As I have traveled my path determined by my transition, there have been some good fights that I must pursue; like breast cancer at the top of my list. There was the fight as to which bathroom I had to use (won), there was the fight to get my name changed (won), to get genital surgery to remove the source of bad hormones because of the cancer (won that after 2 appeals), to change the gender marker on my driver’s license (won after one appeal) that fight was the most fun of all.
So a little background on this fight; my healthcare is now through Medicare, and I have Tricare-For-Life to pay for prescriptions. Now because of the genital surgery that I had I still have my prostrate and must have it checked once a year for levels of PSA and PBH and evaluate my risks of cancer. So Medicare recognizes me as female and the clinical test I need from my Urologist are usually performed on male patient’s and all persons who still have their prostrate, which have to be examined (you know the way; bend over please). So I had my yearly checkup and the claim was denied as stated: “The diagnosis is inconsistent with the patients gender.”. And this was just for my blood work; I will get the same denial form with my doctor’s visit, which should be back soon. Things like this make me crazy sometimes and I call to sit down with the Insurance Advocate at the doctor’s office and discuss the denials and she explain all the steps she had taken to get them to pay the claims. She totally understands and is very supportive.
I realize that to fight with a Government Agency would be a lot of paperwork that is shuffled back and forth and might never be resolved to my satisfaction. But I find how to submit an appeal and find the government form, fill it out with all appropriate documents for justification and put it in the mailbox. Done and gone thinking that all I can do until I get the next rejection and denial.
Then I begin to think that if this happened to me, other trans men and women must have had a similar experience, if they could get gender reassignment surgery; and with female to male there would still be a need for medical care through Medicare, so I message the one person who seems to be on the frontline fighting the good fight for all trans people, and explain my situation.
I contacted Mara Keisling with the National Center for Transgender Equality with my question and concerns. I get a quick message back saying; “Sarah, actually, this problem was addressed last year by the Obama administration. Give me a call and I'll walk you through it. There is a billing code override.” This was already addressed and fixed? I knew that Mara was good at what she does and has an excellent working relationship with this administration but this is so cool; thank goodness my Medicare billing problem has been addressed and fixed by this Administration; but this is more than I could have ever imagined, wow!! Now I have only to get her to explain the steps I have to do to follow through with fixing these billing problems.
So, for those of you who are just becoming Medicare eligible and could have the same billing problems there are the documents that the Center wrote. and look at the section; "What do I do when coverage is denied". I encourage you to contact the NCTE and Ms. Keisling for more information .
￼The following is taken from Chapter 32 of the Medicare Claims Processing Manual
240 – Special Instructions for Services with a Gender/Procedure Conflict (Rev. 1877, Issued: 12-18-09, Effective: 04-01-10, Implementation: 04-05-10)
Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.
The National Uniform Billing Committee (NUBC) has approved condition code 45 (Ambiguous Gender Category) as a result of the increasing number of claims received that are denied due to sex/diagnosis and sex/procedure edits. This claim level condition code should be used by institutional providers to identify these unique claims and alerts the fiscal intermediary that the gender/procedure or gender/diagnosis conflict is not an error allowing the sex related edits to be by-passed.
The KX modifier (Requirements specified in the medical policy have been met) is now a multipurpose informational modifier and will also be used identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries. Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.
240.1 - Billing Instructions for Institutional Providers (Rev. 1877, Issued: 12-18-09, Effective: 04-01-10, Implementation: 04-05-10)