CPT Corner Article from Plastic Surgery News April 2019
Since 2014, when the Department of Health and Human Services directed Medicare to lift the ban on gender-affirming surgery, there has been a significant increase in the number of these procedures performed. In 2017, there was a 155 percent increase in these procedures from the prior year – and today, 19 states have banned blanket denials of gender-affirming procedures.
Some CPT codes have a gender-specific edit that will automatically deny the claim. This can be especially challenging if the patient has already legally changed their gender marker before surgery. As such, it’s recommended to use the –KX modifier, which is defined as “Requirements specified in the medical policy have been met.” This modifier may be used when gender-specific editing may apply to the codes used. Its use will bypass edits, allowing for the claim to move forward with normal processing. Payment should be made if the coverage and reporting criteria have been met for the service.
This article details codes relating to gender-affirming procedures.
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Product Code: CPT-2019-APR