Effective July 1, 2023 : Billing Correctly and Usage of the Condition Code/Modifier for Gender-Specific Services

CMS may reject or return Medicare Part A and Part B claims inappropriately if it appears there’s a mismatch between the procedure or diagnosis code and the reported sex of the patient.  This is a reminder to institutional providers and clinicians that bill for Part B professional claims that a condition code/modifier are available to allow these claims to process correctly.

Effective July 1, 2023, the National Uniform Billing Committee revised Condition Code 45 to Gender Incongruence, defined as “characterized by a marked and persistent incongruence between an individual’s experienced gender and sex at birth.”

For any procedure codes often considered appropriate for only one gender, indicate on the claim detail line if the patient’s experienced gender is different than their sex at birth.  For claims to process correctly:

Institutional providers: Continue to report condition code 45 (Ambiguous Gender Category) for inpatient and outpatient claims related to transgender, intersex, and gender-expansive systems issues.

Clinicians that bill for Part B professional claims: Report the KX modifier for any claims related to transgender, intersex, and gender-expansive systems issues.

Source:  CMS 2023-06-08-MLNConnects