The final rule prohibits the sex discrimination in health care by prohibiting denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping. The provisions of this rule that apply to health insurance or group health plan benefit design have an applicability date of the first day of the first plan year beginning on or after January 1, 2017. Current billing practices include options for submitting claims for transgender patients to avoid initial denials of claims for sex-specific services.
Centers for Medicare & Medicaid Services (CMS) developed modifier KX (Requirements specified in the medical policy have been met) as a multipurpose informational modifier to 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 to allow the claim to continue to process normally.
The National Uniform Billing committee (NUBC) approved condition code 45 (Ambiguous Gender Category) to report on inpatient or outpatient UB claims forms for services that may be inadvertently denied due to sex related edits. This claim level condition code allows the sex related edits to continue through normal processing.
Appropriate use of modifier KX on the CMS 1500 claim form or condition code 45 on institutional UB claim forms will allow normal processing of claims for the transgender population.
Claims for sex-specific services by transgender patients lacking the modifier KX or condition code 45 may result in a denial of the service. Contractual terms prohibit providers from billing patients for these services.
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