22-663 Avoid Claims Denied for Gender Affirming Surgery

Date: 08/29/22

This information applies to Physicians, Hospitals and Ancillary providers. 

Reminder. Report condition code 45 or modifier KX with claim submissions

As a result of an increased number of claims that were denied due to sex/diagnosis and sex/procedure edits, CMS established instructions for correct billing for gender affirming surgery (GAS).

Providers contracting with the Prison Health Care Provider Network (PHCPN) should follow guidelines established by the Centers for Medicare and Medicaid Services (CMS) when billing for services to California Department of Corrections and Rehabilitation (CDCR) patients and Division of Juvenile Justice (DJJ) youth.

Billing for gender/procedure conflict

CMS billing guidelines are as follow:

Institutional CMS-1450

-    Providers should report condition code 45 (Ambiguous Gender Category) on inpatient or outpatient services that can be subjected to gender specific editing (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 allows the sex related edits to be bypassed.

Professional CMS 1500

-    Physicians and non-physician practitioner professional claims should use the KX modifier on the detail line with any procedure code(s) that are gender specific. Use of the KX modifier will identify that the physician/practitioner is performing a service on a patient for whom gender specific editing may apply but should have such editing bypassed.

Additional information

If you have questions regarding the information contained in this update, contact the PHCPN Provider Services Center by email within 60 days or by phone at 877-899-0561.