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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity of Utah Gender Policy Update | OpenPaye…
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    CurrentUniversity of Utah Health PlansPolicy REIMB-037

    Billing for Gender Discordant Claims

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    Coding and claim submission requirements to prevent gender-related procedure or diagnosis edits for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in commercial and Healthy U Medicaid plans.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyBilling for Gender Discordant Claims
    Policy CodePolicy REIMB-037
    Change TypeNo material change
    Effective DateJan 22, 2025
    Last ReviewJan 22, 2025
    Next Review DateJan 22, 2026
    Key ActionReport modifier KX on each applicable gender-specific procedure-code detail line for commercial-plan claims.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    KXRequired modifier
    45Institutional claim condition code
    Commercial and Healthy U MedicaidPlan populations addressed
    NoneHCPCS coding outcome

    Plan-Specific Coverage Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Commercial Plan Billing Criteria

    For commercial-plan claims involving transgender, ambiguous genitalia, or hermaphrodite beneficiaries, apply the appropriate billing indicator when a gender/procedure or gender/diagnosis conflict could occur. Claims may be denied by sex-related edits unless billed properly.

    Apply the applicable billing rule

    • ONE of the following claim-type rules applies

      • Institutional providers: report Condition Code 45 (Ambiguous Gender Category) on any inpatient or outpatient UB-04 claim related to transgender, ambiguous genitalia, or hermaphrodite issues. This claim-level code identifies the unique claim and alerts the plan that the gender/procedure or gender/diagnosis conflict is not an error, allowing sex-related edits to be bypassed and the claim to continue normal processing.
      • Physicians and non-physician practitioners: report the KX modifier on the detail line only with procedure code(s) that are gender-specific for transgender, ambiguous genitalia, or hermaphrodite beneficiaries. The modifier alerts the plan that a gender/procedure or gender/diagnosis conflict is not an error and allows the claim to continue normal processing.
    • The KX modifier is a multipurpose informational modifier and may also be used in conjunction with other medical policies.

      Use KX only on the gender-specific procedure code detail line; use Condition Code 45 at the institutional claim level.

    Medicaid Coverage Hierarchy

    Coverage is determined according to the following hierarchy: Utah Medicaid coverage policies first, then InterQual criteria when available, and finally U of U Health Plans Commercial criteria when Utah Medicaid has no published coverage position and InterQual criteria are unavailable.

    Apply the Medicaid coverage hierarchy

    • Use the State of Utah Medicaid program's published coverage policies and requirements to determine coverage.
    • If Utah State Medicaid has no published coverage position, apply available InterQual criteria.
    • If Utah State Medicaid has no published coverage position and InterQual criteria are not available, apply the U of U Health Plans Commercial criteria.
    • Even when a CPT or HCPCS code is covered by Utah State Medicaid, further evaluation may be required to determine medical necessity for coverage.

    Required Billing Codes

    Applicable modifierModifier
    KXModifier indicating that KX requirements specified in the medical policy have been met.
    Institutional claim condition codeRevenue
    45Condition Code 45, Ambiguous Gender Category, for UB-04 institutional billing.
    Gender-specific CPT proceduresCPT
    Gender-symbol CPT codesCPT procedure codes designated with a female or male gender symbol by the AMA CPT code set.
    No applicable HCPCS codesHCPCS
    No codes listed

    Claim Submission Requirements

    Billing Rule

    Report KX on gender-specific professional service lines

    For commercial-plan claims involving transgender, ambiguous genitalia, or hermaphrodite beneficiaries, physicians and non-physician practitioners must report modifier KX on the detail line only with procedure codes that are gender-specific in the particular case.

    Billing Rule

    Report condition code 45 on institutional claims

    Institutional providers must report condition code 45 on inpatient or outpatient claims related to transgender, ambiguous genitalia, or hermaphrodite issues, including UB-04 claims.

    Denial Risk

    Avoid gender-related claim edit denials

    Claims involving gender-specific edits may be denied unless the applicable KX modifier or condition code 45 is billed properly. These indicators alert the plan that the gender/procedure or gender/diagnosis conflict is not an error and allow normal processing to continue.

    Note

    Use KX with other applicable policies

    The KX modifier is a multipurpose informational modifier and may also be used in conjunction with other medical policies.

    Note

    Apply Utah Medicaid coverage hierarchy

    For Medicaid plans, coverage is determined by the State of Utah Medicaid program. If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, the commercial criteria in this policy apply; covered CPT or HCPCS codes may still require further evaluation to determine medical necessity.

    Key Billing Definitions

    KX Modifier
    DefinitionA multipurpose informational modifier indicating that the KX requirements specified in the medical policy have been met.
    Report onThe detail line only, with the gender-specific procedure code(s).
    When applicableFor transgender, ambiguous genitalia, and hermaphrodite beneficiaries when the procedure code is gender-specific in the particular case or could receive a gender-specific edit.
    Condition Code 45
    DefinitionCondition Code 45, Ambiguous Gender Category, is an institutional claim condition code for UB-04 billing.
    Report onInpatient or outpatient institutional claims related to transgender, ambiguous genitalia, or hermaphrodite issues.
    Claim useIt identifies gender-discordant claims and alerts the plan that a gender/procedure or gender/diagnosis conflict is not an error, allowing sex-related edits to be bypassed.
    Gender-Related Edit
    DefinitionA claim-edit conflict caused by a mismatch between the member's recorded sex and the gender specificity of a procedure or diagnosis.
    Procedure conflictA gender/procedure conflict occurs when the member's recorded sex conflicts with the gender specificity of the billed procedure code.
    Diagnosis conflictA gender/diagnosis conflict occurs when the member's recorded sex conflicts with the gender specificity of the billed diagnosis.
    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyBilling for Gender Discordant Claims
    Policy CodePolicy REIMB-037
    Change TypeNo material change
    Effective DateJan 22, 2025
    Last ReviewJan 22, 2025
    Next Review DateJan 22, 2026
    Key ActionReport modifier KX on each applicable gender-specific procedure-code detail line for commercial-plan claims.
    SourceLink
    On This Page
    Plan-Specific Coverage CriteriaRequired Billing CodesClaim Submission RequirementsKey Billing Definitions
    For the most up-to-date Medicaid policies and coverage information, consult the Utah Medicaid official publications at https://medicaid.utah.gov/utah-medicaidofficial-publications/ or the Utah Medicaid code Look-Up tool.