Some charges for transgender patients may inadvertently deny when the service provided is gender-specific and does not match the gender on the Humana-covered patient’s enrollment or medical record. As outlined in Humana’s “Gender Specific Services for Transgender or Intersex Members: Condition Code 45 and Modifier KX” claims payment policy, physicians, administrators and other health care professionals need to follow the appropriate Medicare guidance for correctly coding gender-specific procedures provided for transgender patients to enable claims to process correctly.
For facility claims, administrators are encouraged to report condition code 45 with an inpatient or outpatient service that is gender-specific. For professional claims, physicians and other health care professionals are encouraged to include modifier KX with a procedure code that is gender-specific. Humana claims processing systems will recognize condition code 45 and modifier KX, when submitted with charges for gender-specific services, as an indication that the services may be medically necessary, despite an apparent conflict between a patient’s reported gender and the gender-specific service provided.
For more information, physicians, administrators and other health care professionals can review Humana’s claims payment policy here by entering “gender specific services” in the search box.