May 4, 2015

Coding for Gender Reassignment Surgery

By

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.

Gender identity disorder (GID) is the formal diagnosis used by healthcare professionals to denote persons who experience significant gender dysphoria (GD). GD is defined by the DSM-V as a condition characterized by the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender determined at birth. Individuals with GD experience confusion associated with their biological gender during their childhood, adolescence, and/or adulthood. These individuals also demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

In recent months, GD has been covered by the mainstream media, first with the highly publicized suicide of teenager Taylor Alesana and most recently the revelations of former track and field champion Bruce Jenner in his 20/20 interview with Diane Sawyer. GD is characterized by the desire to have the anatomy of the opposite sex and the desire to be regarded by others as a member of the opposite sex. 

Most major insurance, including Medicare, cover gender reassignment surgery under very specific guidelines. Though there are many similarities in the medical policies for gender reassignment surgery among the various major insurance companies, if the provider you work for is providing this service, you will need to find the medical policy specific to your patient’s insurance. 

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).

Contact the Author

Comment on this article

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Kathy Pride, CPC, RHIT, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer

Kathy is a proven leader in healthcare revenue cycle management with extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits, and education. She has trained and managed Health Information Management (HIM) professionals in multiple environments. She is currently the Senior Vice President of Coding and Documentation Services for Panacea Healthcare Solutions. Kathy has provided compliance auditing and documentation education to hundreds of physicians and coders throughout her career.

Related Stories

  • CMS Proposes 50 Percent Reduction in Claims Submitted with Modifier 25
    The proposal is on the table as part of proposed E&M changes. EDITOR’S NOTE: The following story was published by RACmonitor on Aug. 16, 2018. By now I am sure that everyone is well aware that the Centers for Medicare…
  • Specialty Physicians Ready to Push Back
    Proposed E&M code changes would impact specialty physicians. Some physicians are probably not very happy with recently proposed changes to the Medicare Physician Fee Schedule. The Centers for Medicare & Medicaid Services (CMS) designed the changes to reduce paperwork and…
  • GAO Findings on Prior Authorization and HATA’s Survey
    HATA survey reveals membership dissatisfaction with prior authorization transactions. In a recent report to the U.S. Senate Committee on Finance, the Government Accountability Office (GAO) was asked to examine the Centers for Medicare & Medicaid Services’ (CMS’s) prior authorization programs,…