E/M level for gender affirming care

[maryek28@outlook.com]

Our clinic recently started doing gender affirming care. The diagnosis is gender dysphoria and usually a medication is prescribed or refilled. Is this considered a stable chronic illness? I'm having a lot of trouble figuring out how to code this. Any help would be appreciated.

 

[TThivierge]

Hello Maryek
Is your office medicine or beh health specialty? I assume gender affirming care is related to LGBT issues. Here are some codes licensed MD or therapist or QHP can use to aid the gender dysphoria affirming care. Patient Education see CPT 98960, Therapy in behavior health CPT 96156-96159, The CPT 99211 is for MD but QHP & RN staff too can use too. CPT 97166 needs of pt. Online email is CPT 99451-99421 but must get pt permission to send an email and telehealth Zoom video or phone calls can be used y MD, NP, PA (CPT 99441-99443) and LPC LCSW or psychologist therapist & QHP (CPT 98966-98968). Ensure providers add amount of minutes in documentation, add dx codes and describe pt problem for any telehealth or any treatments. MD and therapist can use CPT 90832-9087 can add modifier 95 to show type of telehealth. Also ensure put if this is done by phone or video at top of documentation plus all for established pt.

Here are some dx code may help besides adding their chronic conditions if connected to gender affirming care.... see dx blocks of F64, F32, F41, R45 (symptoms in note) or F60 .Here are some other Z dx codes to use on the claim in last place...Z70.9, Z90.79,Z79.810, Z60.0, Z63.9, Z60.2 Z51.81 Z76 or Z71.2
Well hope helped you some with treatment codes...check with your payer too. Good Luck
Lady T

 

[maryek28@outlook.com]

This is a medical clinic. The patients are seeing a nurse practitioner in-person for medication. We are billing these as office visits but it is unclear what level E/M they should be. We bill based on medical decision making, not time. It is not clear to me what type of condition this is. Is it considered a chronic illness? If so, what constitutes an exacerbation of this condition? When it is considered stable? What is the level of risk?

 

[amyjph]

I think this would go back to the E/M definitions and the documentation of the provider. If the patient is coming in for a medication refill and there are no other "complaints" and no changes or issues that would most likely be considered stable/chronic. You would have to look at the note for each individual encounter. Even if they are doing prescription drug management, if there is nothing else that meets one of the other two (problems or data) you are probably looking at level 3 or 2. We can't just look at this condition and assume every one is the same, it goes to the documentation. What constitutes exacerbation is if the provider documents that. Stable is what is documented as such. Try not to look at it by just the condition, look at the unique note for the patient.

See pg. 14-16 on this link. It always goes back to the definitions. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

 

[TThivierge]

Hi MaryE
Yes EVA& Mgnt codes would be used by the NP or telehealth video or phone if warranted & supported. However I d like to add gender-affirming care is a model of care which includes a spectrum of “social, psychological, behavioral or medical (including hormonal treatment or surgery after care) interventions designed to support and affirm an individual’s gender identity. Thus would involve endocrine, possible dx E07 E78 E03, anemia& vitamin levels dx E61 D64, E55 chronic conditions and injection or prescribing dx Z76 or checking levels of medications dx Z51. Other possible dx codes such as: R45. F32 F64 Insomnia G47, HIV dx B20 and STD dx Z11.3 A63 and coordinating lab test if required.
Well hope this helps a bit more
Lady T

 

[kmarceau]

Our office often levels codes GAC visits as lvl 4, but as everyone else mentioned, it's a little different for each patient and you need to be able to support it.

Usually our providers are prescribing medication (or adjusting the dosage), as well as ordering screening labs to verify that the patient is tolerating the prescribed hormones. If the provider orders 3 or more screening labs and does medication management, that would meet the requirements for a lvl 4 visit, regardless of how you classify the diagnosis of Gender Dysphoria in the problem level.

If the provider is not ordering labs, they may not meet the requirements for lvl 4, in which case we do code it as a lvl 3. Our office considers Gender Dysphoria as "stable chronic illness" (though we hate the language). If a patient is experiencing suicidal ideations, or preforming high risk behaviors because of their gender dysphoria, or any of the things that Lady T mentioned above, I have asked providers specifically notate those so that I can add them as additional diagnoses, and support the higher level office visits that way.

Hope that helps a bit more as well. Thank you for providing GAC!
-KM