CurrentFidelis CarePolicy CC.PP.047

Payment Policy: Billing Requirements for Transgender Services

Defines billing and payment criteria for gender-specific procedure codes and institutional claims when a member's recorded gender differs from the gender-specific code billed; applies to practitioner, non-physician practitioner, outpatient and inpatient institutional claims under the health plan.

Policy Summary

PayerFidelis Care

PolicyPayment Policy: Billing Requirements for Transgender Services

Policy CodePolicy CC.PP.047

Change TypeAnnual review (no material clinical changes)

Effective Date

Next Review Date

Key ActionInstitutional providers must report condition code 45 and practitioners must append modifier -KX to bypass gender-specific claim edits.

SourceLink

POLICY UPDATE CHANGES

Conducted annual review, verified codes, updated policy.

condition code 45institutional claims identifier to bypass gender edits

modifier -KXpractitioner/non-physician practitioner identifier to bypass gender edits

MM6638CMS MLN Matters guidance referenced

CC.PP.047internal policy identifier

When Gender-Specific Edits May Be Bypassed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Criteria to bypass gender-specific claim edits

Covered when ALL of the following are met:

ALL of the following

Institutional claims: If the service is billed on an institutional (inpatient or outpatient) facility claim, the claim must include condition code 45 (Ambiguous Gender Category) in the appropriate claim field to bypass gender-specific edits.
Practitioner / Non-physician practitioner claims: If the service is billed by a practitioner or non-physician practitioner, the provider must append modifier -KX to the gender-specific procedure code at the service line to bypass gender-specific edits.
Code editing behavior: The health plan's code editing software will evaluate claims for the presence of condition code 45 (institutional) or modifier -KX (practitioner/service line) and will bypass gender-specific edits when these identifiers are present.
Documentation and placement: Institutional providers should add condition code 45 to the appropriate claim field; practitioners should append modifier -KX on the CPT detail/service line.
Legal basis: This requirement aligns with Section 1557 of the HHS Office for Civil Rights, which prohibits denying or limiting coverage because a member's recorded gender differs from the gender for which services are ordinarily available; identifiers are required to prevent inappropriate denials.

Referenced Codes and Identifiers

Referenced code setsmixed

CPT	Current Procedural Terminology (CPT) — referenced for informational purposes; inclusion or exclusion does not guarantee coverage.
HCPCS	HCPCS Level II referenced for coding guidance (informational).

Identifiers to bypass gender-specific editsmixedCovered

45	Condition Code 45 — Ambiguous Gender Category (institutional claims).
KX	Modifier -KX — Requirements specified in the medical policy have been met (apply on practitioner/non-physician practitioner service line).

Identifiers required to bypass gender edits

Institutional identifierCondition code 45 (Ambiguous Gender Category) must be reported on inpatient and outpatient institutional claims to bypass gender-specific edits.

Practitioner/service‑line identifierAppend modifier -KX to the gender‑specific CPT procedure code on the service line for practitioner and non‑physician practitioner claims to bypass gender edits.

PurposeIdentifiers are required when a member's recorded gender differs from the gender‑specific procedure billed to prevent inappropriate denials per CMS guidance.

Billing Actions Required to Bypass Gender Edits

Billing Rule

Report condition code 45 (institutional) or append modifier -KX (practitioner) to bypass gender edits

Institutional providers must report condition code 45 on inpatient and outpatient institutional claims that are subject to gender-specific editing; practitioners and non-physician practitioners must append modifier -KX to the gender-specific procedure code at the service line to bypass gender edits. The plan's code editing software will evaluate claims for condition code 45 (institutional) or modifier -KX (practitioner) and bypass gender edits when present.

Institutional: include condition code 45 (Ambiguous Gender Category) on inpatient/outpatient institutional claim fields.
Practitioner/service-line: append modifier -KX to the gender-specific CPT procedure code at the line level.

Key Terms

Covered Entity

Covered Entity (definition)A health program or activity, or any part of it, that receives funding from the Department of Health and Human Services (HHS) — e.g., hospitals that accept Medicare, providers that accept Medicaid, Health Insurance Marketplaces and participating issuers.

ScopeApplies to entities receiving Federal financial assistance subject to Section 1557 nondiscrimination requirements.

ImplicationCovered entities must not automatically reject sex‑specific procedures solely because the member's recorded gender differs from the gender associated with the service billed.

Transgender

Transgender (definition)A person who identifies with or expresses a gender identity that differs from the sex assigned at birth.

ContextDefinition used to inform nondiscrimination provisions and billing practices when recorded gender and billed services differ.

Relevance to policyEnsures claims processing and edits accommodate individuals whose gender identity differs from sex assigned at birth to avoid improper denials.

Code Editing Software

Code Editing Software (definition)A rule‑based application that evaluates providers' claims against correct coding principles based on CMS guidelines and coding standards.

FunctionEvaluates claim data and applies gender‑specific edit logic; will bypass gender edits when the required condition code or modifier is present.

Use in this policyThe health plan's code editing software checks for condition code 45 on institutional claims or modifier -KX on practitioner service lines to allow payment of gender‑specific procedures when recorded gender differs.

Policy Updates

2016-10-29initial_creation

Initial policy draft created.

2018-02-15annual_review

Conducted annual review and updated policy template.

2019-04-01annual_review

Conducted review, verified codes, and updated policy.

2020-04-20annual_review

Conducted review, verified codes, updated policy, and removed effective date.

2021-04-25annual_review

Conducted review, verified codes, updated copyright dates, and removed product type.

2022-05-04annual_review

Conducted review, verified codes, and updated copyright dates.

2022-08-30update

Removed broken link from policy.

2023-04-17annual_review

Conducted annual review, verified codes, and updated copyright dates.

2024-06-13annual_review

Conducted annual review, verified codes, and updated policy.

2025-06-26annual_reviewLatest