Variations to code edits or coding policy for claims

Code editing is based on industry standard guidelines.

Kaiser Permanente variations for facility claims

Health plan variations from the general NCCI policy, PTP (procedure to procedure) code edits, OCE, or MCE guidelines will be made transparent to contracted providers.

Kaiser Permanente variations for professional claims

Kaiser Permanente has adopted the Best Practice Recommendation (BPR) for professional claims, 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.

One of the recommendations in this BPR indicates:
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.

Kaiser Permanente is committed to following all recommendations outlined in the BPR. We strive to make any variations to the BPR transparent to our contracted providers when they are put into production or as soon as we become aware of them.

Kaiser Permanente's code editing logic — including general NCCI policy, PTP (procedure to procedure) edits, and the defined payment rule indicators in MPFSDB — is applied to selected professional 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).
• Kaiser Permanente plan benefits take precedence over an industry standard policy (e.g., Kaiser Permanente's preventative care benefits may be richer than Medicare, which could change how code edits are applied).
• Provider contract terms require an exception (proprietary information).

Kaiser Permanente reserves the right to determine criteria for the selection of claims which are subject to code editing application. Criteria might include claim type of service, CPT code, or diagnosis code.

If selection criteria prevented a claim from being analyzed by our code editing software, it would result in the provider not receiving industry standard code editing denials when appropriate. This outcome would be to the provider's benefit.