Urology 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: For Medicare Part A, institutional billing, hospital or ambulatory surgical centers, you will use new condition code 45 (Ambiguous gender category) with claims that may be denied "due to sex/diagnosis and sex/procedure edits," according to recent 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 spells out.

Additionally: For Medicare Part B payments -- payments to physicians and non-physician practitioners -- you will append modifier KX (Requirements specified in the medical policy have been met) to all services billed.

This informs your payer that the services are gender  specific, and your patient meets the requirements to allow normal processing of these claims.

Example: A trans-sexual patient, who has undergone psychological and surgical services to convert him from a male gender to a female gender, has a urological examination (prostate) and a prostate-specific antigen (PSA) blood test. Although he is legally a female, he still requires prostate monitoring for possible malignant prostatic degeneration. Billing this patient for a male disease will often lead to denials of payments based on inconsistency of sexual gender. Speaking with the carrier before billing and appending modifier KX will be helpful in receiving proper reimbursement.

To read more about new condition code 45, go online to the CMS Web site at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6638.pdf.