Provider Manual. Billing and Payment

Transcription

1 Provider Manual Billing and Payment

2 Billing and Payment Kaiser Permanente s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual 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 or

3 Table of Contents SECTION 5: BILLING AND PAYMENT... 8 CONTACTS FOR QUESTIONS METHODS OF CLAIMS FILING Paper Claim Forms Record Authorization Number One Member/ Provider per Claim Form No Fault/ Workers Compensation/Other Accident Record the Name of the Provider You Are Covering For Submission of Multiple Page Claim Entering Dates Multiple Dates of Services and Place of Services Surgical and/or Obstetrical Procedures Billing Inpatient Claims That Span Different Years Interim Inpatient Bills Supporting Documentation for Paper Claims Where to Mail Paper Claims Electronic Data Interchange (EDI) Electronic Claims Forms / Submissions CLAIM FILING REQUIREMENTS Clean Claims Claims Submission Timeframes Claims Processing Turn-Around Time Claim Reconsideration CLAIM ADJUSTMENTS/CORRECTIONS Incorrect Claims Payments

4 5.4.2 Rejected Claims Due to EDI Claims Error REQUIRED IDENTIFICATION INFORMATION Federal Tax ID Number Changes in Federal Tax ID Number National Provider Identification (NPI) MEMBER COST CHARE MEMBER CLAIMS INQUIRIES VISITING MEMBERS CODING FOR CLAIMS Coding Standards Modifiers in CPT and HCPCS Claims Editing Software Program Coding Edit Rules MEDICAL CLAIMS REVIEW THIRD PARTY LIABILITY (TPL) WORKERS COMPENSATION THIRD PARTY ADMINISTRATOR (TPA) PROVIDER CLAIMS APPEALS Provider Claim Payment Appeals Process CLAIM FORM EXAMPLES AND INSTRUCTIONS CMS CMS-1450 (UB-04) Field Descriptions BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES Capitation Payments Evaluation Management (E/M) Services

5 Inpatient E/M Services: Surgical Procedure that Include E/M Services: Preventive Medicine Services: Emergency Rooms Two Physicians Involved in Admitting a Patient from the ER Emergency in the Office Setting Non-Emergency Services Provided in the Emergency Department Emergency Room and Urgent Care Services Submitted on a UB Critical Care Services Patient Located in a Critical Care Unit Not Receiving Critical Care Services Observation Services Injection/ Immunizations Vaccine Immunizations Allergy Immunotherapy Obstetrical Services Admissions for False Labor Anesthesia Services Provided with Deliveries Multiple Physicians Provide Different Components of the Obstetrical Care Antepartum Care Newborn Services Newborn Care When Baby Is Discharged with Mother Newborn Care When Baby is Discharged without Mother Boarder Babies Who Stay Beyond Their Mother s Discharge Date Mother who stays beyond their baby discharge date Surgery Global Period / Surgical Package Endoscopic Procedures Included in the Surgical Package Anesthesia Procedures Included in the Surgical Package

6 Topical/Local/Digital Block Anesthesia Included in the Surgical Package Preoperative Care/Services Included in the Surgical Package Preoperative Care/Services Excluded from the Surgical Package Postoperative Follow-Up Care Included in the Surgical Package Postoperative Follow-Up Care Excluded from the Surgical Package Same-Day Services Excluded from the Surgical Package Assistant Surgeon Co-Surgery (Two Surgeons) Team Surgery Duplicate / Bilateral Procedures Multiple Surgery Reimbursement for Professional and Facility Claims Exploratory/Diagnostic Procedures Cardiac Procedures Cardiac Catheterization Billing Electrophysiologic Studies (EPS), Cardiac Mapping and Ablations EPS and Cardiac Catheterization Cardiac Rehabilitation Transplants Anesthesia Laboratory Procedures Radiology Services Radiation Treatment Interventional Radiology Therapy: Physical/ Occupational/Speech (P.O.S.) COORDINATION OF BENEFITS (COB) How to Determine the Primary Payor Description of COB Payment Methodologies

7 COB Claims Submission Requirements and Procedures Members Enrolled in Two Kaiser Permanente Plans COB Claims Submission Timeframes COB FIELDS ON THE UB-04 and UB-04 CLAIM FORM COB FIELDS ON THE CMS-1500 (HCFA-1500) CLAIM FORM EXPLANATION OF PAYMENT (EOP)

8 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. Contacts For Questions Central Referral Center or , FAX 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 Member Service Department or 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 Denver, CO Member Service Department - Benefit Information or 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 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

9 5.1. Methods of Claims Filing Paper Claim Forms Original CMS-1500 ver 02/12 must be used for all professional services and suppliers. Original CMS-1450 must be used by all facilities (e.g., hospitals, UB-04 form). Original claim forms are those printed in Flint OCR Red J6983 (or exact match) ink 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 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 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 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 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

10 your claim submission Entering Dates Below is an example of how to enter dates on the CMS-1500 (HCFA-1500) Claim Form 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 Surgical and/or Obstetrical Procedures If any surgical and/or obstetrical procedures were performed, record the ICD-10-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-10-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) 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

11 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 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 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 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 Denver, CO Electronic Data Interchange (EDI) Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of

12 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 5 Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated. 6 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. 7 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. 8 Bypass US Mail Delivery: The usage of envelopes and stamps is eliminated. Providers save time by bypassing the U.S. mail delivery system. 9 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 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

13 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 Providers with existing electronic connectivity, please use the Payer ID list below: SSI Change HealthCare/Emdeon 837I/P Self Funded use ENS/Ingenix/OptumInsight 837I/P COKSR Relay Health 837I/P-RH or for new customers and for existing customers 9.3 Claim Filing Requirements 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 Original CMS Form 1500 ver 02/12, and all facility claims (or appropriate ancillary services) to be submitted using the Original CMS Form CMS 1450 (UB04) based on CMS guidelines. Original claim forms are those printed in Flint OCR Red J6983 (or exact match) ink. 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 or CMS 1450 (UB-04 based on CMS guidelines) All applicable data elements of CMS forms should be completed

14 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 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 of your claim may be delayed for receipt of COB information. Claim Corrections - When a claim is received within the contractual timely filing period but is received with missing information, the provider will be required to submit a corrected claim to Kaiser Permanente within forty five (45) calendar days from the date of the original Remittance Advice. 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)

15 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 Request for Additional Information letter 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 Denver, CO 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 Claim Reconsideration Claims submitted for reconsideration must be submitted within the 45 calendar days of the Remittance Advice with proof of timely filing. Examples of reconsiderations are timely filing denials, provider contract payment disputes, and incorrect eligibility denials. Refer to Section 6.6 of this Manual for further information on reconsiderations. Proof of timely filing may include the following documentation and/or situations: EDI Transmission reports (Kaiser Permanente acknowledgement of EDI transaction) Remit notices Denial notices *Hand-written or typed documentation is not acceptable proof of timely filing

16 9.4 Claim Adjustments/Corrections 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 Incorrect Claims Payments For an Underpayment Error: Write or call Claims Customer Service ((303) or (800) ) 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 Remittance Advice to your refund check, as well as a brief note explaining the error. NOTE: If Kaiser Permanente s Remittance Advice 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

17 Denver, CO 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 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 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 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

18 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: Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente Attn: Provider Contracting E. Dakota Avenue Denver, CO 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 Changes in Federal Tax ID Number If your office/facility changes any pertinent information (i.e., tax identification number, phone or fax number, billing address, practice address, etc.) please mail or fax written notice, including the effective date of the change, as soon as possible, or if at all possible, with 90 days advance notice. For changes in Federal Tax-ID numbers, please include a W-9 form with the correct information. Kaiser Permanente Attn: Provider Contracting E. Dakota Avenue Denver, CO 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:

19 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 Visiting Members Kaiser Permanente members who access routine and specialty health services while they are temporarily visiting another Kaiser Permanente region are referred to as visiting members. Kaiser Permanente health benefit plans allow members to receive non-urgent and non-emergent care* while traveling in other Kaiser Permanente regions (excludes HSA qualified, Medicaid only and PPO plans). We refer to their visiting region as the HOST region and where the member lives as their HOME region. Your first step when a visiting Kaiser Permanente member requests services from you. Review the member identification card and confirm their HOME region Medical Record Number (MRN). Verify HOME region benefits, eligibility and cost share by calling the Member Services Call Center (MSCC) number on the member s identification card. If the member does not have their identification card, please call the region s HOME MSCC listed in this flyer. As a reminder, services are covered according to the member s contract benefits, subject to the general visiting member exclusions.* Does the visiting member need a referral to see a network provider? Follow standard referral procedures. What do I need to know if an authorization is required? Visiting members require a HOST MRN for all authorizations.** The member or network provider should call the Chart Accuracy Group at between 8-4PM to get the HOST MRN before submitting the referral request for an authorization. After 4PM, press 0 within the recording and the call be transferred to a representative who will assign the HOST MRN

20 Include the HOST MRN on the referral request submission. Authorization forms can be found at the Community Provider Portal (CPP). Should additional services be required, refer to the Colorado authorization guidelines. As a reminder, services are covered according to the member s contract benefits, subject to the general visiting member exclusions.* What do you need to know when submitting claims? Claims must be submitted to the member s HOME region with the members HOME region medical record number (MRN) included on the claim. Always use the HOME MRN. Never add the HOST MRN on the claim form. If the member does not have an identification card or the HOME region s claim submission address is not on the identification card, please call the corresponding HOME region s MSCC number below to obtain the claims address. If you have a claim status inquiry, refer to the HOME region s MSCC numbers below. If an authorization has been obtained, be sure to add the authorization number on the claim. Where do I send reconsiderations or appeal forms? For reconsiderations or appeals, call the home region s MSCC * Refer to Visiting Member brochure located on the Community Provider Portal. ** EXCEPTION: for DME authorizations, contact the HOME region MSCC. 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 Coding Standards Coding All fields should be completed using industry standard coding as outlined below. ICD-10 To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-10-CM) developed by the Commission on Professional and Hospital Activities. The U.S. Department of Health and Human Services (HHS) has set the compliance date of October 1, 2015 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

21 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 or submit your request and supporting documentation to: CPT Editorial Research and Development American Medical Association 515 North State Street Chicago IL 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 Modifiers in CPT and HCPCS Kaiser Permanente reserves the right to review use of modifiers to ensure accuracy and appropriateness. Improper use of modifiers may cause claims to deny, pend and/or the return of claims for correction

22 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 all modifiers submitted. When submitting claims, use modifiers to: 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. Modifiers Billed with Surgical Procedures Modifier 50 - Bilateral Procedure 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

23 modifier 51 to the additional procedure or service codes(s). We will be using CMS guidelines to determine appropriateness including add on procedures. 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. 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. 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: If all modifiers are used to make payment determination, the claim will be held for manual adjudication and review. 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 Claims Editing Software Program 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 and CMS guidelines. 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. Provider documentation must support services billed

24 Claims are processed utilizing claims editing software product from McKesson ClaimsXten. ClaimsXten includes edit rules such as incidental, bundled and mutually as well as other edits that are recognized by industry guidelines. ClaimsXten will be updated at a minimum quarterly. 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 /ClaimsXten is clinically appropriate and withstands the scrutiny of both payers and providers. 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. We perform code editing to enforce both Kaiser Permanente and nationally accepted coding and payment rules, and to verify the codes you submit are consistent based on the services rendered. Your claims will be subjected to code editing software (McKesson ClaimsXten ). The code edit software assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding and billing of procedure(s). The code edit software may change and edit your claim, perhaps substantially, as a result of industry coding guidelines. When a change is made to your submitted code(s), Kaiser Permanente will provide an explanation of the reason for the change. Possible outcomes include: Accepting the code(s) as submitted. Adding a new code to a claims to comply with generally accepted coding practices that are consistent with Physicians Current Procedural Terminology (CPT), the HCPCS Code Book Denying services for outdated or invalid codes. Denying line items for coding guidelines such as Medically unlikely or CMS National Correct Coding Initiative (NCCI). 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

25 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 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 Provider Representative or Claims Customer Service Major Categories of Claim Coding Errors/Inconsistencies: AMA and CMS Guidelines 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 ClaimsXten. HCPCS codes related to CPT codes ClaimsXten 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. 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

26 Laboratory unbundling edits are applied when certain laboratory tests are billed separately when a pre-defined panel exists that contains all 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 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report. Claim Detail Line Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. Example 2 Explanation: When CPT codes and are performed on the same day, the appropriate comprehensive procedure code would be Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. 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

27 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 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 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. 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. Frequency edits occur when a procedure is billed more often than would be expected in comparison to the units of service or date of service Global Surgical Packaging identifies Evaluation & Management (E&M) codes and

28 supplies billed on a claim within the global period of the surgical procedure. The time frames are set by both the Center of Medicare and Medicaid Services (CMS). New Patient Visit As defined by the AMA, A new patient is one who has not received any professional service from the physician or another physician of the same specialty who belongs to the same group practice within the past 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 and adjustments to the current claim being reviewed. 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 Modifier 26 or TC edits identifies when a procedure billed on a claim may be billed with a professional or technical components (i.e., with Modifiers 26 or TC) may be submitted by multiple providers. The edits ensures that the total reimbursement amount does not exceed the allowable amount. 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 Member Service at 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.) 5.11 Medical Claims Review

29 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 Third Party Liability (TPL) Third Party Liability is coordinated through Equian. P.O. BOX Louisville, KY TEL: Fax: (502) Hours of Operations 8:30 a.m. to 5:00 p.m. Monday-Friday (Eastern Time) 5.13 Workers Compensation Workers Compensation claims are not covered by Kaiser Permanente. We will deny all claims related to Workers Compensation Third Party Administrator (TPA) 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 Provider Claims Appeals Refer to Section 6 of this Manual for the information on provider claims appeals 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 Many

30 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 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 Claim Form Examples and Instructions 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 1 MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER REQUIRED FIELDS FOR CLAIM SUBMISSIONS Not Required INSTRUCTIONS/EXAMPLES 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 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/ 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

31 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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 7 INSURED S ADDRESS Required if Applicable Check the appropriate box for the patient s relationship to the insured. 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 9a OTHER INSURED S POLICY OR GROUP NUMBER Required if Applicable 9b RESERVED FOR NUCC USE Required if Applicable 9c RESERVED FOR NUCC USE Required 9d 10a-c INSURANCE PLAN NAME OR PROGRAM NAME IS PATIENT CONDITION RELATED TO if Applicable Required if Applicable Required When additional insurance coverage exists, enter the last name, first name and middle initial of the insured. 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. Enter the name of the other insured s INSURANCE PLAN or program. 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). 10d CLAIM CODES Not Required Leave blank. Place (State) - enter the State postal code. 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)

32 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES Example: 01/05/ b 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 13 INSURED S OR AUTHORIZED PERSON S SIGNATURE 14 DATE OF CURRENT ILLNESS, INJURY, PREGNANCY 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Not Required Not Required Required if Applicable Not Required 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. Have the patient or an authorized representative SIGN this block, unless the signature is on file. 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 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). Example: 01/05/2006 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/

33 FIELD NUMBER FIELD NAME 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if Applicable INSTRUCTIONS/EXAMPLES 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 19 ADDITIONAL CLAIM INFORMATION Not Required Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization. Leave Blank 20 OUTSIDE LAB CHARGES Not Required Required 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the diagnosis/condition of the patient, indicated by an ICD-10-CM code number. Enter up to 12 diagnostic codes, in PRIORITY order (primary, secondary condition). 22 RESUBMISSION CODE Not Required 23 PRIOR AUTHORIZATION NUMBER Required Enter the prior authorization number for those procedures requiring prior approval. 24 a-j SUPPLEMENTAL INFORMATION Required Supplemental information can only be entered with a corresponding, completed service line. SUPPLEMENTAL INFORMATION, con t. 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

34 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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). 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 Required Enter the CPT/HCPCS codes and MODIFIERS (if

35 FIELD NUMBER FIELD NAME SUPPLIES: CPT/HCPCS, MODIFIER REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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-10-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.) 24h EPSDT FAMILY PLAN Not Required 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 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

36 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 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. 27 ACCEPT ASSIGNMENT Not Required IMPORTANT: This field aids in patient identification by the Provider/Provider. 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. 30 BALANCE DUE Not Required Enter the balance due (total charges less amount paid). 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32 SERVICE FACILITY LOCATION INFORMATION Required Required if Applicable 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. The name and address of the facility where services were rendered (if other than patient s home or physician s office)

37 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES Enter the name and address information in the following format: 1 st Line Name 2 nd Line Address 3 rd 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. Required 33 BILLING PROVIDER INFO & PH # 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

38

39 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 FIELD NAME 1 PROVIDER NAME and ADDRESS 2 PAY-TO NAME, ADDRESS, CITY/STATE, ID # 3a PATIENT CONTROL NUMBER 3b MEDICAL RECORD NUMBER REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required Required Required Not Required INSTRUCTIONS/EXAMPLES Enter the name and address of the hospital or person who rendered the services being billed. Enter the name and address of the hospital or person to receive the reimbursement. Enter the member s control number. IMPORTANT: This field aids in patient identification by the Provider/Provider. 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 6 STATEMENT COVERS PERIOD - FOR REFERENCE ONLY Required Required Enter the federal tax ID of the hospital or person entitled to reimbursement. 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 Required if Enter the two-digit code for the hour during which the (DHR) member was discharged. Applicable 17 PATIENT STATUS Required Enter the discharge status code 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 30 BLANK Not Required Leave blank. Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment.

40 FIELD NUMBER FIELD NAME OCCURRENCE CODES AND DATES OCCURRENCE SPAN CODES AND DATES REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if Applicable Required if Applicable 37 BLANK Not Required Leave blank. INSTRUCTIONS/EXAMPLES Enter the code and the associated date defining a significant event relating to this bill that may affect claims processing. 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 VALUE CODES and Required if AMOUNT Applicable 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 44 PROCEDURE CODE AND MODIFIER Not Required Required Enter the revenue description. 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 BLANK Not Required Leave blank. 48 NON COVERED CHARGES Not Required Enter any non-covered charges. 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. - FOR REFERENCE ONLY

41 FIELD NUMBER FIELD NAME 52 RELEASE OF INFORMATION (RLS INFO) 53 ASSIGNMENT OF BENEFITS (ASG BEN) REQUIRED FIELDS FOR CLAIM SUBMISSIONS Not Required Required if Applicable INSTRUCTIONS/EXAMPLES Enter the release of information certification number Enter the assignment of benefits certification number. 54a-c PRIOR PAYMENTS Required if Applicable - FOR REFERENCE ONLY Not Required 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 Enter the estimated amount due. 56 NATIONAL PROVIDER Required Enter the service provider s National Provider Identifier IDENTIFIER (NPI) (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 Required if Applicable 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 62 INSURED S GROUP NUMBER 63 TREATMENT AUTHORIZATION CODE 64 DOCUMENT CONTROL NUMBER Required if Applicable Required if Applicable Required if Applicable Not Required 65 EMPLOYER NAME Required if Applicable Not Required 66 DX VERSION QUALIFIER 67 PRINCIPAL DIAGNOSIS CODE 67 A-Q OTHER DIAGNOSES CODES Required Required if Applicable 68 BLANK Not Required Leave blank. 69 ADMITTING DIAGNOSIS 70 REASON FOR VISIT (a-c) (PATIENT REASON DX) Required Not Required 71 PPS CODE Required if Applicable 72 EXTERNAL CAUSE OF INJURY CODE (ECI) Required if Applicable Enter the insured s group name. Enter the insured s group number as shown on the identification card. For Prepaid Services claims enter PPS. For ALL inpatient and outpatient claims, enter the referral number. Enter the document control number related to the member or the claim. Enter the employer s name. Indicate the type of diagnosis codes being reported. Note: At the time of printing, Kaiser only accepts ICD-10- CM diagnosis codes on the UB-04. Enter the principal diagnosis code, on all inpatient and outpatient claims. Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail. Enter the admitting diagnosis code on all inpatient claims. Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration. Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology. Enter an ICD-10-CM E-code in this field (if applicable).

42 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS 73 BLANK Not required Leave blank. 74 PRINCIPAL PROCEDURE CODE AND DATE 74 (a e) OTHER PROCEDURE CODES AND DATES Required if Applicable Required if Applicable 75 BLANK Not required Leave blank. 76 ATTENDING PHYSICIAN / NPI / QUAL / ID 77 OPERATING PHYSICIAN / NPI/ QUAL/ ID OTHER PHYSICIAN/ NPI/ QUAL/ ID Required Required If Applicable INSTRUCTIONS/EXAMPLES Enter the ICD-10-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable). Enter other ICD-10-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). 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. Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure. Required if Enter the National Provider Identifier (NPI) and name of any other physicians. Applicable 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. - FOR REFERENCE ONLY

43 - FOR REFERENCE ONLY

44 5.17 Billing Requirements and Instruction for Specific Services Instructions on billing for specific services can also be obtained by contacting Claims and Member Service at 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 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 10 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 Denver, CO 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

45 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 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

46 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 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 postoperative 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

47 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:

48 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 followup 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

49 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: Services of other physicians not providing surgical package services 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

50 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

51 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 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 ( ) given during a preventive medicine visit may be billed separately 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 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

52 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 patient is seen in the emergency department. For urgent or emergency services provided in the office setting, use code (Office services provided on an emergency basis) in addition to the appropriate E/M office visit code 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 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 Critical Care Services 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 Observation Services

53 Use hospital observation E/M codes to report E/M services rendered Injection/ Immunizations Vaccine Immunizations Report the codes through 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 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 ( ). 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: The injection is administered ONLY (the patient brings in the serum)

54 The provider prepares the serum and administers the injection The provider prepares the serum ONLY 5.21 Obstetrical Services 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 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 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 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

55 care is submitted separately. Enter the end date of service on the CMS 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 Newborn Services 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 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

56 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 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 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

57 5.23 Surgery 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

58 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

59 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: Services of other physicians not providing surgical package services 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

60 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

61 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 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

62 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 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

63 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 followup care as part of the reimbursement for the surgical procedure 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: 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

64 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: Services of other physicians not providing surgical package services 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 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: 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,

65 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

66 procedure code specifies a SINGLE service, but another procedure code is available for identifying MULTIPLE services 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 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 Cardiac Procedures Cardiac Catheterization Billing According to the AMA, three procedure codes should be billed for a cardiac catheterization procedure. They are: Catheter code ( ) Injection code ( ) Supervisory code ( ) Example: The following procedure codes may be billed together, and separate reimbursement occurs: Combined right heart catheterization and retrograde left heart

67 catheterization Injection procedure during cardiac catheterization for selective coronary angiography 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 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

68 (procedure codes ). Cardiac ablation (procedure codes ) 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 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: Electrophysiologic study Right heart catheterization and transeptal left heart catheterization is denied as rebundled to 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 Outpatient Cardiac Rehabilitation without ECG monitoring Outpatient Cardiac Rehabilitation with continuous ECG monitoring 5.25 Transplants Kaiser Permanente considers a claim clean when the following requirements are met:

69 Correct Form - Kaiser Permanente requires all professional claims to be submitted using the CMS Form 1500 and all facility claims (or appropriate ancillary services) to be submitted using the CMS Form CMS 1450 (UB04 or 92 based on CMS guidelines. Standard Coding All fields should be completed using industry standard coding. Applicable Attachments Attachments should be included in your submission when circumstances require additional information. Completed Field Elements for CMS Form 1500 (08/05 or 12/90 based on CMS guidelines) Or CMS 1450 (UB-04 or UB92 based on CMS guidelines) All applicable data elements of CMS forms should be completed. A claim is not considered to be Clean or payable if one or more of the following are missing or are in dispute: The format used in the completion or submission of the claim is missing required fields or codes are not active. The eligibility of a member cannot be verified. The responsibility of another payor for all or part of the claim is not included or sent with the claim. Other coverage has not been verified. Additional information is required for processing such as COB information, operative report or medical notes (these will be requested upon denial or pending of claim). The claim was submitted fraudulently. Must comply with coding standards (detailed in Sections and 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 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: pre- and postoperative visits

70 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 5.27 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

71 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 (UB-04)assume the technical component only 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

72 billing for the full component, bill the CPT code ALONE without modifiers Radiation Treatment For radiation treatment management, the following CPT codes apply: Radiation treatment management, five treatments Radiation therapy management with complete course of therapy consisting of one or two fractions only The reimbursement for code 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 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 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 Therapy: Physical/ Occupational/Speech (P.O.S.) KAISER PERMANENTE uses the following guidelines when processing physical, occupational, and speech therapy (PT/OT/ST) claims: Evaluations are to be reported only one time per date of service. Supervised Modalities 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: hot or cold packs and electrical stimulation unattended can be reported

73 per American Medical Association CPT guidelines. Constant Attention Modalities 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 applicable CPT code. Therapeutic Procedures 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 Coordination of Benefits (COB) 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 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

74 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 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 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

75 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) 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 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 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 2016 FIELD NAME 75 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 Enter the policy and/or group number of the insured

76 837P LOOP # FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES OR GROUP NUMBER 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 entry in Field 11d (Is There Another Health Benefit Plan?). NOTE: For each entry in this field, there must be a corresponding Entry in 9d (Insurance Plan Name or Program Name) 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 NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). 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 entry in Field 11d (Is There Another Health Benefit Plan?). 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. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?) CLM 10 IS PATIENT S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? 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) N/A 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? PLACE (State) Enter the state the Auto Accident occurred in. 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

77 837P LOOP # FIELD NUMBER FIELD NAME 2300 DTP 14 DATE OF CURRENT --Illness (First symptom) --Injury (Accident) --Pregnancy (LMP) 2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY INSTRUCTIONS/EXAMPLES 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 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) AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field

78 837I LOOP # FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES 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: A = primary payer B = secondary payer C = tertiary paper 2320 SBR 2320 SBR 64 ESC (Employment Status Code of the Insured) Note: This field has been deleted from the UB EMPLOYER NAME (Employer Name of the Insured) Enter the code used to define the employment status of the insured individual (listed in Field 58). Record entries in the following order: A = primary payer B = secondary payer C = tertiary paper 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: A = primary payer B = secondary payer C = tertiary paper 2300 H (UB-92) 67 A-Q (UB- 04) 2300H1 77(UB-92) 72 (UB-04) DIAGNOSIS CODE The primary diagnosis code should be reported in Field 67. Additional diagnosis code can be entered in Field EXTERNAL CAUSE OF INJURY CODE (E-CODE) If applicable, enter an ICD-10-CM E-code in this field 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

79 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 entry in Field 11d (Is There Another Health Benefit Plan?). NOTE: For each entry in this field, there must be a corresponding Entry in 9d (Insurance Plan Name or Program Name) 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 NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). N/A 9c EMPLOYER S NAME or SCHOOL NAME 2330B NM 9d INSURANCE PLAN NAME or PROGRAM 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 entry in Field 11d (Is There Another Health Benefit Plan?). Enter the name of the insurance plan or program, of the insured individual named in Field 9. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?) CLM 10 IS PATIENT S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? 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) PLACE (State) Enter the state the Auto Accident

80 837P LOOP # FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES 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 DTP 14 DATE OF CURRENT --Illness (First symptom) --Injury (Accident) --Pregnancy (LMP) 2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 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 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) AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field

81 5.32 Explanation of Payment (EOP)