EDITOR’S NOTE: Kathy Pride is continuing her reporting on health issues that have been covered in the national news media as they relate to ICD-10.Guidelines common in the policies researched for this article are:
- The individual must be at least 18 years of age;
- The individual must be diagnosed with GID or GD;
- The individual must have successfully lived and worked with the desired gender role full-time for at least 12 months to two years (depending on policy/insurance) without returning to the original gender;
- Gender reassignment surgery must be a covered benefit of the individual’s policy;
- The individual must participate in a recognized gender identity treatment program;
- The individual must not have gender identity as a symptom of another mental health disorder;
- The individual must undergo 12 months of continuous hormonal therapy; and
- The individual must obtain letters that attest to the psychological aspects of the candidate’s GID (each policy is specific to the criteria and provider specialty providing the letter).
The following are commonly covered diagnoses for gender reassignment; however, it is important to research your patient’s insurance coverage to determine coverage, as specific coverage for individual and group policies can vary within an insurance company. Just because two patients are covered by the same insurance company does not necessarily mean their policies cover the same services.
Covered diagnoses in ICD-9-CM include:
- 302.50 – Trans-sexualism with unspecified sexual history
- 302.51 – Trans-sexualism with asexual history
- 302.52 – Trans-sexualism with homosexual history
- 305.53 – Trans-sexualism with heterosexual history
- 305.58 – Gender Identity disorder in adolescents or adults
The covered diagnosis in ICD-10-CM is the following:
F64-F64.9 Gender identity disorder
You must also refer to the individual’s policy for a list of procedures (CPT codes) covered for gender assignment disorder. Many of the policies do not accept the codes 55970 Intersex surgery; male to female or 55980 Intersex surgery; female to male. Rather, they require that the claim be filed with the CPT code that represents the specific procedure. For example, for male-to-female surgery the following may be coded:
- Orchiectomy (54520, 54690)
- Penectomy (54125)
- Vaginoplasty (57335)
- Colovaginoplasty (57291-57292
- Clitoroplasty (56805)
- Labiaplast(58999)
- Breast augmentation (19324-19325)
- Tracea shave/reduction thyroid chondroplasty (31899)
Please note that the list above is only an example and is not to be considered a complete list of procedures, nor is it to be considered compliant with any specific medical policy. Due to the number of specific policies, it would be difficult to list all policies and applicable codes in this article.
The bottom line is this: do your research before you provide gender reassignment surgery to your patient. Understanding the limitations of coverage will help your patient make an informed decision as to whether they can afford the surgery, and it will help you, the provider, get paid appropriately for the services you provide.
About the Author
Kathy Pride, CPC, RHIT, CCS-P, is vice president of professional services for Panacea Healthcare Solutions. Kathy has extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits and education. She is also an approved ICD-10 Trainer through the American Health Information Management Association (AHIMA) and a previous member of the AAPC National Advisory Board (1998 – 2000).
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