General Surgery Coding Alert

Question: I've heard that Medicare has a new way to override gender-specific edits, when appropriate, based on patient circumstances. Are we supposed to use a specific  modifier?

Arizona Subscriber

Answer: You'll use new condition code 45 (Ambiguous gender category) with claims that may be denied "due to sex/diagnosis and sex/procedure edits," according to MLN Matters article MM6638.

You'll use this code when "the service performed is gender specific (i.e., services that are considered female or male only)," the article notes. "This claim level condition code should be used by providers to identify these unique claims and to allow the sex-related edits to be processed correctly by Medicare systems and allow the service to continue normal processing," the MLN Matters article indicates.

There's more: You'll also append modifier KX (Requirements specified in the medical policy have been met) to the claim to let your payer know that the services are gender specific but that your patient meets the requirements and the claim should process normally. To read more about new condition code 45, go online to the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6638.pdf.