Primary Care Coding Alert

Question: A provider prescribed a patient a retinoid, which requires a urine pregnancy test (UPT) for female patients. The patient was born female and legally changed their gender, including registering the change with their payer, Medicaid, but the UPT claim was denied due to a gender mismatch (UPTs aren’t required for male patients). Is there a way for us to bill this?

Washington Subscriber

Answer: For this situation, you should look to a modifier. The Centers for Medicare & Medicaid (CMS) Pub 100-04 Medicare Claims Processing says:

“For Part B claims processing, the KX modifier shall be billed on the detail line with any procedure code(s) that are gender specific. The definition of the KX modifier is: Requirements specified in the medical policy have been met. Use of the KX modifier will alert the MAC that the physician/practitioner is performing a service on a patient for whom gender specific editing may apply, but should have such editing by-passed for the beneficiary. The CWF shall override any gender specific edits for procedure codes billed with the KX modifier and allow the service to continue normal processing.”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC