Wiki Transgender patients

[Jessim929]

Now that transgenderism is becoming more and more common, is anyone having problems with getting certain claims paid?

Here's my case: I work for Urology, and one of my docs saw a fully post-op (per chart) male to female patient. HOWEVER, patient still had a prostate, which was enlarged and the primary focus of the visit, so BPH is the diagnosis used. Insurance rejected as not gender appropriate. Using the gender dysmorphia diagnosis on the claim did not help matters.

Same doctor has also recently done a bilat orchopexy on a patient in the midst of reassignment. I do not know if the insurance has paid or denied it yet, but if they have the patient as "female" and they're having testes removed, I can't imagine it being paid without appeal.

Is this just going to be a fact of life or what? I'd appreciate any insight.

Thanks!

 

[kathrynw]

Hello,

This article will hopefully be helpful in providing some guidance.

https://www.aapc.com/blog/36829-identify-transgender-coding-mishaps/

Namely this excerpt.

Stay Up-to-date on Official Guidelines
Question: “If I record the patient’s perceived identity, will claims for gender-specific services be denied?”

Insurance companies require that every patient be identified as either male or female, and provides coverage for gender-specific treatments based on that gender marker. “This creates difficulties for transgender patients whose bodies may not match male and female stereotypes,” the authors of the transgender healthcare guide write.

For example, a transgender man may still have a uterus and require gynecological exams. Providers are generally able to reverse gender-related denials, but not without both the provider and patient being inconvenienced.

The Centers for Medicare & Medicaid Services (CMS) already thought of this. Medicare covers medically necessary hormone therapy and sex reassignment, as well as routine preventive care, regardless of gender markers.

CMS advises institutional providers to use claim level condition code 45 Ambiguous gender category to identify such claims that pose a gender/procedure conflict. The code alerts the system that the gender/procedure or gender/diagnosis conflict is not an error, allowing the sex-related edits to be bypassed.

Fee-for-service providers should use modifier KX Requirements specified in the medical policy have been met to identify services for transgender, ambiguous genitalia, and hermaphrodite patients. Append this modifier only to the procedure code(s) that are gender specific for transgender, ambiguous genitalia, and hermaphrodite patients.