Forum - Questions & Answers

Jun 16th, 2015 - petunia 195 

Transgender patient diagnosis

We have a patient who is transgender. Initially a female with a recto-vaginal fistula. Seton was placed and the patient has returned to clinic for 2 office visits since. Both have been billed with dx 619.1 Digestive-genital tract fistula, female. We are being rejected due to dx does not match patient gender which is now a male. Has anyone had this happen for them yet. We are not sure how we should be billing the dx,?

Any ideas would be appreciated.

Jun 16th, 2015 - Kat31477 56 

re: Transgender patient diagnosis

Interesting situation. Have you spoken with the insurance company directly to receive guidance? Or you can request the patient contact the insurance regarding why they have denied the claim. Or you could appeal stating the facts of the case. I cannot imagine they will uphold the denial when presented with all of the relevant information. Most systems are set to automatically deny a claim when the dx code does not match the patient's gender, but those auto-denials can be overridden. Good luck!

Jun 16th, 2015 - petunia 195 

re: Transgender patient diagnosis

I may have to call the carrier myself. I do all of our coding and provide guidance to our billing team when we have problems. We have (our billing team) contacted the carrier and were told that they can not override the edit becasue the system now tells them this the patient is a male and should not have a recto-vaginal fistula. I'm going to call the carrier myself and see if I can get it overridden. We have sent in notes and explained the patient is transgender and we are using the correct dx from what I can tell. Thank you :)

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