Have you had insurance claims refused because your gender didn’t “match” the procedure?

Sometimes, people with intersex conditions/DSD find that the coverage claims they file to their insurance companies are mistakenly denied when the procedures do not “match” their identified genders. For example, a woman with androgen insensitivity syndrome (AIS) may require screenings for testicular cancer. With this type of gender-specific procedure, when the claim system checks the claim for errors, it looks for a match between the gender specified for the procedure and the gender of the patient. If the system determines a mismatch, the claim is presumed to be in error and is denied. For those members of the intersex/DSD community who face this problem, a new coding system may present a solution.

Centers for Medicare & Medicaid Services (CMS) recently issued an updated policy regarding certain procedures and codes, including codes that can be used to override this “gender-procedure conflict” that billing systems look for. Condition code 45 is the code that institutional providers, such as hospitals, should use to prevent this problem. Practitioners, such as doctors, should use a different code called the “KX modifier.” This code has a number of uses; in the case of a mismatch between the procedure’s gender code and the patient’s gender, the KX modifier tells the system to ignore it.

The CMS policy only directly affects Medicare and Medicaid practices. However, private insurers tend to adopt the same codes that Medicare and Medicaid use, so it is likely that private insurers will also begin using these codes in the same way.

Although individual patients are not responsible for filing these claim forms, it is helpful for people with intersex conditions/DSD and their families who have encountered this problem to be aware of the solutions. If you know you or your child is going to have a procedure that could potentially result in a mismatch when the insurance claim is processed, you can avoid the problem by making sure that the practitioner or institution providing the procedure uses one of these codes when filing the claim.

For More Information

The entire policy is available at: https://www.cms.gov/manuals/downloads/clm104c32.pdf. Please refer to section 240.

If you have questions, or need help with this process, please contact AIC.

© 2011 AIC

This fact sheet offers general information only and is not intended to provide guidance or legal advice regarding anyone’s specific situation. Please bear in mind that this is an evolving area of law in which there is bound to be uncertainty. Do not rely on this information without consulting an attorney or the appropriate agency.

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