Reports have circulated in the news lately about the Department of Health and Human Resources (HHS) banning the CDC (Centers for Disease Control and Prevention) from using certain words. Transgender is one of those words. Although there has been a lot of talk and speculation as to what this all means, Dr. Brenda Fitzgerald, Director of CDC, disputed this report as a "mischaracterization" and further stated, "HHS will continue to use the best scientific evidence available to improve the health of all Americans." What we know, for now, is that transgender is still very much a part of our healthcare vocabulary.   

Gender Dysphoria (formerly known as gender identity disorder) and transgender are terms used to describe a strong, persistent feeling of discomfort in a person whose expressed gender conflicts with the gender assigned at birth. For instance, a person with the anatomy of a male may actually feel like a female. Likewise, a person with the anatomy of a female may feel like a male. This can lead a person to desire a body of the opposite gender and to be accepted by those of that gender. This feeling of gender mismatch can cause major distress, anxiety, and depression, which can affect a person's everyday life. 

According to the National Institutes of Health, it has often been difficult to determine the number of transgender individuals living in the U.S. due to social stigma, discrimination, harassment, and physical and sexual abuse. However, CDC's Behavioral Risk Factor Surveillance System (BRFSS) conducted a U.S. study in January 2017 and concluded that about 150,000 youth, ages 13 to 17, identify as transgender, and about 1.4 million adults, 18 and older, identify as transgender.  

What Gender Dysphoria Is Not
According to the American Psychiatric Association (APA) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender dysphoria is not considered a mental illness, which is why it is no longer called gender identity disorder. Many individuals consider the former term offensive. 

Transsexualism, a severe form of gender dysphoria, is also an outdated term. 

Gender dysphoria is not homosexuality. A person's sense of gender is different than their sexual orientation. 

Gender dysphoria is not transvestitism, which refers to cross dressing.  

Etiology
The cause is unknown, but it is suspected that hormones in the womb play a part.
 
Symptoms and Diagnosis
Symptoms present differently in children than in adults; therefore, the diagnostic criteria for gender dysphoria is different for each.  

A child may be diagnosed with gender dysphoria when the condition is experienced for at least 6 months and displays in two or more of the following: 

Teens and Adults
A teen or adult may be diagnosed with gender dysphoria when the condition is experienced for at least 6 months and displays in two or more of the following: 

ICD-10-CM Diagnosis Codes
Once the above criteria are met, codes from F64.0-F64.9 may be used to describe the type of gender dysphoria diagnosed. 

There is also a status code for personal history of sex reassignment (Z87.890).

Note that ICD-10 still uses the outdated terms of gender identity disorder and transsexualism. However, changes are coming for ICD-11, and the five diagnoses codes will be replaced by two gender incongruence codes. One code will be for adolescents and adults, and one code will be for children. These codes will be found in a new chapter called "Conditions Related to Sexual Health" rather than in Chapter 5 (“Mental, Behavioral, and Neurodevelopmental Disorders”) where they currently reside. 

Undiagnosed or Untreated Gender Dysphoria
Approximately 71 percent of individuals who go undiagnosed or untreated for gender dysphoria will be diagnosed with conditions such as mood disorder, anxiety disorder, schizophrenia, depression, substance abuse, eating disorder, or suicide attempt.

Treatment
The goal of treatment is to help individuals with gender dysphoria come to terms with others' reactions to them. It is not to change how the person feels about his or her gender. Talk therapy can help; and medications, such as puberty blockers and hormones, can change the appearance. Gender reassignment surgery is also a goal for many who wish to change their appearance. After transitioning, a person may no longer feel dysphoria, but may still need therapy to deal with others' lack of understanding. 

Once a person provides the required documentation, gender reassignment surgery can be performed. The individual may choose to under undergo breast surgery, genital surgery, or a combination of the two. The decision is based on what is best for the patient.  

Breast Surgery Documentation Requirements
This may consist of all or some of the following procedures: hysterectomy, ovariectomy, orchiectomy, or salpingo-oophorectomy. Sex reassignment surgery is medically necessary when all of the following criteria are met:

- Gender dysphoria that is ongoing and well documented

- Ability to make a fully informed decision and able to consent to treatment

- Is at least 18 years old

- Has any notable medical or mental health issues under reasonable control

Genital Surgery Documentation Requirements
This may consist of all or some of the following procedures: metoidioplasty, phalloplasty, penectomy, vaginoplasty, labiaplasty, clitoroplasty, vaginectomy, urethroplasty, scrotoplasty, or placement of testicular prostheses. Sex reassignment surgery is medically necessary when all of the following criteria are met:

CPT Coding for Gender Reassignment Surgery
Once the criteria have been met, the following gender reassignment surgical procedures are typically considered medically necessary and covered as a proven benefit:

55970 - (Intersex surgery; male to female) involves the following staged procedures to remove portions of the male genitalia and form female external genitals: 

55980 - (Intersex surgery; female to male) involves the following staged procedures to form a penis and scrotum using pedicle flaps and free-skin grafts: 

• Portions of the clitoris and adjacent skin are used. 
• Prostheses are often placed in the penis to make a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum. 
• Vagina is closed or removed.
  

The CPT codes listed below are for informational purposes only and may not be covered depending on the individual's policy. It is not an all-inclusive list. Once you understand the coverage limitations, the patient can make a decision as to which procedure he/she may want performed, and the provider can get the proper reimbursement based on the services provided. 

Transwoman procedures (Male to Female)
19325 - Mammaplasty, augmentation; with prosthetic implant
54125 - Amputation of penis; complete
54520 - Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54690 - Laparoscopy, surgical; orchiectomy
56805 - Clitoroplasty for intersex state
57291 - Construction of artificial vagina; without graft
57292 - Construction of artificial vagina; with graft
57335 - Vaginoplasty for intersex state

Transman procedures (Female to Male)
19303 - Mastectomy, simple, complete
53430 - Urethroplasty, reconstruction of female urethra
54660 - Insertion of testicular prosthesis (separate procedure)
55180 - Scrotoplasty; complicated
56625 - Vulvectomy simple; complete
57110 - Vaginectomy, complete removal of vaginal wall
58150 - Total abdominal hysterectomy (corpus and cervix), with or without removal of tubes(s), with or without removal of ovary(s)
58552 - Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
58570 - Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less;
58571 - Laparoscopy, surgical, with total hysterectomy, for uterus 250g or less; with removal of tube(s) and/or ovary(s)
58720 - Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

Cosmetic Services
Services that are routinely excluded from coverage and considered cosmetic for the treatment of gender dysphoria may include the following:

Again, the individual's policy will need to be reviewed to determine which treatments are considered cosmetic and consequently not covered. 

Data Collection and Screenings
Gender identity data should be collected on an ongoing basis, which includes both current gender identification and the gender assigned at birth. The gender marker (male or female) should be recorded in the medical record based on the patient's insurance policy, and staff should be trained on the best way to collect gender identification. This information is needed so the provider can perform preventive screenings based on the patient's physical characteristics. For example, a female who expresses as a man may not have chosen to undergo a mastectomy. This would mean that the individual has the same risks for breast cancer as any other natal woman. Another example would be that of a transwoman who retained the prostate. If hormones have not been taken, a prostate cancer screening may be medically necessary since the individual would be at risk the same as any other natal man. 

Billing
If a transgender patient is seen for services unrelated to gender, the carrier should be consulted as to whether the transgender ICD-10 code should be used on the claim. In many cases, the F64.x code should be used as a secondary code on claims for unrelated services.  

Medicare and most insurance carriers require that all Part A claims for transgender inpatient and outpatient services include condition code 45 (Ambiguous Gender Category) in order to avoid being denied. This condition code is to be used by providers to let the fiscal intermediary know that the gender/procedure or gender/diagnosis conflict is not a mistake and that the sex-related edit should be ignored.  

Modifier KX should be used for Part B professional claims to identify services for transgender patients. This modifier should be appended to the procedure code(s) that is gender specific for transgender patients. That way if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier will alert the carrier that it is not an error and the claim can go through with normal processing. 

Conclusion
In summary, individuals with gender dysphoria deserve the same unbiased healthcare as any other individual. They do not choose to have this long-term feeling of body and gender mismatch. It is a burden that requires professional and social support. Gender reassignment surgery is only part of the process to achieve positive behavioral and medical outcomes. It is important to review each policy for coverage and limitations, to get prior authorization, and to ensure that medical documentation supports the services billed. 

Debbie Jones, CPC, CCA, is an Administrative Specialist at CertificationCoachingOrg (cco.us). She can be contacted at debbie.jones0730@gmail.com.