Overcome Gender Identity Barriers in Healthcare

Overcome Gender Identity Barriers in Healthcare

Part 2: Know the codes and documentation to help prove medical necessity for gender-related surgical procedures.

Patients with gender conflict have stereotyping and depression to overcome; don’t let staff and billing be another obstacle they must face when getting medical care. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) helps to remove gender identity stigma, how to apply proper coding to medical claims, and how to prove medical necessity.

DSM-5 Helps Eliminate “Disorder” Labels

Part of removing stigma is choosing the right words with which to describe the condition. DSM-5 replaced the diagnostic name “gender identity disorder” with “gender dysphoria,” and made other important clarifications in the designation criteria. 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.”

The 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. Gender dysphoria has its own chapter in DSM-5 and is separated from “Sexual Dysfunctions and Paraphilic Disorders.”

To be diagnosed with gender dysphoria, there must be a notable difference between the patient’s expressed gender and experienced gender, and it must continue for six months.

Get Familiar With ICD-10-CM Codes

F64.0      Transsexualism

Transsexualism is also referred to as transgender, which is a type of gender dysphoria that can manifest as early as 2 years of age. A transsexual person experiences a gender identity that is not consistent with their biological sex, causing the transsexual person significant distress that impairs their ability to function. A person with transsexualism may feel so strongly that they belong to the opposite sex that they will undergo sexual reassignment therapy. Sexual reassignment almost always involves surgery, in addition to hormone therapy.

F64.1      Dual role transvestism

Use additional code to identify sex reassignment status (Z87.890)

Excludes1: gender identity disorder in childhood (F64.2)

Excludes2: fetishistic transvestism (F65.1)

Transvestism is also referred to as cross-dressing. Dual role transvestism has three distinct criteria:

  • An individual wants to dress like the opposite sex;
  • The motivation is not a sexual desire to be the opposite sex; and
  • The individual does not wish to permanently change their assigned sex.

A dual role transvestite lives in both worlds: the gender to which their physical sex coincides and the gender opposite of their physical sex. Although the latter is what the individual identifies with more, the need to be this sex is not a debilitating obsession.

F64.2      Gender identity disorder of childhood

Gender dysphoria in children

Excludes1: gender identity disorder in adolescence and adulthood (F64.0)

Excludes2: sexual maturation disorder (F66)

F64.8      Other gender identity disorders

F64.9      Gender identity disorder, unspecified

Gender identity disorder encompasses several conditions that are characterized by a disparity between the individual’s biological sex and their perceived sexual identity. Another term for this condition is gender incongruity.

To be classified as a gender identity disorder, this mismatch between biological and perceived gender must be accompanied by significant emotional distress and impair the individual’s ability to function in daily life.

Pay Attention to Documentation Required by Insurance

Gender reassignment surgery is intended to be a permanent change between an individual’s gender identity and physical appearance — it is not easily reversible. A careful and accurate diagnosis is essential for treatment and can be made only as part of a long-term diagnostic process involving a multidisciplinary specialty approach that includes:

  • An extensive case history;
  • Gynecological, endocrine, and urological examination; and
  • A clinical psychiatric/psychological examination.

Note: A patient’s self-assessment and desire for sex reassignment cannot be viewed as reliable indicators of gender dysphoria.

The behavioral health professional’s role is essential in providing documentation about medical necessity for gender reassignment. After the individual is professionally assessed, the provider’s documentation and formal recommendation are sent to medical and surgical specialists. Documentation recommending hormonal or surgical treatment should be comprehensive and include ALL the following:

  • Individual’s general identifying characteristics
  • Initial and evolving gender, and sexual and psychiatric diagnoses
  • Details regarding the type and duration of received psychotherapy or evaluation
  • Extent to which eligibility criteria have been met
  • Mental health professional’s rationale for hormone therapy or surgery
  • Degree to which the individual has followed the standards of care and the likelihood of continued compliance
  • Whether the mental health professional is a part of a gender team

Coverage Depends on the State, Insurance, and Documentation

The Affordable Care Act includes a nondiscrimination provision (Section 1557) that is very detailed and specifically prohibits discrimination based on gender identity, but it does not require health insurance policies to “cover any particular procedure or treatment for transition-related care.”

Depending on the state, insurance, and documentation, health plan coverage may be offered if ALL the following are documented:

  • The patient is 18 years of age or older.
  • The patient has a definitive 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.
  • The patient’s medical and mental health providers document there are no contraindications to the planned surgery and agree with the plan (within three months of the prior authorization request).

There are also surgical-specific procedure documentation requirements.

FTM Gender Reassignment and Documentation

Documentation requirements vary depending on the procedure. For example:

Breast surgery (such as initial mastectomy, breast reduction) requires one letter of support from a qualified mental health professional.

Hysterectomy and salpingo-oophorectomy require that BOTH of the following additional criteria are met:

  • Documentation of at least 12 months of continuous hormonal sex reassignment therapy.
  • Recommendation of sex reassignment surgery (genital surgery) by two qualified mental health professionals with written documentation submitted to the physician performing the genital surgery. At least one letter should be a comprehensive report. Two separate letters or one letter with two signatures is acceptable. One letter from a master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist.

Vaginectomy requires ALL the following criteria are met:

  • Documentation of at least 12 months of continuous hormonal sex reassignment therapy (may be simultaneous with real-life experience).
  • Individual has lived within the desired gender role for at least 12 continuous months, which includes a wide range of life experiences and events (for example, family events, holidays, vacations, season-specific work, or school experiences), including notification to partners, family, friends, and community members (for example, at school, work, other settings) of their identified gender.
  • Recommendation of sex reassignment surgery (genital surgery) by two qualified mental health professionals with written documentation submitted to the physician performing the genital surgery. At least one letter should be a comprehensive report. Two separate letters or one letter with two signatures is acceptable. One letter from a master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist.

MTF Gender Reassignment and Documentation

Orchiectomy requires BOTH of the following additional criteria are met:

  • Documentation of at least 12 months of continuous hormonal sex reassignment therapy.
  • Recommendation for sex reassignment surgery (genital surgery) by two qualified mental health professionals with written documentation submitted to the physician performing the genital surgery. At least one letter should be a comprehensive report. Two separate letters or one letter with two signatures is acceptable. One letter from a master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist.

What Is NOT Considered Medically Necessary

Cryopreservation or storage of embryo and sperm and cosmetic procedures often are not considered medically necessary as part of gender reassignment and are not covered by insurance.

Cosmetic, noncovered services include:

Abdominoplasty

Blepharoplasty

Breast enlargement procedures, including augmentation mammoplasty, implants, and silicone injections of the breast

Calf implants

Cheek/malar implants

Chin/nose implants

Collagen injections

Electrolysis

Face/forehead lift

Brow lift

Hair removal/hair transplantation

Penile prosthesis (noninflatable/inflatable)

Testicular expanders

Jaw shortening/sculpturing/facial bone reduction

Laryngoplasty

Lip reduction/enhancement

Liposuction

Mastopexy

Neck tightening

Nipple/Areola reconstruction

Pectoral implants

Removal of redundant skin

Replacement of tissue expander with permanent prosthesis testicular insertion

Rhinoplasty

Scrotoplasty

Second stage phalloplasty

Skin resurfacing (for example, dermabrasion, chemical peels)

Surgical correction of hydraulic abnormality of inflatable (multi-component) prosthesis including pump and/or cylinders and/or reservoir

Testicular prostheses

Trachea shave/reduction thyroid chondroplasty

Voice modification surgery

Voice therapy/voice lessons

 

Professionals Must Attest to Medical Necessity

Some payers and states require two letters of medical necessity from any of the following:

  • A licensed psychiatrist, psychologist, psychiatric nurse practitioner, or clinical social worker who has treated the patient for a minimum of 12 months
  • Physician, psychiatrist, psychologist, psychiatric nurse practitioner, or clinical social worker who has evaluated the patient
  • Primary care provider of the patient
  • A letter of medical necessity is needed to support the patient’s wish to pursue surgery. The letter should indicate the patient has:
  • A persistent and well-documented case of gender dysphoria and the procedure is medically necessary to treat the patient’s gender dysphoria;
  • Lived for at least a year in the gender role that matches their gender identity;
  • Received mental health counseling or psychotherapy, as deemed necessary;
  • No medical or mental health conditions that would make the procedure medically inappropriate, or has medical or mental health conditions that are reasonably well-controlled prior to the procedure;
  • The cognition and capacity to make a fully informed decision and to consent to the treatment; AND
  • Received hormone therapy for 12-24 months, depending on the patient and procedure (or describe why hormone therapy is not medically appropriate for them).

When to Use Modifiers 45 and KX

When submitting claims for gender reassignment for facility claims, administrators are encouraged to report condition code 45 Ambiguous gender category with an inpatient or outpatient gender-specific service. For professional claims, physicians and other healthcare professionals are encouraged to include modifier KX Requirements specified in the medical policy have been met with a procedure code that is gender-specific.

Common ICD-10-CM Codes for FTM

The following codes are commonly found on female-to-male (FTM) charts; the insurance company still lists the patient as female:

E28.9      Ovarian dysfunction, unspecified

N94.9     Unspecified condition associated with female genital organs and menstrual cycle

N91.5     Oligomenorrhea, unspecified [scanty or infrequent menstruation]

N95.0     Postmenopausal bleeding [primary absence of menstruation]

N91.2     Amenorrhea, unspecified [secondary absence of menstruation]

N94.10   Unspecified dyspareunia

N94.11   Superficial (introital) dyspareunia

N94.12   Deep dyspareunia

N94.19   Other specified dyspareunia

N94.819              Vulvodynia, unspecified

N90.89   Other specified noninflammatory disorders of vulva and perineum

Q52.6     Congenital malformation of clitoris

N64.4     Mastodynia

E28.2      Polycystic ovarian syndrome

Common ICD-10-CM Codes: MTF

The following codes are commonly found on male-to-female (MTF) charts; the insurance company still lists the patient as male:

N50.0     Atrophy of testis

N50.9     Disorder of male genital organs, unspecified

N62         Hypertrophy of breast

E89.5      Postprocedural testicular hypofunction [post procedural/post-ablative testicular hypofunction]

E29.1      Testicular hypofunction

Get Past Insurance Barriers

Look for the next article in this series, where we will discuss insurance barriers, what your facility can do to help create a safe environment for patients, and the key takeaways from this series.

Read the first article of this gender identity series, which first appeared in the December issue of Healthcare Business Monthly to read “Part 1: Know the limitations of EMRs and the importance of quality data collection.”


About the Authors:

Danielle Erickson, CPC, CCS, is a health information management educator with Optum360 with 15 years’ experience in auditing, education, and revenue management. She holds an Associate of Applied Science in Medical Billing and Coding from Northland College East Grand Forks, Minn. Erickson is a member of the Fargo, N.D., local chapter.

Litriana (Lee) Shimano, CPC, CMDP, CCP, PCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an educator with a 30-year background in the healthcare industry. She has had management roles in physician-based services in multiple settings, including private practice, academic health systems, and managed care companies. Shimano has extensive experience leading coding departments, development and delivery of coding education training for all audiences, quality audits for internal staff and external clients, workflow improvement, coding and billing support, and revenue cycle management. She is a member of the Loma Linda, Calif., local chapter.

2 Responses to “Overcome Gender Identity Barriers in Healthcare”

  1. Kelly Duty says:

    I’m interested in learning more about the legalities involved especially in regards with coding and billing

  2. Jaime Orlich says:

    Great information, thanks!

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