All PlansBilling CodesMedium impact
22-663 Avoid Claims Denied for Gender Affirming Surgery
Health Net·CA · Plastic Surgery, Urology, OB-GYN +1 more·Reimbursement
We identified it
Jun 20, 2026
Summary
To prevent claim denials for gender affirming surgery, providers must now use condition code 45 on CMS-1450 forms for institutional claims and modifier KX on CMS-1500 forms for professional claims when billing gender-specific procedures. This allows sex-related edits to be bypassed for patients receiving gender affirming care.
Action Required
Immediately: Billing team must update procedures to use condition code 45 on all CMS-1450 institutional claims for gender-specific procedures that may trigger sex/diagnosis edits. Providers must add modifier KX to procedure codes on CMS-1500 professional claims for gender-specific services. Update billing software rules and train staff on proper modifier usage to prevent claim denials.