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Gender Dysphoria and Gender Reassignment Procedures
- Consistently stating he is really a girl when he has the physical characteristics of a boy or that she is really a boy with the physical characteristics of a girl
- Strong preference for friends of the same sex that he/she identifies with
- Having an aversion to clothes, toys, and games typical for boys or girls
- Refusing to urinate in the position that other boys or girls do
- Stating he/she wants the genitals of the other sex instead of the genitals that he/she has
- Believing he/she will grow up to be a person of the sex he/she identifies with even though currently he/she has the physical characteristics of the other gender
- Experiencing substantial distress about the changes his/her body goes through during puberty
- Believing that his/her gender is not in line with his/her body
- Loathing of his/her genitals, which may cause an avoidance to taking showers, changing clothes, or having intercourse so that he/she won't have to look at or touch his/her genitals
- Extreme desire to have the genitals gone
- F64.0 - Gender dysphoria in adolescents and adults
- F64.1 - Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery)
- F64.2 - Gender dysphoria in children
- F64.8 - Other specified gender dysphoria
- F64.9 - Gender dysphoria, unspecified
- Written psychological assessment from one or more qualified behavioral health providers experienced in gender dysphoria treatment who has assessed the patient and documented all of the following:
- The same requirements as listed above for breast surgery
- Completed 12 months or more of successful, ongoing full-time, real-life experience in the desired gender
- Completed 12 months of ongoing cross-sex hormone therapy appropriate for the desired gender, unless medically contraindicated
- Treatment plan, including ongoing followup and care by a qualified behavioral health provider experienced in treating gender dysphoria
- Penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
- Urethral opening is moved to a position similar to that of a female.
- Vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split-thickness grafts.
- Labia are created out of skin from the scrotum and adjacent tissue.
- Stent or obturator is usually left in place in the newly created vagina for three weeks or longer.
- 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.
- Liposuction (fat removal)
- Rhinoplasty (nose reshaping)
- Rhytidectomy (face lift)
- Blepharoplasty (removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat)
- Hair removal or hair transplantation
- Facial feminizing (such as facial bone reduction)
- Chin augmentation (chin reshaping or chin enhancing)
- Collagen injections
- Lip reduction/enhancement (lip size decrease or enlargement)
- Cricothyroid approximation (voice modification)
- Trachea shave/reduction thyroid chondroplasty (thyroid cartilage reduction)
- Laryngoplasty (laryngeal reshaping framework - voice modification surgery)
- Mastopexy (breast lift)
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Coding Update: Breast Augmentation and Removal for Gender Affirming Surgery
April 29, 2022
The American Medical Association (AMA) recently updated their guidance for the correct Current Procedural Terminology (CPT ® ) codes to use when filing claims for breast removal and breast augmentation as part of gender reassignment surgeries. Blue Cross and Blue Shield of Illinois (BCBSIL) has updated its system to align with AMA and American Academy of Professional Coders (AAPC) billing guidance, as summarized below.
What’s New For gender affirming breast reduction and/or removal for transgender male and non-binary members, the AMA and AAPC guidance is to use CPT code 19318 for breast reduction/reduction mammaplasty. Claims for gender affirming breast reduction and/or removal for transgender male and non-binary members should not be coded with 19303 for complete mastectomy +19350 for nipple/areola reconstruction.
Background The AMA recommends the use of CPT code 19303 for the treatment or prevention of breast cancer . It recommends CPT code 19318 for reduction mammaplasty when breast tissue is removed for breast-size reduction and not for treatment or prevention of breast cancer .
The AAPC does not recommend the use of CPT code 19350 for nipple reconstruction in transmasculine gender reassignment . AAPC advises that CPT code 19318 may be used to reflect reshaping of the nipple for cosmetic purposes.
BCBSIL Resources Refer to BCBSIL Medical Policy SUR717.001 - Gender Assignment Surgery and Gender Reassignment Surgery with Related Services for more information. Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual .
CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.
COMMENTS
When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male): Breast reconstruction (e.g., mastectomy) - removal of breast. Hysterectomy - removal of uterus. Salpingo-oophorectomy - removal of fallopian tubes and ovaries.
Use code Z87.890 Personal history of sex reassignment for sex reassignment surgery (SRS) status. Procedural Coding. 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
GENDER REASSIGNMENT SURGERY MODEL NCD I. Indications, Limitations of Coverage and/or Medical Necessity 1 II. Documentation Requirements 4 III. Providers of Gender Reassignment Surgery 5 IV. Common CPT Codes 5 V. ICD-9 and ICD-10 Codes 8 VI. References 9 Written by Transgender Medicine Model NCD Working Group.
Gender Reassignment Surgery (GRS) may be MEDICALLY NECESSARY when ALL of the following candidate criteria are met and supporting provider documentation is provided: The candidate is at least 18 years of age, AND. The candidate has been diagnosed with gender dysphoria (ICD-9 Code 302.85 gender identity disorder), including meeting ALL of the ...
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. F64.0 - Gender dysphoria in adolescents and adults. F64.1 - Dual role transvestitism (not enough gender dysphoria to show interest in gender reassignment surgery)
Gender reassignment surgery is a general term to describe a surgery or surgeries that affirm a person's gender identity. CMS National Coverage Determinations (NCDs) ... each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) 15773 Grafting of autologous fat harvested by liposuction technique ...
There are various Z codes that providers may use, but the following codes may apply to visits with a transgender patient, depending on the patient's situation: Z87.890 (Personal history of sex reassignment). You'll use this code to describe patients who have undergone sex reassignment surgical procedures in the past.
April 29, 2022. The American Medical Association (AMA) recently updated their guidance for the correct Current Procedural Terminology (CPT ®) codes to use when filing claims for breast removal and breast augmentation as part of gender reassignment surgeries.Blue Cross and Blue Shield of Illinois (BCBSIL) has updated its system to align with AMA and American Academy of Professional Coders ...
Answer. You might consider using diagnosis code F64.0, Transsexualism, in addition to an appropriately leveled Evaluation and Management (E/M) code. Please note that per ICD-10-CM inclusive notes for F64.0, code F64.0 covers both "gender identity disorder in adolescence and adulthood" and "gender dysphoria in adolescents and adults.".
In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862 (a) (1) (A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis. (This policy last reviewed August 2016.)