General Surgery Coding Alert

Coding for gender-specific services can be complex and require a comprehensive explanation of medical necessity. Plus, if you add in payers’ billing nuances, you’ve got a perfect storm for denials.

Background: During the Healthcon 2024 presentation, “Gender-Specific Services & Billing,” Keisha Wilson CCS, CPC, CPCO, CPMA. CRC, CPB, AAPC-approved instructor, discussed the importance of interacting respectfully with patients of all gender identities and coding gender identification correctly to avoid claim denials. Read on for tips to ensure your claims aren’t denied due to payer-perceived gender discrepancies.

Code These Gender-Specific Procedures Regardless of Orientation

Wilson discussed that there are times when gender-specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Just a few examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
• Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

These claims can easily be denied if you are not careful when it comes to proving medical necessity regardless of which gender box is checked on the claim or medical record. “During registration, discuss organ inventory and health monitoring with the patient,” said Wilson. “If there is a family history of breast or prostate cancer, for example, the patient will need to have regular screenings.”

Utilize Condition Codes and Modifiers

For any procedure codes normally considered appropriate for one gender, indicate on the claim detail line if the patient’s experienced gender differs from their assigned sex at birth.

“To avoid a denial, you will use the National Uniform Billing Committee’s revised Condition Code 45 (Ambiguous gender category) to indicate gender incongruence between an individual’s experienced gender and the one they were assigned at birth,” said Wilson. This code was made effective July 1, 2023, and it alerts the payer that the gender/procedure or gender/diagnosis conflict is not an error, allowing the claim to continue normal processing. These can be listed in boxes 18-28 on the UB04 form.

Wilson explained that institutional providers should continue to report condition code 45 for inpatient and outpatient claims related to transgender, intersex, and gender-expansive systems issues. And clinicians that bill for Medicare Part B professional claims should report the KX (Requirements specified in the medical policy have been met) modifier for any claims related to transgender, intersex, and gender-expansive systems issues.

Condition codes defined: Condition codes are two-digit numeric or alphanumeric symbols that depict various facets of a patient’s condition, the services rendered, the service setting, and/or billing circumstances that may influence how an institutional claim is handled by a payer.

Use Z Codes for Transgender Claims

ICD-10-CM codes from section Z00-Z99 Factors Influencing Health Status and contact with Health Services may also be a necessary addition to a claim for a transgender patient to help avoid a denial.

There are various Z codes that providers may use, but the following codes may apply to visits with a transgender patient, depending on the patient’s situation:

• Z87.890 (Personal history of sex reassignment). You’ll use this code to describe patients who have undergone sex reassignment surgical procedures in the past.
• Z79.890 (Hormone replacement therapy). This code may be helpful to describe the status of a patient who has been on hormone replacement therapy (HRT) for a long period of time, and depends on the specific medication used, as not all drugs qualify as HRT.
• Z79.899 (Other long term (current) drug therapy). If the patient has been on a particular medication for a long period of time but it doesn’t fit into one of the other categories, such as HRT, you’ll report Z79.899.

“Z codes [other reasons for healthcare encounters] may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter,” Wilson added.

Understand These Challenges With Payers

“It’s advisable to check with your payers on their specific policy on services furnished to transgender patients,” said Wilson. “Coding will depend on what services are provided, and it is best practice to obtain their definitive list of covered and noncovered services from your payers.”

As of 2016, EmblemHealth has instructed all claim editing systems and vendors to turn off all gender-based rules, as well as all facility claims reported with condition code 45 and all professional claims reported with the following ICD-10-CM diagnosis codes:

• F64.0 (Transsexualism)
• F64.1 (Dual role transvestism)
• F64.8 (Other gender identity disorders)
• F64.9 (Gender identity disorder, unspecified)
• Z87.890 (Personal history of sex reassignment)

These codes, and/or reporting modifier KX, will exclude the claim from gender-conforming editing.

Per UnitedHealthcare (UHC) reimbursement guidelines, the UHC Community Plan will apply gender edits to Arizona, District of Columbia, Kansas, Missouri, and North Carolina Medicaid claims when diagnosis and/or procedure codes are reported inappropriately for the patient’s gender.

CIGNA’s coverage for treatment of gender dysphoria, including gender reassignment surgery and related services, may be governed by state and/or federal mandates.

Pocket This Advice on Circumventing Claim Denials

Wilson stressed the importance of keeping your staff updated on changes in gender coding and collecting information accurately the first time to avoid denials. “It is crucial to collect and verify accurate patient information, including their gender. Double-check that the patient’s gender is correctly recorded in the electronic health record [EHR] or any other billing system,” she counseled.

Wilson also stated that offices should “provide comprehensive training programs to all staff members involved in the revenue cycle management process. This training should emphasize the importance of accurate gender identification and its potential impact on claim denials.”

If you do receive a claim denial due to a gender issue or inconsistency on a claim, Wilson suggested the following:

• Contact the payer to get further clarification on the matter and provide any necessary documentation or justification for the diagnosis.
• Monitor future claims to ensure that similar issues do not arise again and take proactive steps to prevent such errors or discrepancies.
• Review the patient’s medical record and documentation to ensure the diagnosis is accurately reported.
• Query the healthcare provider for discrepancies or ambiguities in the diagnosis coding.