Hysterectomy for medical reasons on transgender patient

hoierj

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Hello,
A physician is ordering hysterectomy for medical reasons-bleeding and cramping-on a patient that is transgender female to male. He is keeping his ovaries, doesn't take hormones, and no longer takes testosterone as he is happy with his current state of masculinity. Do you report F64.0 even though the surgery is not being done to complete his reassignment? All of the above is documented in the office visit note; however the physician is upset because reporting F64.0 feels discriminatory. How do you handle this?
Thanks!
 

csperoni

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If you are not performing the hysterectomy due to transitioning, then I would not code F64.0 in that situation. For pro-fee, you only code the diagnoses you are treating, or that impact patient care. In this situation, it does not seem to be appropriate.
I will note depending on what status the insurance company has your patient as, you may get a denial. You may want to consider modifier -KX which Medicare specifically advised was to be used to override any gender related edits in transgender patients.
 

hoierj

Contributor
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If you are not performing the hysterectomy due to transitioning, then I would not code F64.0 in that situation. For pro-fee, you only code the diagnoses you are treating, or that impact patient care. In this situation, it does not seem to be appropriate.
I will note depending on what status the insurance company has your patient as, you may get a denial. You may want to consider modifier -KX which Medicare specifically advised was to be used to override any gender related edits in transgender patients.
Thank you.
 
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