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Provider Notice issued 11/26/2024
| To: | All Medical Assistance Program Providers |
| Date | November 26, 2024 |
| Re: |
Modifier KX and Condition Code 45 on Claims for Services for Transgender, Ambiguous Gender, and Hermaphrodite Patients Effective September 1, 2024 |
This notice informs providers of new billing requirements to avoid rejections on claims for transgender, ambiguous gender, and hermaphrodite patients. This applies to Medicaid fee-for-service (FFS) and managed care organization (MCO) claims effective with dates of service beginning September 1, 2024.
Public Act 102-1141 allows people to change the gender on their birth certificate by signing a statement affirming their gender designation or intersex condition. This has prompted HFS claim editing changes to avoid discrepancies between incoming claim information, sex-specific procedure and diagnosis coding, and the HFS customer database.
· 837 Institutional Claim Format or Equivalent
To bypass the R16 - Services Invalid for Recipient Sex procedure and diagnosis code edit, providers must report Condition Code 45 - Ambiguous Gender Category on claims containing sex-specific services or diagnoses that may conflict with the customer’s gender identity.
· 837 Professional Claim Format or Equivalent
To bypass the R16 edit for professional claims, modifier KX must be billed on the service line containing the procedure code that is gender specific and may conflict with the customer’s gender identity. Use of modifier KX on the claim will also bypass any gender specific diagnosis code editing.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the applicable MCO.
Kelly Cunningham, Administrator
Division of Medical Programs