Nearly 2 million Americans identify as transgender, meaning their gender identity is different from what they were assigned at birth. If your practice sees a transgender patient — even if the visit isn’t related to gender transition services — you may need to know which diagnosis codes apply to the visit, and that’s not always easy.
Take a look at four tips that can help you properly bill your claims every time you see a transgender patient.
1. Start With the F64 Category
Although the diagnosis codes may not line up perfectly with your patient’s specific situation, your best bet in most cases is to start with the F64 category in ICD-10-CM, which describes Gender Identity Disorders. Check out the following codes to get a feel for your options:
• F64.0 — Transsexualism. This code describes gender dysphoria, gender identity disorder, transgender, and gender incongruence in adolescents and adults.
• F64.1 — Dual role transvestism. You’ll use this code when the patient cross-dresses but does not identify as the other gender. This is not typically considered a code for transgender patients since the gender identity of patients with transvestism will usually match what they were assigned at birth.
• F64.2 — Gender identity disorder of childhood. This code is used when pediatric patients are experiencing gender dysphoria or gender incongruence. It typically applies to patients under the age of 18.
• F64.8 — Other gender identity disorders. Many providers select this code for all transgender patients because they’re unsure of when to report a more specific code. The problem with doing this is that if you aren’t coding to the highest level of specificity, you could have to return any reimbursement if you’re audited. Therefore, you should save this code for when your patient’s situation truly doesn’t fit into one of the categories above.
• F64.9 — Gender identity disorder, unspecified. If the provider did not document which gender identity disorder the patient had and you cannot query them after the fact, you can turn to this unspecified code.
2. Use “Z” Codes When Warranted
In some instances, you may need a code from the Factors Influencing Health Status and Contact With Health Services section of ICD-10-CM. These codes range from Z00 to Z99, and typically provide a reason for the encounter or offer more information about why the patient presented.
There are hundreds of 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.
• Z79.890 — Other long term (current) drug therapy, hormone replacement therapy. This code may be helpful to describe the status of a patient who has been on hormone replacement therapy (HRT) for a long period of time, and depends on the specific medication used, as not all drugs qualify as HRT.
• Z79.899 — Other long term (current) drug therapy. If the patient has been on a particular medication for a long period of time but it doesn’t fit into one of the other categories, such as HRT, you’ll report Z79.899.
3. Get to Know KX Modifier, Condition Code 45
Depending on your payer, even the above ICD-10-CM codes may not help you collect for your claim if the insurer has gender-specific edits in place. Therefore, some payers (including Medicare) may want you to apply condition code 45 (Ambiguous Gender Category) to your claim if you want to collect for services that are traditionally performed on patients of a certain gender, but that gender doesn’t match what’s on your patient’s file.
Medicare and many other insurers may also require you to append modifier KX (Requirements specified in the medical policy have been met) to gender-specific procedure codes. It tells the payer that you realize you’re performing a procedure that doesn’t match the patient’s reported gender, but that you’re asking the insurer to pay it anyway due to extenuating circumstances.
For instance, you may need to use this condition code and modifier if a patient who is listed as male receives a hysterectomy.
4. Check Insurance Coverage Ahead of Time
Payment for transgender patient services is a constantly evolving situation, so always check with your payers ahead of time to evaluate what’s covered and what isn’t. Some payers will reimburse certain surgeries (for instance, a mastectomy) but will deny others (like facial feminization surgery), and you won’t know until you get all the policies in writing directly from the payer.
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