CMS updating “sex conflict edits” lists

Medicare, like most private insurance, uses what it call "sex conflict edits" to flag claims where the patient's recorded sex is atypical for the diagnosis or service in the claim. As most on this list know well, this causes serious problems for transgender folks.

CMS periodically updates its lists of diagnosis and services for which it applies "sex conflict edits" as part of its payment regulations. Last week CMS proposed its latest updates.

As many of you will also know, Medicare has long had a workaround for providers in the know, where providers can add a modifying code when billing for a service (condition code 45) to avoid this problem. Unfortunately, many providers don't know about this, as it’s currently buried in page 185 of chapter 32 of the Medicare Claims Processing Manual.

I've always thought the value of sex conflict edits was unproven and dubious, and should be questioned. I’ve never seen any analysis or data from any agency or insurer on the need for and value of this practice. Short of challenging them, it may be worth asking CMS to at least prominently spell out this workaround more prominently in annual coding tables and guidelines, and anywhere else sex conflict edits are mentioned.