My physicians experience rejections when billing for services and procedures related to gender affirming surgery. These surgeries are also referred to as gender confirming surgery or by an older term “gender re-assignment surgery.” These issues primarily impact Obstetrics, General Surgeons, Plastic Surgeons and Anesthesiologists but may impact other physician specialties as well. Billing rejections of this type are usually associated with assessment explanatory code:
39BA – GENDER RESTRICTION: HSC and/or diagnosis does not agree with the gender of the patient.
In this post, we’re going to go through AHS billing codes related to gender affirming surgeries get rejected and what you can do to ensure these claims are paid.
For more on age related restrictions, we have another post available here.
Understanding why your billing codes get rejected:
Alberta Health restricts billing of certain services and procedures based on the gender of the patient and the associated inferred gender of the procedure. For example, if a hysterectomy is performed on a patient that is registered as male, Alberta Health assumes the billing is in error.
These rejections confuse physicians because Alberta Health approves gender-affirming surgical care before procedures occur. Why is Alberta Health rejecting the billing claim if they themselves approved the procedure for that specific patient? The answer is that there isn’t a connection between the approval for the surgery that comes from Alberta Health Services and the payment for the service that comes from the Alberta Healthcare Insurance Plan (AHCIP). So even though the surgery has been approved, AHCIP won’t know that when you submit your claim.
What codes are most impacted?
There are four codes most commonly impacted by rejections associated with gender affirming surgeries:
81.99 A – Hysterectomy, any method
83.9 A – Operations on the adnexa, any method
97.43 Unilateral augmentation mammoplasty by implant or graft prosthesis
7.22A Mastectomy with retention of areola and nipple
To our knowledge, Alberta Health does not provide phalloplasty, metoidioplasty or vaginoplasty within provincial health care facilities.
How to correctly bill for gender affirming care:
The first item to check is the registered gender is your patient at the time of the service. Rejections are usually caused by a mis-match between the registered gender of the patient and the inferred gender of the procedure.
Female to Male:
Let’s give an example of a patient undergoing female to male related procedures (hysterectomy, operations on the adnexa, mastectomy with retention of areola and nipple).
Registered Female: If the patient is registered as female at the time of service, then you should have no issues submitting your billing claims
Registered Male: If the patient is registered as a male at the time of service, physicians need to provide supporting text stating that the patient was registered as a female at birth, they have since be registered as a male, and this service was provided as part of gender affirming surgery. This supporting information can be sent with the claim at the time of initial submission.
Male to Female:
Let’s take a different example of a patient undergoing male to female related procedures (augmentation mammoplasty).
Registered Female: If the patient is registered as female at the time of service, you should not have issues submitting your billing claims
Registered Male: If the patient is registered as a male at the time of service, physicians need to provide supporting text stating that the patient was registered as a male at birth and this service is provided as part of gender affirming surgery. This supporting information can be sent with the claim at the time of initial submission.
What to do if your claim has been rejected:
You’ll need to submit the required supporting text. This text provides the patient’s registered gender at birth, their current registered gender, and informs the billing assessor that the services were provided as part of gender affirming surgery.
Once this supporting text is provided, these claims are not typically further refused.
Getting claims related to gender affirming surgery paid and rejections resolved is fairly straight forward. You just need to be aware of how Alberta Health assess the claim and provide supporting text as required based on the patient’s registered gender. Do you have other issues related to gender affirming billings? Let us know! Billing issues change and evolve, and we’re always happy to hear experience from physicians.