January 12, 2015

Healthcare Industry Turns Attention to Gender Identity Dysphoria in Wake of Teen’s Suicide

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Note: ICD-10 and Gender Identity Disorder featured today on Talk Ten Tuesdays, 10 ET - Register here.

Gender identity dysphoria, formerly known as gender identity disorder, hit the mainstream media recently due to the tragic suicide of Leelah Alcorn of Kings Mill, Ohio. The 17-year-oldended her life in part to bring attention to the bullying and insensitive treatment of people who are transgender. 

To avoid stigma and ensure clinical care for individuals who see themselves as a different gender, DSM-5 replaces the diagnostic name “gender identity disorder” with “gender dysphoria” and makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dys­phoria is the presence of clinically significant distress associated with the condition.

According to the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria. This revision is intended to better characterize the experiences of affected children, adolescents, and adults.

Most medical professionals agree that identifying as transgender is not a disorder or mental illness/condition. However, persons experiencing gender dysphoria – anyone who suffers severe distress, anxiety, and depression due to a strong feeling that they are not the gender they physically appear to be – need a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas. When it comes to access to care, many of the treatment options for this condition include counsel­ing, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender.

According to the DSM-5 Sexual and Gender Identity Disorders Work Group, it was felt that removing the condition as a psychiatric diagnosis, as some had suggested, might jeopardize access to care. But removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology; it also removes the connotation that the patient is “disordered.”

Unfortunately, ICD-9-CM and ICD-10-CM have not changed their axis of classification from disorder to dysphoria to match DSM-5. If you look up “dysphoria” in the index of either classification, you will not find gender identity as a subterm under the main term “dysphoria.”

 

In order to locate this condition, one must continue to look under the main term “disorder” to find “gender-identity” as a subterm. 

Once you locate the main term and subterm in the index, coding guidelines tell us to validate our selection in the tabular section and follow any additional instructional notes such as “use additional codes” and excludes 1 and excludes 2 instructions. The code, F64.1 (Gender identity disorders in adolescence and adulthood) provides us with three different instructional notes.

The first is to use an additional code to identify sex reassignment status.  The parenthetical note guides the coder to Z87.890. You should only use code Z87.890 (Personal history of sex reassignment) if the patient has completed a sex reassignment.

The second instructional note, excludes 1: gender identity disorder in childhood (F64.2) instructs the coder to not use code F64.1 if the patient’s diagnosis is gender identity disorder in childhood; rather they should use the code F64.2.

The third instructional note, excludes 2: fetishistic transvestism (F65.1), instructs the coder that the diagnosis of fetishistic transvestism is not included in the diagnosis of gender identity disorder.  However, it is appropriate to code both conditions if both conditions exist.

It is also important to code all secondary conditions documented by the provider at the time of the encounter. These may include depression and anxiety. See a full listing of depression disorders under Mood Disorders, Categories F30-F39, and a full listing of Anxiety disorders under Categories F40-F48.

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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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.