Coding for the Transgender Process Services 

I have a physician who is starting treatment for the transgender process on a patient. She came in to discuss the process and received a prescription for testosterone. How can I code it correctly?

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.”

Medicare

Per the CMS Transmittal, condition code 45, Ambiguous Gender Category, needs to be reported on Part A Medicare claims to identify transgender- or hermaphrodite-related cases. The presence of this condition code on your claim will allow sex-related edits to be bypassed so your claim can be processed like other regular Medicare claims.

Meanwhile, modifier KX, Requirements specified in the medical policy have been met, should be appended to any gender-specific procedure code reported on Part B Medicare claims. This modifier informs Medicare that the procedure is performed on a beneficiary for whom gender-specific editing may apply, but that Medicare should allow the edit to be overridden.

Commercial Payers

Please note that commercial payers may or may not follow Medicare guidelines. It’s advisable to check with your payers first on their specific policy on services furnished to transgender patients. Coding will depend on what services are provided, and it is best practice to obtain from your payers their definitive list of covered and noncovered services.

Whatever your patient’s insurance may be, you would use the gender marker indicated in their insurance record when preparing your claim for submission.