Wiki Transgender Services LA Care denials

[yira@huntingtonorthopedics.com]

Hello, is anyone having issues with LA Care denials? I work for a provider that does gender reassignment surgeries, we mostly work with LA Care since they are located in LA.
My issue is that LA Care does not follow Medicare coding guidelines and even following their specific guideline of the AG and 51 in all the codes they still deny the claim for bundling or modifiers.
fi someone could please guide me to where I can find more LA Care coding for transgender services I will appreciate it. I have researched the Medicaid website but there is not a lot on transgender services.

 

[TThivierge]

Hi Yira,
Here are 2 web sites may help you with CPT codes and common rules on gender surgery and coding.
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53793
https://www.unicare.com/dam/medpolicies/unicare/active/guidelines/gl_pw_a051166.htm

Basic rules are..... patient usually dealing with this gender change for more than a year, need 2 MH therapists written recommendations , must be over age of 18 years old, pre approval , usually payer not cover extra cosmetic surgery of skin remove from under arms, legs Etc. and suggest do Breast and Prostate screenings before trans surgery. If patient changes name ensure the payer is aware of new name on policy.
Modifiers used are 58 staged planned, 59 multiple procedures and KX for transgender. Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries.

Here are some common Z dx codes use at end of claims if apply Z87.890, Z90.79, Z90.11-13, Z17.0 Z13.89 Z93 , Z90.710 Z90.12
And here are some dx code blocks related to transgender dx F64, , F65, R45.4, R45.81 R46.6 N50.0 N98.8 N46.121, N46.021 E23.0 E29.1 . Also other mental health conditions can be combined with if applicable to patient circumstances F40, F32, F42 ,F06 F51, G47,F60.5

Well I hope helped you a bit

Lady T

 

[yira@huntingtonorthopedics.com]

that is what I use for most of my payors, but my issue is with LA Care, they do not want to go with this guideline or common rules and they ask us to go with the Medi-cal guideline and that one says
When multiple procedures are performed at the same operative session, providers should identify the major procedure with modifier-AG, and identify the secondary, additional, or lesser procedures by adding modifier -51 to the secondary procedure codes (with the exception of special circumstances when providers are instructed in “Billing Multiple Modifiers” on a following page to use modifier -99 to indicate the additional procedures). The procedure code identified with modifier -AG is paid at 100 percent of the Medi-Cal reimbursement rate. The procedure code(s) identified with modifier-51 will generally be paid at 50 percent of the Medi-Cal reimbursement rate.
what I also have is that the provider ends up doing more than one procedure on the patient, for example, will do breast reconstruction, liposuction, and abdominoplasty at the same time, and even when I use the modifiers for the main procedures, they end up getting a bundle or denied for the modifier. I have been trying to understand LA Care guidelines for a year.