Code editing and review process for professional claims

Code editing process at Kaiser Permanente

Kaiser Permanente has a claims code editing process in place which assures:

Provider claims are coded based on recognized industry standard guidelines.
Kaiser Permanente code edits are applied based on industry standard guidelines.
We are meeting coding requirements of Medicare and other regulatory entities.
Costs for administration of claims are reduced for both providers and Kaiser Permanente.
Our consumers’ claims are submitted and processed consistently and appropriately based on the services they received.

Code editing based on industry standard guidelines

Kaiser Permanente has adopted the Best Practice Recommendation (BPR) for Claim coding policy and edits: standardization & transparency as outlined in Washington State Senate Bill 5346 and published through the administration simplification work of Washington Healthcare Forum.

Highlights of the best practice recommendation:

1. Health plans and provider organizations will adopt and appropriately implement:

  • Industry standard National Correct Coding Initiative (NCCI) policy and guidelines, including PTP (procedure to procedure) code edits (i.e., Column One/Column Two Correct Coding Edit Table, Mutually Exclusive Table).
  • Industry standard payment rules and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB):
    • Status of "B" = Bundled Codes
    • Global Surgery
    • Multiple Procedures (Modifier 51)
    • Bilateral Surgery (Modifier 50)
    • Assistant at Surgery
    • Co-surgeons (Modifier 62)
    • Team Surgery (Modifier 66)
    • Endoscopic Base Codes (Indicator 3)

2. Health plan variations from the general NCCI policy, PTP (procedure to procedure) code edits or the defined payment rule indicators in MPFSDB will be made transparent to contracted providers.

Code Editing Logic

Kaiser Permanente’s code editing logic is applied to claims for all lines of business unless:

  • Regulations are specific to a particular line of business (e.g., LCD/NCD logic is applied to Medicare claims only).
  • Health plan benefits take precedence over an industry standard policy (e.g., Kaiser Permanente’s preventative care benefits might be richer than Medicare, which could change how code edits are applied).
  • Contract terms require an exception.
  • Variations to coding policy or specific code edits are specifically called out as required by the BPR.

For information regarding Kaiser Permanente variations to NCCI coding policy, PTP code edits, or MPFSDB indicators, see variations to code edits or coding policy for claims.

General code editing logic applied includes, but is not limited to:

  • CMS guidelines are used as the basis for applying coding policy.
  • NCCI coding policy which explains the rationale for the PTP (procedure to procedure).
  • PTP (procedure to procedure) code edits (i.e., Column One/Column Two Correct Coding Edit Table, Mutually Exclusive Table).
  • MPFSDB indicators called out in the BPR.
  • Other indicators listed in the MPFSDB that are industry standard; including but not limited to:
    • Professional/technical component indicators (modifier 26/modifier TC).
    • Other status codes.
    • Global surgery indicators.
    • Pre-operative, intra-operative, post-operative percentages.
  • Medically Unlikely Edits (MUE), Units of Service edits.
  • American Medical Association (AMA) CPT guidelines where applicable (e.g., add-on codes, E&M code requirements, separate procedures, modifiers, unlisted procedures etc.).
  • Local Coverage Determinations (LCD) edits – Medicare.
  • National Coverage Determinations (NCD) edits – Medicare.
  • Maternity Coding – AMA CPT coding with additional logic published by American College of Obstetricians and Gynecologists (ACOG).
  • Procedure vs. Age Edits.
  • Procedure vs. Gender Edits.
  • Diagnosis vs. Age Edits.
  • Diagnosis vs. Gender Edits.
  • Diagnosis codes should be coded to the highest specificity required for each code based on ICD-10 guidelines.
  • Refer to ICD-10 guidelines in determining if a diagnosis code can be billed in the primary position, secondary position, or either position.
  • Each diagnosis code should be "pointed" to the correct procedure code. Incorrect pointing could result in claim line denials.
  • For laboratory or pathology claims, the requesting physician must supply the initial diagnosis. For lab services interpreted by a physician/pathologist, they are responsible for correcting that diagnosis, if necessary, when the final results of the test are available. The final diagnosis should be billed on the claim.

Code review process

Kaiser Permanente might review a provider’s claims in more detail, either through the code editing process or claims audit process. In order to complete these audits it might be necessary for us to request the medical records documentation which supports the services billed/coded in order to complete these audits. Many factors might prompt a review requiring medical records documentation. Some common examples are:

  • Codes with modifier 22 or 59.
  • "Unlisted" codes.
  • High level E&M codes.
  • Codes billed with an unusual number of units.
  • An unusual combination of procedures performed.
  • Coding trends identified.

If medical records documentation is required, you will receive written notification requesting medical records.

Provider reconsideration of a code edit or coding policy

For additional information on how to submit a provider reconsideration related to a specific code edit or a Kaiser Permanente coding policy, see provider reconsideration of a code edit or coding policy for professional claims.

Content on this page is from the provider manual | Disclaimer