MLN Matters® Number: MM6638 Revised
Related Change Request (CR) #: 6638
Related CR Release Date: December 18, 2009
Effective Date: April 1, 2010
Related CR Transmittal #: R1877CP
Implementation Date: April 5, 2010
Note: This article was revised on December 21, 2009, to reflect a revised CR 6638 that was issued on December 18, 2009. The CR release date, transmittal number, and the Web address for accessing CR 6638 were revised in this article. All other information remains the same.
Provider Types Affected
This article is for physicians, non-physician practitioners, and providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.
Provider Action Needed
Impact to You
This article is based on Change Request (CR) 6638 which provides instructions for completing Part A and Part B claims for gender specific services for beneficiaries who are transgender, hermaphrodites, or have ambiguous genitalia.
What You Need to Know
Claims for some beneficiaries are being rejected by Medicare systems due to gender specific edits, and this is resulting in inappropriate denials for Part A and Part B claims. CR 6638 instructs that for Part A claims processing, institutional providers should report condition code 45 (Ambiguous Gender Category) on inpatient or outpatient services that can be subjected to gender specific editing (i.e., services that are considered female or male only) for the above defined beneficiaries. CR 6638 instructs physicians and non-physician practitioners that for Part B professional claims the KX HCPCS modifier (Requirements specified in the medical policy have been met) should be billed on the detail line with any procedure code(s) that are gender specific for the affected beneficiaries.
What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
Claims for some services for beneficiaries described above may be inadvertently denied due to sex related edits unless these services are billed properly.
As a result of the number of subject claims received that are being denied due to sex/diagnosis and sex/procedure edits, the National Uniform Billing Committee (NUBC) approved condition code 45 (Ambiguous Gender Category) to identify these unique claims and to allow the sex related edits to be processed correctly. CR 6638 instructs institutional providers submitting Part A claims to report condition code 45 (Ambiguous Gender Category) on inpatient or outpatient services for effected beneficiaries where the service performed is gender specific (i.e., services that are considered female or male only). This claim level condition code should be used by providers to identify these unique claims and to allow the sex related edits to be processed correctly by Medicare systems and allow the service to continue normal processing. Payment will be made if the coverage and reporting criteria have been met for the service.
The KX HCPCS modifier, which is defined as “Requirements specified in the medical policy have been met”, is a multipurpose informational modifier for Part B professional claims. In addition to its other existing uses, the KX HCPCS modifier should also be used to identify services that are gender specific (i.e., services that are considered female or male only) for effected beneficiaries on claims submitted by physicians and non-physician practitioners to Medicare carriers and MACs. Use of the KX HCPCS modifier will alert the carrier/MAC that the physician/practitioner is performing a service on a patient for whom gender specific editing may apply, and that the service should be allowed to continue with normal processing. Payment will be made if the coverage and reporting criteria have been met for the service.
Additional Information
The official instruction, CR 6638, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1877CP.pdf on the CMS website.
If you have questions, please contact the Palmetto GBA Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.