Local Coverage Article Billing and Coding

Billing and Coding: Gender Reassignment Services for Gender Dysphoria

A53793

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Article ID
A53793
Article Title
Billing and Coding: Gender Reassignment Services for Gender Dysphoria
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
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Article Guidance

Article Text

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ 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 ™ 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.

Services that are considered cosmetic for the treatment of gender dysphoria are not covered.

This list is not all-inclusive:

  • Liposuction: removal of fat
  • Rhinoplasty: reshaping of nose
  • Rhytidectomy: face lift
  • Blepharoplasty: removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat
  • Hair removal/ hair transplantation
  • Facial feminizing (e.g., facial bone reduction)
  • Chin augmentation: reshaping or enhancing the size of the chin
  • Collagen injections
  • Lip reduction/enhancement: decreasing/enlarging lip size
  • Cricothyroid approximation: voice modification that raises the vocal pitch by simulating contractions of the cricothyroid muscle with sutures
  • Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage
  • Laryngoplasty: reshaping of laryngeal framework (voice modification surgery)
  • Mastopexy: breast lift

For a list of additional services that are considered cosmetic and therefore, non-covered, please refer to LCD L33428-Cosmetic and Reconstructive Surgery.

Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt [i.e., as soon as medically feasible] repair of accidental injury or for the improvement of the functioning of a malformed body member.

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.

Coding Information

CPT/HCPCS Codes

Group 1

(14 Codes)
Group 1 Paragraph

Transwoman procedures (male to female)

*NOTE:For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services.

The following CPT® codes will be considered when applicable criteria have been met:

Group 1 Codes
CodeDescription
19325 BREAST AUGMENTATION WITH IMPLANT
54125 AMPUTATION OF PENIS; COMPLETE
54520 ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH
54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY
55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED
55970 INTERSEX SURGERY; MALE TO FEMALE
56800 PLASTIC REPAIR OF INTROITUS
56805 CLITOROPLASTY FOR INTERSEX STATE
57291 CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT
57292 CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT
57295 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH
57296 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN ABDOMINAL APPROACH
57335 VAGINOPLASTY FOR INTERSEX STATE
57426 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, LAPAROSCOPIC APPROACH

Group 2

(31 Codes)
Group 2 Paragraph

Transman procedures (female to male)

*NOTE:For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services.

The following CPT® codes will be considered when applicable criteria have been met:

Group 2 Codes
CodeDescription
19303 MASTECTOMY, SIMPLE, COMPLETE
53420 URETHROPLASTY, 2-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE
53425 URETHROPLASTY, 2-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; SECOND STAGE
53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA
54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE)
55175 SCROTOPLASTY; SIMPLE
55180 SCROTOPLASTY; COMPLICATED
55980 INTERSEX SURGERY; FEMALE TO MALE
56625 VULVECTOMY SIMPLE; COMPLETE
57106 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;
57110 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;
58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);
58180 SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)
58260 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
58262 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)
58275 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY;
58290 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58541 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
58542 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58543 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
58544 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58550 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
58552 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58570 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;
58571 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58572 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;
58573 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)
58720 SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)

Group 3

(50 Codes)
Group 3 Paragraph

All unlisted procedure codes will suspend for medical review.

The following CPT® codes are considered cosmetic. When billed with any Covered ICD-10 Codes listed below, the service will not be covered (list may not be all-inclusive):

Group 3 Codes
CodeDescription
11950 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1 CC OR LESS
11951 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1.1 TO 5.0 CC
11952 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 5.1 TO 10.0 CC
11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); OVER 10.0 CC
15769 GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
15771 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE
15772 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 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 TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; 25 CC OR LESS INJECTATE
15774 GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 25 CC INJECTATE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15775 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS
15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS
15820 BLEPHAROPLASTY, LOWER EYELID;
15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD
15822 BLEPHAROPLASTY, UPPER EYELID;
15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
15824 RHYTIDECTOMY; FOREHEAD
15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, P-FLAP)
15826 RHYTIDECTOMY; GLABELLAR FROWN LINES
15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK
15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP
15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY
15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH
15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG
15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP
15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK
15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM
15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); FOREARM OR HAND
15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); SUBMENTAL FAT PAD
15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA
15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK
15877 SUCTION ASSISTED LIPECTOMY; TRUNK
15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY
15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY
17380 ELECTROLYSIS EPILATION, EACH 30 MINUTES
19316 MASTOPEXY
19350 NIPPLE/AREOLA RECONSTRUCTION
21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL)
21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE
21122 GENIOPLASTY; SLIDING OSTEOTOMIES, 2 OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN)
21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)
21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL
21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT)
21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT)
21209 OSTEOPLASTY, FACIAL BONES; REDUCTION
30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP
30410 RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP
30420 RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR
30430 RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK)
30435 RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES)
30450 RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(5 Codes)
Group 1 Paragraph

The following diagnosis codes are considered covered when applicable criteria have been met:

Group 1 Codes
CodeDescription
F64.1 Dual role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
Z87.890 Personal history of sex reassignment

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All other diagnosis codes will be denied as non-covered.

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2021 R13

Under CPT/HCPCS Codes Group 1: Codes descriptor was revised for 19325. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

01/01/2020 R12

Under CPT/HCPCS Codes Group 2: Codes CPT® code 19304 was deleted. CPT® was inserted throughout the article where applicable. Under CPT/HCPCS Codes Group 3: Codes added 15769, 15771, 15772, 15773 and 15774. This revision is due to the 2020 Annual CPT/HCPCS Code Update and is effective on January 1, 2020.

10/03/2019 R11

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

11/15/2018 R10

Under Article Text added the verbiage “be submitted along with the claim and” after the verbiage “The individual’s medical record must” in the third paragraph from the bottom of the section.

02/26/2018 R9 The Jurisdiction "J" Part A and Part B Contracts for Alabama (10111/10112), Georgia (10211/10212) and Tennessee (10311/10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these 6 contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 6 Part A and B contract numbers) have been completed in this revision.
04/27/2017 R8 Under Article Text – Grammatical and punctuation changes were made throughout text. Revised sentence under B. to read “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:”
10/01/2016 R7 Under Covered ICD-10 Codes the description was revised for ICD-10 code F64.1. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.
10/01/2015 R6 Under CPT/HCPCS Codes-Group 3 Paragraph the bolded verbiage was removed for the Group 3 CPT codes.
10/01/2015 R5 Under Article Text in the first sentence of the first paragraph corrected “DSM-V-TR, 2013” to now read “Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 ™. Under Non-Surgical Treatment, deleted “also” found in the third sentence of the last paragraph as this was redundant. Under Trans-Specific Cancer Screenings in the third bullet of the fifth paragraph corrected “DSM-IV-TR” to now read “Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 ™. Under Surgical Treatments for Gender Reassignment corrected the title of the specific LCD cited in the sixth paragraph. Under CPT/HCPCS Codes-Group 1 Paragraph revised the verbiage in the *Note and deleted the following, “See Article Text for included surgeries.” Under CPT/HCPCS Codes-Group 2 Paragraph added the *Note. Under CPT/HCPCS Codes-Group 3 Paragraph the verbiage was revised in the second sentence. Under Covered ICD-10 Codes Paragraph added the first sentence. Under Non-Covered ICD-10 Codes corrected the spelling of “diagnosis.”
06/11/2015 R4 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed from the LCDs. For consistency, they are also being removed from the articles.
10/01/2015 R3 Under Covered ICD-10 codes added ICD-10 codes F64.2, F64.8, F64.9 and Z87.890 per TDL-150320. Under Associated Documents, subheading Statutory Requirements URL(s) added Title XVIII of the Social Security Act §1862(a)(1)(A).
10/01/2015 R2 Under Article Text deleted the following statement and replaced it with the definition of cosmetic surgery as defined by manual instruction: "Cosmetic services may improve an individual's physical appearance but provide no significant improvement in physiologic function. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function."
10/01/2015 R1 Under CPT/HCPCS Codes added the NOTE. Under Covered ICD-10 Codes deleted the paragraph related to Z87.890 and deleted ICD-10 code Z87.890 as this code was redundant with F64.1.

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Updated On Effective Dates Status
02/03/2021 01/01/2021 - N/A Currently in Effect You are here
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Keywords

  • Gender Reassignment
  • Gender Dysphoria