Posted and filed under Coding, Payers.

Earlier this week, Advize Health partnered with Grassi Healthcare Advisors to host a webinar on transgender healthcare. This webinar sought out to educate the healthcare community not only on coding for transgender patients, but on every aspect of care for this critically underserved population, from claims denials to the cost of transitioning. The convergence of Grassi and Advize Health’s experience with transgender patients and transgender coding/billing resulted in an in-depth, enlightening, and engaging session. Through the analysis of a medical record audit, multiple conversations with experienced clients, and a dash of research – we learned about the needs of the community. Now, we’d like to share some of our insights with those who may have missed the broadcast.

In 2017, 33% of surveyed trans people reported that physicians and other care providers refused to see them because of their gender identity. This statistic is staggering, though not surprising when you consider that 25% of transgender patients avoid receiving healthcare out of fear of mistreatment or misconduct. The data on the treatment of non-Caucasian trans people is even more disheartening.  During the course of the presentation, both Advize and Grassi were determined to highlight the co-morbidities of such discrimination. The correlation between lack of social acceptance and support systems often results in poverty, homelessness, and can exacerbate the presence of behavioral health concerns such as depression and anxiety.The

The Affordable Care Act prohibits most health insurers from discriminating based on gender identity and transgender status. Even with the ACA’s policies, just 17 states have legal protections for transgender patients.

Taking into consideration these factors, plus the cost of transitioning, from surgeries to hormone replacement – it’s clear that healthcare for transgender patients can be quite rigorous for patients and their providers. Every single procedure or office visit requires clinical documentation, and this is where the administrative side of healthcare struggles. Insurers each have different guidelines and policies on how to document care for transgender patients, and failure to comply with their rules could result in denials. Appeals are possible, but considering the hundreds of thousands of Medicare appeal that are waiting in the queue, this can be an arduous process on its own. In order to prevent problems with reimbursement, it is imperative to understand what to bill or what to code for transgender patients. And perhaps what’s even more important to understand is exactly which services are covered by insurance.

Covered Services

  • It’s illegal for an insurance company to deny coverage for treatments typically associated with one gender based on the gender listed in the insurance company’s records or the sex you were assigned at birth.
    • Ex. An insurance company can’t deny a transgender woman coverage for a prostate exam because she is listed as female in her records or coverage for gynecological care because her sex assigned at birth was male.
  • In general all medical necessary services for gender reassignment surgery should be covered:
    • genital surgery,
    • “top” surgery (female-to-male) & “lower” surgery (male to female)
    • body sculpting, and
    • facial feminization surgery. This is a procedure that previously was not covered because payers considered it to be “cosmetic” can now be covered if it treats gender dysphoria.

Non-Covered Services

  • Cryopreservation, storage of reproductive tissue
  • Post reassignment
    • Reversal of genital or breast surgery
    • Reversal of sterilization services
  • Cosmetic Services
    • Abdominoplasty
    • Breast augmentation- unless 24 months of HRT had negligible growth
    • Face, brow, and forehead lifts
    • Collagen injections
    • Drugs to promote hair growth or loss
    • Electrolysis unless required for vaginoplasty or phalloplasty
    • Hair transplant, lip reduction
    • Liposuction, thyroid chondroplasy, and voice therapy