CurrentUnitedHealthcarePolicy N/A

Gender-based claim editing for diagnosis and procedure codes

This reimbursement policy governs application of gender edits to diagnosis and procedure codes for UnitedHealthcare Community Plan Medicaid products in specified states, affecting claims submitted by network and non-network providers on CMS-1500/UB-04 forms.

Policy Summary

PayerUnitedHealthcare

PolicyGender-based claim editing for diagnosis and procedure codes

Policy CodePolicy N/A

Change TypeAttachment updates; state exception added

Effective DateN/A

Next Review DateN/A

Key ActionProviders may append modifier KX to bypass gender-specific edits when documentation supports the service for the beneficiary.

SourceLink

POLICY UPDATE CHANGES

Attachments Section: Updated Arizona Medicaid Procedure to Gender Policy List (multiple dated updates listed).

State Exceptions Section: New Jersey added.

5Medicaid states covered

multipleArizona attachment updates

2008Policy origin

Applicability and Exceptions

Gender edit application and state exceptions

Apply gender-based claim edits to specified state Medicaid products, with listed state exceptions and modifier-based bypasses.

Gender edits are applied to claims when diagnosis and/or procedure codes are reported inappropriately for the patient’s gender for UnitedHealthcare Community Plan Medicaid products in the following states: AZ, DC, KS, MO, NC.

State exceptions and special rules

Arizona (AZ): AHCCCS publishes customized state gender-designated CPT and ICD-10 code lists; AHCCCS requires review of documentation and authorization before denying for inappropriate gender; CPT and HCPCS codes billed with modifier KX are exempt from gender edit requirements for Arizona Medicaid.
Kansas (KS): Kansas Medicaid applies gender editing only to ICD-10 codes; Kansas publishes a customized state-identified ICD-10 gender list included in this policy; Kansas will bypass gender-related edits when modifier KX is billed.

Policy Summary

PayerUnitedHealthcare

PolicyGender-based claim editing for diagnosis and procedure codes

Policy CodePolicy N/A

Change TypeAttachment updates; state exception added

Effective DateN/A

Next Review DateN/A

Key ActionProviders may append modifier KX to bypass gender-specific edits when documentation supports the service for the beneficiary.

SourceLink

On This Page

Codes, Modifiers, and State Attachments

Modifier exempting gender editsModifierCovered

KX	Modifier indicating requirements specified in policy have been met; used to bypass gender edits for identified beneficiaries per MLN Matters #6638

State gender-designated code lists (attachments)mixed

Arizona ICD-10 list	ICD-10 codes with designated appropriate gender for Arizona Medicaid (attachment)
Arizona CPT list	CPT/Procedure codes with designated appropriate gender for Arizona Medicaid (attachment)
Kansas ICD-10 list	ICD-10 codes with designated appropriate gender for Kansas Medicaid (attachment)
Missouri ICD-10 list	ICD-10 codes with designated inappropriate gender for Missouri Medicaid (attachment)
Missouri CPT list	CPT/Procedure codes with designated inappropriate gender for Missouri Medicaid (attachment)

State-specific application

States where gender edits are appliedArizona (AZ), District of Columbia (DC), Kansas (KS), Missouri (MO), North Carolina (NC)

Arizona special rulesAHCCCS publishes customized CPT and ICD-10 gender lists; requires documentation review and authorization before denying for inappropriate gender; CPT/HCPCS codes billed with modifier KX are exempt from gender edits.

Kansas special rulesKansas Medicaid applies gender editing only to ICD-10 codes and publishes a customized ICD-10 gender list; modifier KX bypasses gender-related edits per state guidelines.

Missouri special rulesMissouri publishes customized CPT and ICD-10 gender-designated lists included in this policy's attachments.

New Jersey notePer section 4.2.15 of NJ DMAHS, New Jersey is exempt from this policy.

Billing and Documentation Actions

Prior Authorization

Append modifier KX when documentation supports bypassing gender edit

Providers may append modifier KX to identify services for which gender-specific editing should be bypassed when documentation supports the service for the beneficiary; Arizona and Kansas explicitly exempt KX-billed services from gender edits. Use KX to alert the carrier/MAC that the service should be allowed to continue with normal processing when coverage and reporting criteria are met.

Per MLN Matters #MM6638, the KX modifier is defined as 'Requirements specified in the medical policy have been met' and should be used to identify gender-specific services to bypass editing.
Arizona: CPT and HCPCS codes billed with modifier KX are exempt from gender edit requirements for Arizona Medicaid; AHCCCS requires documentation review and authorization before denying for inappropriate gender.
Kansas: Per state guidelines, Kansas will bypass gender related edits when modifier KX is billed.

Key Terms

Gender editing

ImpactGender editing can result in incorrect denials for claims for transgender and hermaphrodite members if not handled with state-specific exceptions or modifiers.

Source authoritiesDesignations based on WHO ICD-10-CM, specialty societies, CMS, AMA, or AHA Coding Clinic.

KX modifier (use to bypass gender edits)

Modifier meaningKX modifier: 'Requirements specified in the medical policy have been met' — a multipurpose informational modifier per MLN Matters #6638 used on Part B professional claims.

Use to bypass gender editsUse of KX alerts the carrier/MAC that the service is gender-specific for the beneficiary and that gender-specific editing should be bypassed so the claim continues normal processing when documentation supports the service.

State applicationArizona and Kansas explicitly exempt or bypass gender edits when KX is billed; AHCCCS cites CMS guidance that KX should bypass gender editing for affected beneficiaries.