Wiki Kaiser Denials 88305

[mconner001]

We are getting denials from Kaiser for our pathology services stating the diagnosis code is not appropriate. When there are no findings on the pathology report and the provider took biopsies because of GI issues, for example R19.7, diarrhea, I've been billing with the R code (the indication) in this situation and getting the denials.
The EOB tells me to 'refer to the 835 Healthcare Policy Identification Segment' which hasn't helped me figure out why they are denying. I've reviewed the CMS Manual, chapter 10 but can't seem to find any direction for this scenario. ICD-10 guidelines seem to be indicating that I am billing this correctly. I called in and spoke with a representative but she was unable to help.
What am I missing? Your thoughts would be appreciated.

 

[danachock]

Hi mconner001,
Did you find this website? https://wa-provider.kaiserpermanente.org/provider-manual/billing-claims/claims/claims-ra
Inside this link it states:

Our electronic 835 remittance advice must use only the HIPPA-compliant action codes. As of Jan. 8, 2014, our paper EOP will contain only HIPPA-compliant action codes and will no longer display Kaiser Permanente-specific codes. If you have difficultly interpreting the codes, check the Washington Publishing Company's code lists or review your claim via OneHealthPort for Kaiser Permanente-specific codes. If you need additional assistance, contact our Provider Assistance Unit.

If you don't have access to their portal which is usually reserved for "billers" only. I would first reach out to your billing team to see who has access and can capture these "Kaiser specific codes" to share with you or have your Fed ID and all that necessary stuff available and just call and chat with them yourself. Yes, I know everyone likes to push this onto a biller but sometimes things fall through the cracks deferring charges, waiting for a biller to call and receive answers to not have all the answers and again wait some more. As a coder when you call them you already have the question(s) you need to ask ready to roll and based on their response(s) may have additional questions so instead of possibly 2 or 3 calls made by a biller a coder can sometimes get those necessary answers in one call.
Thank you for listening and have a wonderful evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT

 

[mconner001]

I appreciate your replying however, after reading MY post I realize that I was not as specific as I should have been. The denial stems from the diagnosis code not supporting the service. We did a colonoscopy and the provider took random biopsies because of R19.7 and the pathology came back with no findings - normal mucosa, etc. I billed with the indication for the biopsies.

What I am having trouble locating and what the Kaiser representative couldn't tell me is what specifically they are basing this denial on. I don't find anything in the Medicare guidelines indicating that I should be billing it any differently than I have done. I don't see the basis for the Kaiser denial. ICD 10 guidelines indicate I am billing this correctly, in my interpretation.

Am I billing my pathology charge correctly?