CMS-1450 claim form: Field 54 (Prior Payments)

5.17.4 Members Enrolled in Two Kaiser Permanente Plans

Some members may be enrolled under two separate plans offered through Kaiser Permanente (dual coverage). In these situations, contracted providers need only submit ONE claim under the primary plan to Kaiser Permanente for processing.

5.17.5 COB Claims Submission Timeframes



If Kaiser Permanente is the secondary payor, any Coordination of Benefits (COB) claims must be submitted for processing within 45 days of the date of the Explanation of Benefits or statement of remittance..

5.17.6 COB FIELDS ON THE UB-04 and UB-04 CLAIM FORM

The following fields should be completed on the CMS-1500 (HCFA-1500) claim form, to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments

837P LOOP #

FIELD NUMBER

FIELD NAME INSTRUCTIONS/EXAMPLES

2330A NM 9 OTHER INSURED’S NAME When additional insurance coverage exists (through a

spouse, parent, etc.) enter the LAST NAME, FIRST NAME, and MIDDLE INITIAL of the insured.

NOTE: This field must be completed when there is an

entry in Field 11d (Is There Another Health Benefit Plan?).

2330A NM 9a OTHER INSURED’S POLICY OR GROUP NUMBER

Enter the policy and/or group number of the insured individual named in Field 9. If you do not know the policy

number, enter the Social Security number of the insured individual. NOTE: Field 9a must be completed when there is an


NOTE: For each entry in this field, there must be a

corresponding Entry in 9d (Insurance Plan Name or Program Name).

2320 DMG 9b OTHER INSURED’S DATE OF BIRTH/SEX

Enter date of birth and sex, of the insured named in Field 9.

The date of birth must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971



N/A 9c EMPLOYER’S NAME or SCHOOL NAME

Enter the name of the employer or school name (if a student), of the insured named in Field 9. NOTE: This field must be completed when there is an




837P LOOP #

FIELD NUMBER


2330B NM 9d INSURANCE PLAN NAME or PROGRAM NAME

Enter the name of the insurance plan or program, of the insured individual named in Field 9.



2300 CLM 10

IS PATIENT’S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? PLACE (State)

Check “yes” or “no” to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Field 24.

NOTE: If yes, there must be a corresponding entry in

Field 14 (Date of Current Illness/ Injury) and in Field 21 (Diagnosis).

PLACE (State) Enter the state the Auto Accident

occurred in.

N/A 11d IS THERE ANOTHER HEALTH BENEFIT PLAN?

Check “yes” or “no” to indicate if there is another health benefit plan. (For example, the patient may be covered under insurance held by a spouse, parent, or some other person). NOTE: If “yes,” then Field Items 9 and 9a-d must be

completed.

2300 DTP 14 DATE OF CURRENT --Illness (First symptom) --Injury (Accident) --Pregnancy (LMP)

Enter the date of the current illness or injury. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2004

2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Enter the diagnosis and if applicable, enter the Supplementary Classification of External Cause of Injury and Poisoning Code. NOTE: This field must be completed when there is an

entry in Field 10 (Is The Patient’s Condition Related To).

2320 AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field 29.



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

The following fields should be completed on the CMS-1500 (HCFA-1500) claim form, to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed.

Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments

837I LOOP #

FIELD NUMBER


2320 SBR

61 GROUP NAME

(Insured Group Name)

Enter the name of the group or plan through which the

insurance is being provided to the insured individual (listed in Field 58). Record entries in the following order:

A = primary payer B = secondary payer C = tertiary paper

2320 SBR

62 INSURANCE GROUP NO. Enter the identification number, control number, or code assigned by the carrier or administrator to identify the GROUP under which the individual (listed in Field 58) is covered. List entries in the following order:


2320 SBR

64 ESC (Employment Status Code of the Insured) Note: This field has been deleted from the UB-04.

Enter the code used to define the employment status of the insured individual (listed in Field 58). Record entries in the following order:


2320 SBR

65 EMPLOYER NAME (Employer Name of the Insured)

Enter the name of the employer who provides health care coverage for the insured individual (listed in Field 58). Record entries in the following order:


2300 H1 67-76

(UB-92) 67 A-Q (UB-

04)

DIAGNOSIS CODE The primary diagnosis code should be reported in Field 67. Additional diagnosis code can be entered in Field 68-76.

2300H1 77(UB-92) 72 (UB-04)

EXTERNAL CAUSE OF INJURY CODE (E-CODE)

If applicable, enter an ICD-9-CM “E-code” in this field.



837P

LOOP # FIELD

NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES

2330A NM 9 OTHER INSURED’S NAME When additional insurance coverage exists (through a

spouse, parent, etc.) enter the LAST NAME, FIRST NAME, and MIDDLE INITIAL of the insured.



2330A NM 9a OTHER INSURED’S POLICY OR GROUP NUMBER

Enter the policy and/or group number of the insured individual named in Field 9. If you do not know the policy

number, enter the Social Security number of the insured individual. NOTE: Field 9a must be completed when there is an


NOTE: For each entry in this field, there must be a

corresponding Entry in 9d (Insurance Plan Name or Program Name).

2320 DMG 9b OTHER INSURED’S DATE OF BIRTH/SEX

Enter date of birth and sex, of the insured named in Field 9.

The date of birth must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971



N/A 9c EMPLOYER’S NAME or SCHOOL NAME

Enter the name of the employer or school name (if a student), of the insured named in Field 9. NOTE: This field must be completed when there is an


2330B NM 9d INSURANCE PLAN NAME or PROGRAM NAME

Enter the name of the insurance plan or program, of the insured individual named in Field 9.



2300 CLM 10

IS PATIENT’S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? PLACE (State)

Check “yes” or “no” to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Field 24.

NOTE: If yes, there must be a corresponding entry in

Field 14 (Date of Current Illness/ Injury) and in Field 21 (Diagnosis).

PLACE (State) Enter the state the Auto Accident

occurred in.

N/A 11d IS THERE ANOTHER HEALTH BENEFIT PLAN?

Check “yes” or “no” to indicate if there is another health benefit plan. (For example, the patient may be covered under insurance held by a spouse, parent, or some other



837P LOOP #

FIELD NUMBER


person). NOTE: If “yes,” then Field Items 9 and 9a-d must be

completed.

2300 DTP 14 DATE OF CURRENT --Illness (First symptom) --Injury (Accident) --Pregnancy (LMP)

Enter the date of the current illness or injury. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2004

2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Enter the diagnosis and if applicable, enter the Supplementary Classification of External Cause of Injury and Poisoning Code. NOTE: This field must be completed when there is an

entry in Field 10 (Is The Patient’s Condition Related To).

2320 AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field 29.



5.18. Explanation of Payment (EOP) (Required)

Documents

Provider Manual - Kaiser Permanenteinfo.kaiserpermanente.org/info_assets/cpp_cod/cod_providermanual... · Kaiser Permanente Provider Manual 3 Table of Contents ... 5.16.7.4 Antepartum