“Denied” or “Denials” are words those in the revenue cycle department detest hearing. Denials regarding a claim can incur for various reasons and can take various steps to resolve. When a claim is denied, the billing office reviews the reasons for denial, corrects it, and promptly resubmits them with the appropriate information. Verifying a patient’s demographic information is essential to a visit, even before the patient sees the doctor. Procedure and diagnosis codes that providers and clinicians select are also imperative; they are gender-specific diagnosis codes, and providers, coders, and billing staff would want to ensure the codes used are correct before billing.
For example, although a patient may identify as transgender, there are still some preventative services they may need yearly. A transgender female may still require PSA checks as they still have a prostate and a family history of prostate cancer. A male transgender person may still require PAPs because they have a uterus and a family history of cervical/uterine cancer. Ensuring the correct diagnosis code and modifiers are submitted is essential for a claim to be processed and paid.
The physician/QHP (Qualified Healthcare Professional) could submit everything correctly, e.g., diagnosis, CPT, and HCPCS codes, but the claim can still be denied. When the revenue cycle department looks for the reason for denial, it may indicate that demographic information was incorrect and that the information submitted contradicted the information the insurance companies possessed in their files. Verifying and entering the gender of a patient is significant when it comes to billing. This blog post will discuss ensuring billing regarding gender-specific guidelines, CMS updates as of July 1, 2023, and the role provider documentation and front desk registrations play.
Gender-Specific Services: Billing Correctly and Usage of the Condition Code/Modifier
CMS recently put out an MLN on June 8th stating that they may reject or return Medicare Part A and Part B claims inappropriately billed if there’s a mismatch between the procedure or diagnosis code and the reported sex of the patient. This reminds institutional providers and clinicians who bill for Part B professional claims that a condition code/modifier is available to allow these claims to process correctly.
Per CMS, effective July 1, 2023, the National Uniform Billing Committee revised Condition Code 45 to Gender Incongruence, “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 from 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.
Sex & Gender Identity
Sex refers to a person’s biological/anatomical status and is typically assigned based on external anatomy at birth. Sex is typically categorized as male, female, or intersex. Gender identity is one’s internal sense of self and gender, whether that is man, woman, neither, or both. Unlike gender expression, gender identity is not outwardly visible to others.
In 2023, it is not uncommon for a doctor’s office to see patients who may have had some change to their “sex “or how they want to be identified: male, female, non-binary, transgender. The staff has to be trained on the appropriate way to ask a patient for demographic information that won’t offend the patient or break any HIPAA violations. Understanding the patient and how to obtain and confirm the information without upsetting and offending the patient is imperative. HIPAA requires healthcare providers and health plans to protect patient privacy regarding specific information.
The information obtained should also be verified with the insurance company. Since no one wants to receive a bill, explaining to the patient the importance of this information and the need for transparency is essential.
Front desk and registration personnel will want to ensure that they are verifying the patient’s demographic information for both new and established patients. Established patients can have a significant change within a month, and it is necessary to ensure that that information is updated in the EHR. Do not be afraid to ask the patient if there have been any changes to their information since the last visit. Life gets overwhelming, and patients can easily forget to mention that they have had a name change. Always ensure you have a recent copy of the patient’s most recent insurance card and verify that patient’s insurance eligibility before each visit, even if you saw them a week ago. So much can change in a few hours, days, and weeks.
How a patient is registered in the system is another crucial step. Electronic Health Records (EHRs) should be current, updated, and compliant. The EHRs are structured with sections to include how the patient wants to be identified, “their experience gender is different from that at birth”, their legal name on the insurance card, and how they would like to be addressed. It is important to relay to staff the importance of capturing this information and ensuring its accuracy.
Provider and clinical documentation should support medical necessity and why specific procedures are needed and performed. Documentation of any family history affecting the patient and any social determinants of health should be linked and documented. Any challenges that may affect the patient in their environment. If the patient is having surgery, are there any risks or benefits that may affect the patient and any additional conditions they may have? What counselling and coordination of care was provided? Providers should ensure that documentation supports any gender reassignment and that all information from clinical information is updated. It is also essential for providers to build rapport with their patients and explain the required documentation needed.
Modifier KX should be reported when billing part B claims related to transgender, intersex, and gender-expansive systems issues. This will ensure that Medicare Administrative Contractors (MACs) should process these claims following the original guidance set forth by CMS in 2009.
Having an office workflow and policies for caring for patients and processing claims through a scrubber before billing is vital. The scrubber will stop a claim before going out once an error is detected; the coder or biller in charge of the scrubber must understand the medical necessity and coding guidelines to ensure that the appropriate codes and modifiers are used.
Adequately training staff in documentation, coding, empathy, respect, and caring when communicating with patients—yearly training on HIPAA, minimum necessary, policy changes, and updates is vital to an organization and physician practice. The World Professional Association of Transgender Health (WPATH) has a wealth of information on educating individuals and organizations and equipping them to understand and provide treatment for gender dysphoria in medicine.
To schedule training for your organization or private practice providers or schedule a chart review, email us today at firstname.lastname@example.org or visit the website and fill out the “contact us” form.