Medicaid Colorado – Claims Editing Bypass for Gender Restrictions

Many procedures that are restricted to a member’s assigned sex at birth are still medically necessary after legally changing their gender. Currently, these claims must be reprocessed to bypass the gender edits. Effective June 29, 2022, these claims will process through interChange when the following billing guidance is used with gender-specific procedures that conflict with the member’s identified gender:

CMS-1500/837P claims: Providers should enter the KX modifier to the appropriate line item.

UB-04/837I claims: Providers should enter condition code 45 to indicate a procedure is medically necessary despite a gender conflict.

The Gender-Affirming Care Billing Manual will be updated to include the new KX modifier and condition code 45.