Billing and Coding: Gender Reassignment Services for Gender Dysphoria

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of
Mental Disorders - Fifth Edition, DSM-5TM as a condition characterized by the
"distress that may accompany the incongruence between one's experienced or
expressed gender and one's assigned gender" also known as "natal gender",
which is the individual's sex determined at birth. Individuals with gender
dysphoria experience confusion in their biological gender during their
childhood, adolescence or adulthood. These individuals demonstrate clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.  
  
GD is characterized by the desire to have the anatomy of the other sex, and
the desire to be regarded by others as a member of the other sex. Individuals
with GD may develop social isolation, emotional distress, poor self-image,
depression and anxiety. The diagnosis of GD is not made if the individual has
a congruent physical intersex condition such as congenital adrenal
hyperplasia.  
  
**Gender Reassignment Therapy**  
  
GD cannot be treated by psychotherapy or through medical intervention alone.
Integrated therapeutic approaches are used to treat GD, including
psychological interventions and gender reassignment therapy. Gender
reassignment therapy, either as male-to-female transsexuals (transwomen) or as
female-to-male transsexuals (transmen), consists of medical and surgical
treatment that changes primary or secondary sex characteristics.  
  
Initially, the individual may go through the real-life experience in the
desired role, followed by cross-sex hormone therapy and gender reassignment
surgery to change the genitalia and other sex characteristics. The difference
between cross-sex hormone therapy and gender reassignment surgery is that the
surgery is considered an irreversible physical intervention.  
  
Gender reassignment surgical procedures are not without risk for
complications; therefore, individuals should undergo an extensive evaluation
to explore psychological, family, and social issues prior to and post-surgery.  
  
Additionally, certain surgeries may improve gender- appropriate appearance but
provide no significant improvement in physiological function. These surgeries
are considered cosmetic and are non-covered.  
  
 **NON-SURGICAL TREATMENT**  
  
Initiation of cross-sex hormone therapy may be provided after a psychosocial
assessment has been conducted and informed consent has been obtained by a
health professional.  
  
The criteria for cross sex hormone therapy are as follows:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Member must be at least 18 years of age;
  4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily
preclude access to cross-sex hormones. These concerns should be managed prior
to or concurrent with treatment of gender dysphoria.  
  
Cross-sex hormonal interventions are not without risk for complications,
including irreversible physical changes. Medical records should indicate that
an extensive evaluation was completed to explore psychological, family and
social issues prior to and post treatment. Providers should also document that
all information has been provided and understood regarding all aspects
associated with the use of cross-sex hormone therapy, including both benefits
and risks.  
  
 **READINESS FOR THE TREATMENT OF GENDER DYSPHORIA**  
  
Readiness criteria for gender reassignment surgery includes the individual
demonstrating progress in consolidating gender identity, and demonstrating
progress in dealing with work, family, and interpersonal issues resulting in
an improved state of mental health. In order to check the eligibility and
readiness criteria for gender reassignment surgery, it is important for the
individual to discuss the matter with a professional provider who is well-
versed in the relevant medical and psychological aspects of GD. The mental
health and medical professional providers responsible for the individual's
treatment should work together in making a decision about the use of cross-sex
hormones during the months before the gender reassignment surgery. Transsexual
individuals should regularly participate in psychotherapy in order to have
smooth transitions and adjustments to the new social and physical outcomes.  
  
**TRANS-SPECIFIC CANCER SCREENINGS**  
  
Professional organizations such as the American Cancer Society, American
College of Obstetricians and Gynecologists and the US Preventive Services Task
Force provide recommended cancer screening guidelines to facilitate clinical
decision-making by professional providers. Some cancer screening protocols are
sex/gender specific based on assumptions about the genitalia for a particular
gender. There is little data on cancer risk specifically in transsexual
individuals.  
  
There is difficulty in recommending sex/gender specific screenings (e.g.,
breast, cervix, ovaries, penis, prostate, testicles and uterus) for
transsexual individuals because of their physiologic changes. For example,
transmen who have not undergone a mastectomy have the same risks for breast
cancer as natal women. In transwomen, the prostate typically is not removed as
part of genital surgery, so individuals who do not take feminizing hormones
may be at the same risk for prostate cancer as natal men. Therefore, cancer
screenings (e.g., mammograms, prostate screenings) may be indicated based on
the individual's original gender.  
  
Gender specific screenings may be medically necessary for transgender persons
appropriate to their anatomy. Examples include:

  1. Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
  2. Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Claims for gender reassignment surgery will be reviewed on a case-by-case
basis. Surgical treatment of gender reassignment surgery for gender dysphoria
may be eligible when medical necessity and documentation requirements outlined
within this article are met.  
  
Surgical treatment for gender dysphoria may be considered medically necessary
when **ALL** of the following criteria are met:

  * The individual is at least 18 years of age.
  * A gender reassignment treatment plan is created specific to an individual beneficiary
  * The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 TM diagnosis of GD:

**  A.** __A marked incongruence between one 's experienced/expressed gender
and assigned gender, of at least 6 months duration, as manifested by at least
two of the following:  
__

  1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.   
  

  2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender.   
  

  3. A strong desire for the primary and/or secondary sex characteristics of the other gender.   
  

  4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).   
  

  5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).  
  

  6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).

**  B.** _The condition is associated with clinically significant distress or
impairment in social, occupational or other important areas of functioning._

  * One letter from a mental health professional that the patient has had, at minimum, twelve months of psychotherapy therapy sessions attesting to all of the following clinical criteria:   

    1. That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
    2. That the patient has had persistent and chronic gender dysphoria.
    3. That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.
  * The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
  * Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).
  * The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

**  SURGICAL TREATMENTS FOR GENDER REASSIGNMENT**  
  
When all of the above criteria are met for gender reassignment surgery, the
following genital surgeries may be considered for transwomen (male to female):

  * Orchiectomy - removal of testicles
  * Penectomy - removal of penis
  * Vaginoplasty - creation of vagina
  * Clitoroplasty - creation of clitoris
  * Labiaplasty - creation of labia
  * Mammaplasty - breast augmentation
  * Prostatectomy -removal of prostate
  * Urethroplasty - creation of urethra

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
  * Vaginectomy - removal of vagina
  * Vulvectomy - removal of vulva
  * Metoidioplasty - creation of micro-penis, using clitoris
  * Phalloplasty - creation of penis, with or without urethra
  * Urethroplasty - creation of urethra within the penis
  * Scrotoplasty - creation of scrotum
  * Testicular prostheses - implantation of artificial testes

Services or procedures may not be covered when the criteria and documentation
requirements outlined within this article are not met.

The determination of whether to cover gender reassignment surgery and related
care for a particular individual is based on whether the item or service is
reasonable and necessary to treat the beneficiary's medical condition after
considering the individual's specific circumstances. These decisions are made
after the individual has obtained the medical service and a claim has been
submitted by the Medicare provider.  
  
The individual's medical record must be submitted along with the claim and
support the services billed. These medical records may include but are not
limited to: records from the professional provider's office, hospital, nursing
home, home health agencies, therapies, and test reports.  
  
When reporting procedure code 55970 (Intersex surgery; male to female), the
following staged procedures to remove portions of the male genitalia and form
female external genitals are included:

  * The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
  * The urethral opening is moved to a position similar to that of a female.
  * A 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.
  * A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting CPT code 55980 (Intersex surgery; female to male), the
following staged procedures to form a penis and scrotum using pedicle flap
grafts and free skin grafts are included:

  * Portions of the clitoris are used, as well as the adjacent skin.
  * Prostheses are often placed in the penis to create a sexually functional organ.
  * Prosthetic testicles are implanted in the scrotum.
  * The vagina is closed or removed.