Clear Up Misconceptions About Transgender Coding
Acceptance has paved the way to more accurate diagnoses and improved health outcomes, but insurance coverage hinges on proper coding.
By Marcia A. Maar, MFA, COC, CPC, CRC, AAPC Fellow, AAPC, MACRA Proficient, and Michelle A. Dick, BS
Transgender is a broad term used for people whose gender identity or gender expression differs from their assigned sex at birth. Proper diagnosis and procedural coding of transgender medical services begins with understanding the spectrum of gender identity variations.
Although there is no universally accepted definition of the word “transgender,” here are some terms you should know when coding patients with gender dysphoria:
Bigendered — Individuals who identify as both or alternatively male and female, as no gender, or as a gender outside the male or female binary.
Crossdresser — Individuals who dress in clothing associated with the opposite sex — for reasons that include a need to express femininity or masculinity, artistic expression, performance, or erotic pleasure — but do not identify as that gender. The term “transvestite” was previously used to describe a crossdresser, but it is now considered derogatory and should not be used.
Female-to-male (FTM) — Someone who was identified as female at birth but identifies and portrays his gender as male. This term is often used after the individual has taken some steps to express his gender as male, or after medically transitioning through hormones or surgery (aka, transman).
Gender identity — A person’s innate identification as a man, woman, or something else that may (or may not) correspond to the person’s external body or assigned sex at birth.
Intersex — Individuals with a set of congenital variations of the reproductive system that are not considered typical for either male or female. This includes newborns with ambiguous genitalia, a condition that affects one in 2,000 newborns in the United States each year.
Male-to-female (MTF) — Someone who was identified as male at birth but identifies and portrays her gender as female. This term is often used after the individual has taken some steps to express her gender as female, or after medically transitioning through hormones or surgery (aka, transwoman).
Transsexual — An individual who strongly identifies with the other sex and seeks hormones or gender-affirmation surgery, or both, to feminize or masculinize the body. This person may live full-time in the cross-gender role.
Common Criteria for Gender Reassignment
For payers to cover gender reassignment, like all other procedures, medical necessity needs to be proven. There must be evidence of a strong and persistent cross-gender identification (e.g., the individual is insistent on being the other sex). This cross-gender identification must not merely be a desire for perceived cultural advantages of being the other sex. There must be evidence of persistent discomfort about the patient’s assigned sex or a sense of inappropriateness in the gender role of that sex.
Transgender diagnosis is not made if the individual has a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The Tufts Health Plan (accessible online), for example, may offer coverage if:
- The patient is 18 years of age or older.
- The patient has a definite diagnosis of persistent gender dysphoria that has been documented by a qualified licensed mental health professional, such as a psychiatrist, psychologist, or other licensed physician experienced in the field.
- The patient has received continuous hormone therapy for 12 months or more under the supervision of a physician.
- The patient has lived as their reassigned gender full time for 12 months or more. (Bullets 3 and 4 may occur concurrently.)
- The patient’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan (within three months of the prior authorization request).
ICD-10-CM Coding Tied to Gender Transition
Gender dysphoria is manifested in a variety of ways, including a strong desire to be treated as the other gender or to be rid of sex characteristics, or a strong conviction that the patient has feelings and reactions typical of the other gender.
For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign to him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be verbalized. When coding gender dysphoria, look to F64 Gender identity disorders category of codes:
F64.1 Dual role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnosis adds a post-transition specifier for people who are living full time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition. Use code Z87.890 Personal history of sex reassignment for sex reassignment surgery (SRS) status.
Although there is no specific procedure code for people diagnosed with gender dysphoria who are choosing to transition, there are two CPT® codes that pertain to intersex surgery:
55970 Intersex surgery; male to female
55980 Intersex surgery; female to male
Codes 55970 and 55980 apply to surgery for newborns with ambiguous genitalia, as well.
Although not a comprehensive list, here are common procedures performed during gender transition surgery:
Vaginectomy (FTM) – Look to codes such as 58275 Vaginal hysterectomy, with total or partial vaginectomy, 57111 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy), etc.
Urethroplasty (MTF and FTM) – Look to applicable CPT® codes 53410 – 53430.
Phalloplasty (FTM) – 55899 Unlisted surgery of the male genital system, for metoidioplasty and phalloplasty
Scrotoplasty (MTF) – 55175 Scrotoplasty; simple and 55180 Scrotoplasty; complicated
Penectomy (MTF) – 54125 Amputation of penis; complete
Vaginoplasty (MTF) – 57335 Vaginoplasty for intersex state
Labiaplasty (MTF) – 56625 Vulvectomy simple; complete
Clitoroplasty (MTF) – 56805 Clitoroplasty for intersex state
There are also surgical procedures associated with intersex surgery that payers typically consider to be cosmetic:
Abdominoplasty – 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
Blepharoplasty – 15822 Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery)
Otoplasty – 69300 Otoplasty, protruding ear, with or without size reduction
Rhinoplasty – 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
Genioplasty – 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)
Rhytidectomy – 15828 Rhytidectomy; cheek, chin, and neck
Privacy and Respect Is Important
Remember when coding and reporting patient services for gender dysphoria always recognize and respect the process of transitioning gender. These individuals have an exceptionally high suicide rate and require unique healthcare needs.
The patient has the right to confidentiality. The physician and staff should not reveal confidential communications or information without the consent of the patient, unless provided for by law or by the need to protect the welfare of the individual or public interest.
Evolution of Gender Dysphoria
Although gender dysphoria has been around throughout history, transgender surgery only began in the early 1900s. Here is a time line of its progress in the medical field:
1930 – Under the care of Magnus Hirschfeld, Lili Elbe became the first person to undergo transsexual surgery.
1933 – Most of Hirschfeld’s research was destroyed by the Nazis.
1940s – Michael Dillon is the first modern female-to-male (FTM) individual to undergo phalloplasty surgery. He transitioned in England in the early 1940s.
1948 – Clinical support of medically transitioning people began in the United States with Harry Benjamin, who used the term “transsexual” to describe people who physically change their body to be congruent with their gender identity. In 1948, he prescribed estrogens to bring about physical changes in his first transsexual patient.
1952 – Christine Jorgenson was the first American to publicly acknowledge traveling to Denmark for sex reassignment surgery (SRS).
1956 – Georges Burou, MD, the pioneer of modern techniques, performed one-stage SRS in Casablanca.
1960-1970 – Gender identity centers were established at Johns Hopkins, Stanford University, and the University of Minnesota, which legitimized the care and diagnosis of transgender individuals.
1973 – Burou had performed over 3,000 MTF operations by 1973.
1979 – The first standards of care for transsexuals were published by the Harry Benjamin International Gender Dysphoria Association, now known as the World Professional Association of Transgender Health.
1980 – Transsexualism was included in the third edition of the DSM (DSM-III).
2014 – The Affordable Care Act (ACA) removed discrimination against transgender status as a pre-existing condition.
For information on transgender coding and healthcare rulings, read the following articles in AAPC’s Knowledge Center:
Mesics, Sandra. (2015) Clinical Care of the Transgender Patient. Sacramento, CA. NetCE:
The Centers for Medicare & Medicaid Services (CMS), Gender Reassignment Surgery Model NCD
Source: Mesics, Sandra. (2015) Clinical Care of the Transgender Patient. Sacramento, Calif. NetCE
Marcia A. Maar, MFA, COC, CPC, CRC, AAPC Fellow, AAPC MACRA Proficient, works in risk adjustment for a local non-profit health insurance company in Rochester, N.Y. She is the president of the Flower City Professional Coders local chapter in Rochester, N.Y.
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