Being stuck in a body that doesn’t seem to fit is not all that unusual these days. Therefore, understanding gender dysphoria and gender reassignment procedures is necessary to correct coding.
What Is Gender Dysphoria
Gender Dysphoria (formerly known as gender identity disorder) and transgender are terms used to describe a strong, persistent feeling of discomfort in a person whose expressed gender conflicts with the gender assigned at birth.
For instance, a person with the anatomy of a male may actually feel like a female.
Likewise, a person with the anatomy of a female may feel like a male. This can lead a person to desire a body of the opposite gender and to be accepted by those of that gender.
According to WebMD, this feeling of gender mismatch can cause major distress, anxiety, and depression, which can affect a person’s everyday life.
The National Institutes of Health reports that it has often been difficult to determine the number of transgender individuals living in the U.S. This difficulty is due to social stigma, discrimination, harassment, and physical and sexual abuse.
However, CDC’s Behavioral Risk Factor Surveillance System (BRFSS) conducted a U.S. study in January 2017 and concluded that about 150,000 youth, ages 13 to 17, identify as transgender. Furthermore, about 1.4 million adults, 18 and older, identify as transgender.
What Gender Dysphoria Is Not
According to the American Psychiatric Association (APA) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender dysphoria is not considered a mental illness, which is why it is no longer called gender identity disorder. Many individuals consider the former term offensive.
Transsexualism, a severe form of gender dysphoria, is also an outdated term.
Gender dysphoria is not homosexuality. A person’s sense of gender is different than their sexual orientation.
Gender dysphoria is not transvestitism, which refers to cross-dressing.
Etiology of Gender Dysphoria
The cause is unknown, but it is suspected that hormones play a part in the womb.
Symptoms and Diagnosis
Symptoms present differently in children than in adults; therefore, the diagnostic criteria for gender dysphoria is different for each.
A child may be diagnosed with gender dysphoria when the condition is experienced for at least 6 months and displays in two or more of the following (according to WebMD):
- Consistently stating he is really a girl when he has the physical characteristics of a boy or that she is really a boy with the physical characteristics of a girl
- Strong preference for friends of the same sex that he/she identifies with
- Having an aversion to clothes, toys, and games typical for boys or girls
- Refusing to urinate in the position that other boys or girls do
- Stating he/she wants the genitals of his/her true sex instead of the genitals that he/she has
- Believing he/she will grow up to be a person of the sex he/she identifies with even though currently he/she has the physical characteristics of the other gender
- Experiencing substantial distress about the changes his/her body goes through during puberty
Teens and Adults
A teen or adult may be diagnosed with gender dysphoria when the condition is experienced for at least 6 months and displays in two or more of the following:
- A certainty that his/her true gender is not in line with his/her body
- Loathing of his/her genitals, which may cause the need to avoid showers, changing clothes, or having sex so that he/she won’t have to look at or touch his/her genitals
- Extreme desire to have the genitals gone
Once the above criteria are met, codes from F64.0-F64.9 may be used to describe the type of gender dysphoria diagnosed:
0 – Gender dysphoria in adolescents and adults
1 – Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery)
2 – Gender dysphoria in children
8 – Other specified gender dysphoria
9 – Gender dysphoria, unspecified
Note that ICD-10 still uses the outdated terms of gender identity disorder and transsexualism. However, changes are coming for ICD-11, and the five diagnoses codes will be replaced by two gender incongruence codes, according to the World Health Organization.
One code will be for adolescents and adults, and one code will be for children. These codes will be found in a new chapter called “Conditions Related to Sexual Health” rather than in Chapter 5 (“Mental, Behavioral and Neurodevelopmental Disorders”) where they currently reside.
Undiagnosed or Untreated Gender Dysphoria
Approximately 71% of individuals who go undiagnosed or untreated for gender dysphoria will be diagnosed with other mental health conditions at some point, states WebMD. That includes mood disorders, anxiety disorders, schizophrenia, depression, substance abuse, eating disorders, or suicide attempts.
The goal of treatment is to help individuals with gender dysphoria come to terms with others’ reactions to them. It is not to change how the person feels about his or her gender.
Talk therapy can help, and medications, such as puberty blockers and hormones, can change the appearance. Gender reassignment surgery is also a goal for many who wish to change their appearance. After transitioning, a person may no longer feel dysphoria but may still need therapy to deal with others’ lack of understanding.
Once a person provides the required documentation, gender reassignment surgery can be performed. The individual may choose to undergo breast surgery, genital surgery, or a combination of the two. The decision is based on what is best for the patient.
Breast Surgery Documentation Requirements (according to United Healthcare)
Breast surgery may consist of all or some of the following procedures: hysterectomy, ovariectomy, orchiectomy, or salpingo-oophorectomy. Sex reassignment surgery is medically necessary when all of the following criteria are met:
- Written psychological assessment from one or more qualified behavioral health providers experienced in gender dysphoria treatment who have assessed the patient and documented all of the following:
- Gender dysphoria that is ongoing and well documented
- Ability to make a fully informed decision and able to consent to treatment
- Is at least 18 years old
- Has any notable medical or mental health issues under reasonable control
Genital Surgery Documentation Requirements
Genital surgery may consist of all or some of the following procedures: metoidioplasty, phalloplasty, penectomy, vaginoplasty, labiaplasty, clitoroplasty, vaginectomy, urethroplasty, scrotoplasty, or placement of testicular prostheses. Sex reassignment surgery is medically necessary when all of the following criteria are met:
- The same requirements as listed above for breast surgery
- Completed 12 months or more of successful, ongoing full-time, real-life experience in the desired gender
- Completed 12 months of ongoing cross-sex hormone therapy appropriate for the desired gender, unless medically contraindicated
- Treatment plan, including ongoing followup and care by a qualified behavioral health provider experienced in treating gender dysphoria
CPT Procedure Coding
Once the criteria have been met, the following gender reassignment surgical procedures are typically considered medically necessary and covered as a proven benefit:
55970 – (Intersex surgery; male to female) involves the following staged procedures to remove portions of the male genitalia and form female external genitals:
- Penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
- Urethral opening is moved to a position similar to that of a female.
- Vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split-thickness grafts.
- Labia are created out of skin from the scrotum and adjacent tissue.
- Stent or obturator is usually left in place in the newly created vagina for three weeks or longer.
55980 – (Intersex surgery; female to male) involves the following staged procedures to form a penis and scrotum using pedicle flaps and free skins grafts:
- Portions of the clitoris and adjacent skin are used.
- Prostheses are often placed in the penis to make a sexually functional organ.
- Prosthetic testicles are implanted in the scrotum.
- Vagina is closed or removed.
Many carriers do not allow CPT codes 55970 and 55980 (intersex surgery) to be used on the claim form, and providers must instead bill for the individual procedures performed. Prior authorization is also required before services are provided.
The CPT codes listed below are for informational purposes only and may not be covered depending on the individual’s policy. It is not an all-inclusive list. Once you understand the coverage limitations, the patient can make a decision as to which procedure he/she may want to be performed, and the provider can get the proper reimbursement based on the services provided.
Transwoman procedures (male to female)
19325 – Mammaplasty, augmentation; with prosthetic implant
54125 – Amputation of penis; complete
54520 – Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54690 – Laparoscopy, surgical; orchiectomy
56805 – Clitoroplasty for intersex state
57291 – Construction of artificial vagina; without graft
57292 – Construction of artificial vagina; with graft
57335 – Vaginoplasty for intersex state
Transman procedures (Female to Male)
19303 – Mastectomy, simple, complete
53430 – Urethroplasty, reconstruction of female urethra
54660 – Insertion of testicular prosthesis (separate procedure)
55180 – Scrotoplasty; complicated
56625 – Vulvectomy simple; complete
57110 – Vaginectomy, complete removal of vaginal wall
58150 – Total abdominal hysterectomy (corpus and cervix), with or without removal of tubes(s), with or without removal of ovary(s)
58552 – Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
58570 – Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;
58571 – Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
58720 – Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
Services that are routinely excluded from coverage and considered cosmetic for the treatment of gender dysphoria may include the following:
- Liposuction (fat removal)
- Rhinoplasty (nose reshaping)
- Rhytidectomy (face lift)
- Blepharoplasty (removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat)
- Hair removal or hair transplantation
- Facial feminizing (such as facial bone reduction)
- Chin augmentation (chin reshaping or chin enhancing)
- Collagen injections
- Lip reduction/enhancement (lip size decrease or enlargement)
- Cricothyroid approximation (voice modification)
- Trachea shave/reduction thyroid chondroplasty (thyroid cartilage reduction)
- Laryngoplasty (laryngeal reshaping framework – voice modification surgery)
- Mastopexy (breast lift)
Again, the individual’s policy will need to be reviewed to determine which treatments are considered cosmetic and consequently not covered.
Data Collection and Screenings
Gender identity data should be collected on an ongoing basis, which includes both current gender identification and the gender assigned at birth. The gender marker (male or female) should be recorded in the medical record based on the patient’s insurance policy, states AAPC.
Staff should be trained on the best way to collect gender identification. This information is needed so the provider can perform preventive screenings based on the patient’s physical characteristics.
For example, a female who expresses as a man may not have chosen to undergo a mastectomy. This would mean that the individual has the same risks for breast cancer as any other natal woman.
Another example would be that of a transwoman who retained the prostate. If hormones have not been taken, a prostate cancer screening may be medically necessary since the individual would be at risk the same as any other natal man.
If a transgender patient is seen for services unrelated to gender, the carrier should be consulted as to whether the transgender ICD-10 code should be used on the claim. In many cases, the F64.x code should be used as a secondary code on claims for unrelated services.
Medicare and most insurance carriers require that all Part A claims for transgender inpatient and outpatient services include condition code 45 (Ambiguous Gender Category) in order to avoid being denied. This condition code is to be used by providers to let the fiscal intermediary know that the gender/procedure or gender/diagnosis conflict is not a mistake and that the sex-related edit should be ignored, according to the Medicare Claims Processing Manual.
Modifier KX should be used for Part B professional claims to identify services for transgender patients. This modifier should be appended to the procedure code(s) that are gender-specific for transgender patients. That way if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier will alert the carrier that it is not an error and the claim can go through with normal processing.
In summary, individuals with gender dysphoria deserve the same unbiased healthcare as any other individual. They do not choose to have this long-term feeling of body and gender mismatch. It is a burden that requires professional and social support. Gender reassignment surgery is only part of the process to achieve positive behavioral and medical outcomes. It is important to review each policy for coverage and limitations, to get prior authorization, and to ensure that medical documentation supports the services billed.
I originally wrote this article and it was first published in BC Advantage/www.billing-coding.com under the title, “Gender Dysphoria and Gender Reassignment Procedures” and is reprinted here with permission.
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