In recent months, we have been seeing an increase in the number of states issuing restrictions or full bans on youth gender affirming care. Currently, there are 19 states with restrictions on gender-affirming care, with many implementing penalties, fines and a potential for civil or legal action against providers. Please click here to view a MedPageToday interactive map with the state-by-state listing, which includes potential ramifications to providers falling outside the state guidelines.
In addition to state restrictions, some carriers are implementing separate polices on youth gender affirming care. Blue Cross Blue Shield of Kansas recently issued an update to their Medical Policy, which requires all individuals be at least 18 years old. Please click here to view the full policy.
For pathology related services, the most commonly billed CPT® codes for gender affirming care are as follows:
• 88309- Breast, radical mastectomy; Vulva resection; Prostate radical resection
• 88307- Breast, simple mastectomy; Uterus, hysterectomy (w/ or w/o ovaries); Penis, amputation; Prostate resection
• 88305- Ovary w/ or w/o fallopian tube
• 88302- Testis, castration
For diagnosis code reporting, the most commonly billed diagnosis code for gender affirming care is F64-Gender Dysphoria.
Per CMS guidelines:
For Part B claims processing, the KX modifier shall be billed on the detail line with any procedure code(s) that are gender specific. The KX modifier indicates requirements specified in the medical policy have been met. Use of the KX modifier will alert the MAC that the physician/practitioner is performing a service on a patient for whom gender specific editing may apply, but should have such editing by-passed for the beneficiary. The CWF shall override any gender specific edits for procedure codes billed with the KX modifier and allow the service to continue normal processing.
CPT copyright 2022 American Medical Association. All rights reserved.
