Submitting Claims with Gender/Procedure Conflict

Date Issued: 11/23/2016

Effective January 1, 2017, providers submitting facility claims with gender/procedure code mismatches should report condition code 45 (Ambiguous Gender Category) on inpatient or outpatient claim submission that may be subjected to gender-specific editing (i.e., services that are considered female or male only). This is required for all products in order to comply with Section 1557, the nondiscrimination provision of the Affordable Care Act (ACA).

Specific requirements include, but are not limited to:

  • Gender Discrimination: Section 1557 builds on prior federal civil rights laws to prohibit sex discrimination in health care. The final rule requires that women be treated equally with men in the health care they receive and also prohibits the denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity and sex stereotyping.
  • This rule also requires covered health programs and activities to treat individuals consistent with their gender identity. For claims processing or utilization review functions, this includes the need to evaluate and potentially modify claims systems to address gender dysphoria and to ensure that claims are not denied solely on the basis of gender.

Physicians and non-physician practitioners should submit professional claims with the modifier KX for any detail line with procedure codes that are gender-specific for affected beneficiaries.

The KX modifier is defined as “requirements specified in the medical policy have been met”. This modifier indicates 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 without gender/code mismatch edits being applied.

Additional information regarding this law is available at HHS Office of Civil Rights.