Eliminate Transgender or Hermaphrodite Denials

Claims for some transgender or hermaphrodite services may be inadvertently denied due to sex-related edits unless these services are billed properly. The National Uniform Billing Committee (NUBC) approved condition code 45 Ambiguous gender category to identify these unique claims and to allow proper processing.

MLN Matters article 6917 instructs:


“Institutional providers should report condition code 45 (Ambiguous Gender Category) on inpatient claims related to transgender or hermaphrodite beneficiaries where the service performed is gender specific (i.e., services that are considered female or male only). This claim level condition code should be used by providers to identify these unique claims and to allow the claims to bypass Medicare’s sex related edits and to be processed correctly.”

For the official instructions, go to the Centers for Medicare & Medicaid Services (CMS) website.

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