You Can’t Have Both!

Oh yes we can!

I run into problems when I have my annual physical exam when I have a prostate exam and a mammogram, the insurance company computer goes ballistic.

My last annual physical was in the fall and as usual I get a message that the insurance company will not cover the prostate exam because I am female, then the doctor’s bills me for the exam and I’m stuck in the middle again.

For those on Medicare or Medicaid the answer is simple… Code 45.

B. Policy: For Part A claims processing, institutional providers shall report condition code 45 (Ambiguous Gender Category) on any outpatient claim related to transgender or hermaphrodite [Yuck! They use the derogatory term instead of intersex] issues. This claim level condition code should be used by providers to identify these unique claims and also allows the sex related edits to be by-passed. The CWF shall override any gender specific edits when condition code 45 is present and allow the service to continue normal processing.

For Part B claims processing, the KX modifier shall be billed on the detail line with any procedure code(s) that are gender specific. The definition of the KX modifier is: Requirements specified in the medical policy have been met. Use of the KX modifier will alert the MAC that the physician/practitioner is performing a service on a patient for whom gender specific editing may apply, but should have such editing by-passed for the beneficiary. The CWF shall override any gender specific edits for procedure codes billed with the KX modifier and allow the service to continue normal processing.

For non-Medicare or Medicaid patients it is also KX,

Fee-for-service providers should use modifier KX Requirements specified in the medical policy have been met to identify services for transgender, ambiguous genitalia, and hermaphrodite patients. Append this modifier only to the procedure code(s) that are gender specific for transgender, ambiguous genitalia, and hermaphrodite patients.

We are also covered in the Affordable Care Act (ACA) or Obamacare. According to Health and Human Services,

The final rule also prohibits a covered entity from denying or limiting coverage, denying or limiting a claim, or imposing additional cost sharing or other limitations, on any health services that are ordinarily or exclusively available to individuals of one gender, based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different than the one to which the health care services are ordinarily or exclusively available. For example, when a plan covers medically appropriate pelvic exams, coverage cannot be denied for an individual for whom a pelvic exam is medically appropriate based on the fact that the individual either identifies as a transgender man or is enrolled in the health plan as a man.

The ACA could be our savior for states that are denying us healthcare!

Here in Connecticut the Insurance Commissioner issued… BULLETIN IC-34 which basically says, that anything covered for cis-gender patients is covered for trans patients, including electrolysis.

Also one insurance company balked at covering us and the patient filed a complaint with the Commission on Human Rights and Opportunity (CHRO) and they ruled in our favor GLAD wrote about here and you can read the actual ruling here.

Compared to the Republican state we are fully covered.