Gender mismatch denial

SharonCollachi

True Blue
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Clovis, CA
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A couple of hours ago I read a question on getting a PSA test paid for a mtf patient by Medicare, and now, no matter what I search I cannot find it. So if you're still looking for an answer, here it is:

The short answer is, you need condition code 45 for facilities; modifier KX for professionals.

From the Medicare Claims Processing Manual (click for link):

240 – Special Instructions for Services with a Gender/Procedure Conflict(Rev. 1877, Issued: 12-18-09, Effective: 04-01-10, Implementation: 04-05-10)Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.The National Uniform Billing Committee (NUBC) has approved condition code 45 (Ambiguous Gender Category) as a result of the increasing number of claims received that are denied due to sex/diagnosis and sex/procedure edits. This claim level condition code should be used by institutional providers to identify these unique claims and alerts the fiscal intermediary that the gender/procedure or gender/diagnosis conflict is not an error allowing the sex related edits to be by-passed.The KX modifier (Requirements specified in the medical policy have been met) is now a multipurpose informational modifier and will also be used identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries. Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.

240.1 - Billing Instructions for Institutional Providers(Rev. 1877, Issued: 12-18-09, Effective: 04-01-10, Implementation: 04-05-10)Institutional providers are to report condition code 45 on any inpatient or outpatient claim related to transgender, ambiguous genitalia, or hermaphrodite issues.

240.2 – Billing Instructions for Physicians and Non-Physician Practitioners(Rev. 1877, Issued: 12-18-09, Effective: 04-01-10, Implementation: 04-05-10)The KX modifier is to be billed on the detail line only with the procedure code(s) that is gender specific for transgender, ambiguous genitalia, and hermaphrodite beneficiaries. (NOTE: The KX modifier is a multipurpose informational modifier, and may also be used in conjunction with other medical policies.)
 
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