Kaiser Permanente payment policies

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) payment policies are designed to assist you when submitting claims to Kaiser Permanente. They are consistently updated to promote accurate coding and policy clarification. This information is to be used as a reference and not intended to address every aspect of claim reimbursement.

Kaiser Permanente recognizes industry medical societies, including but not limited to the following when processing claims and developing our payment policies.

  • American Medical Association (AMA)
  • American College of Obstetricians and Gynecologists (ACOG)
  • American Health Information Management Association (AHIMA)
  • American Academy of Professional Coders (AAPC)
  • Centers for Disease Control and Prevention (CDC)
  • Centers for Medicare & Medicaid Services (CMS) written policy
  • CMS Local Carrier and National Carrier Determinations (LCD NCD)
  • CMS Manuals and Publications
  • CPT Assistant
  • CPT Manual, including code definitions and associated text
  • Federal Register
  • HCPCS Manual, including code definitions and associated text
  • Integrated Outpatient Code Editor (I/OCE)
  • International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) official guidelines for coding and reporting
  • Medically Unlikely Edits
  • National Correct Coding Policy Manual for Part B Medicare Carriers (NCCI)
  • National Physician Fee Schedule Relative Value File
  • Uniform Billing Editor

Providers are responsible for accurate claims submissions. Billed codes should be fully supported in the medical records and/or office notes.

Coverage of any service is determined by a member’s eligibility, benefit limits for the service or services rendered and the application of the Plan’s Medical Policy.

Final payment is subject to the application of claims adjudication edits common to the industry and the Plan's facility services claims coding policies. Reimbursement is restricted to the provider's contract and/or the scope of practice as well as the fee schedule applicable to that provider.

If you have questions or would like more information, contact the Provider Assistance Unit toll-free at 1-888-767-4670.

All materials are in a print-friendly PDF format, and will open in a new tab.

7th Character ICD-10 and Therapy Codes (PDF)

Access, Elect, and Kaiser Permanente Options Federal plans out-of-network reimbursement (PDF)

Allergen Immunotherapy (PDF)

Ambulance Services (PDF)

Annual Well Visit Billed With Preventive Medicine Evaluation (PDF)

Applied Behavioral Analysis (ABA) Therapy (PDF)

Assistant Surgeon (PDF)

Associate Level Mental Health Care (PDF)

Behavioral Health Add-On Codes (PDF)

BRACAnalysis Large Rearrangement Test (BART) (PDF)

Breast Reconstruction Free Flap Procedure (PDF)

Canalith Procedure (PDF)

Chromoendoscopy and Narrow Band Imaging (PDF)

CLIA Non-Waived Tests in Office (PDF)

CLIA Waived Tests in Office (PDF)

Code Editing (PDF)

Computer-aided Detection (CAD) for Mammography (PDF)

Cosmetic Procedures (PDF)

Critical Care When Patient is Discharged to Home (Facility) (PDF)

Diagnosis Related Group (DRG) Payment and Review (PDF)

Drug Waste (PDF)

Durable Medical Equipment (PDF)

Early Elective Deliveries (PDF)

Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Policy (PDF)

Emergency Department (ED) Professional Claim Coding (PDF)

Evaluation & Management (E&M) Services with Preventive Services (PDF)

Facility Charges for Evaluation and Management Services (PDF)

Fetal Non-stress Tests (PDF)

Fracture Care Without Manipulation (PDF)

High Level Evaluation and Management Services with a Diagnosis of "No Abnormal Findings" (PDF)

Hospital-Acquired Conditions, Never Events & Adverse Events (PDF)

ICD-10 CM Diagnosis Code Combinations (Excludes1) (PDF)

Influenza Vaccinations (PDF)

Initial Hospital E&M Upcoding (PDF)

Injectable Drugs (PDF)

Laboratory (PDF)

Manipulative Services (Chiropractic) (PDF)

Modifiers (PDF)

Modifiers JA and JB (PDF)

Multiple Procedure Payment Reduction (MPPR) - Multiple Diagnostic Imaging (PDF)

Multiple Procedure Payment Reduction (MPPR) - Outpatient Hospital Claims (PDF)

Multiple Procedure Payment Reduction (MPPR) - Professional Claims (PDF)

National Drug Code (NDC) Billing Requirements (PDF)

Neurostimulator Electrode (PDF)

Non-Contracted Provider Reimbursement (PDF)

Non-Covered Services (PDF)

Non-Preventive Services Provided During a Preventive Visit (PDF)

Pharmacist Reimbursement (PDF)

Portable X-Ray Equipment Transportation (PDF)

Prepayment Bill Review - Line Item Deduction (LID) (PDF)

Prepayment Bill Review - Medical Necessity (PDF)

Prepayment Bill Review - Trauma (PDF)

Prolonged Services (PDF)

Revenue Code Billed Without Required Procedure Code (PDF)

Robotic Assisted Surgery (PDF)

Self-Treatment or Treatment of Immediate Family Members (PDF)

Services Incidental to Inpatient Admissions (PDF)

Shared Medical Appointments (Group Visits) (PDF)

Short Stay / 2 Midnight Rule (PDF)

Sinuplasty Billed with Functional Endoscopic Sinus Surgery (FESS) (PDF)

Split Night Sleep Study (PDF)

Surgical Codes - Anatomical Modifiers (Professional Claims) (PDF)

Telehealth Services (Medicare) (PDF)

Telemedicine Services (Commercial) (PDF)

Thirty Day Readmission (PDF)

Unlisted Codes (PDF)

Unspecified ICD-10 CM Diagnosis Codes (PDF)

Urine Drug Screen (PDF)

Venipuncture (PDF)

Virtual Care (PDF)

Women's Health (PDF)

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