Coding for Gender-Affirming Health Care

By Susan Chapman, MA, MFA, PGYT for For The Record

Gender identity is how individuals perceive themselves, be it different or the same as the sex they were assigned when they were born.¹ Gender identity differs from gender expression in that the former refers to one’s psychological experience, or sense, of gender while the latter pertains to one’s gender presentation according to cultural standards like feminine and masculine dress. Gender identity also differs from sexual orientation in that sexual orientation indicates the type of individual to whom a person is attracted and not how one identifies.²

Typically, gender identity is categorized in three ways. A person is considered cisgender if they identify with the sex they were assigned at birth.³ A transgender individual is “a person whose sex assigned at birth … does not align their gender identity.”² Nonbinary refers to individuals who do not identify as either male or female, gender binary, or who may be fluid in their gender identification.⁴

Transgender and nonbinary people may choose to seek gender-affirming health care, which “consists of an array of services that may include medical, surgical, mental health, and nonmedical services.”⁵ Different states have different laws and guidelines pertaining to gender-affirming health care. Depending on the state, some Medicaid policies, like those of Washington and Indiana, require patients to be living in their gender and on hormone replacement therapy (HRT) for 12 or more months before becoming eligible for surgical options.

HRT and surgery are significant aspects of one’s gender-identity path. And, as rules for gender-affirming health care evolve, coding and documentation in those areas can present unique challenges. “Unfortunately, there can be obstacles even though something like a prescription for an injection of testosterone feels like it should be straightforward, but even with some of our more lenient states and payers that have really good policies, it can be incredibly tricky,” says Jessica Kelley, who previously served as the coding and documentation integrity manager for a nonprofit, multistate health care facility. “Fortunately, there are add-on modifiers to help bypass any payer issues related to gender-based denials.”

One example is modifier KX, which typically signals that even though a patient has met the allowed reimbursement threshold, the provider deems continued care necessary.⁶ It can be used in circumstances other than gender-affirming health care, too, for things like infusion pumps and bypassing mental health care reimbursement limits. “If I send a claim out for a patient with a gender identifier of ‘M’ for male, but I added a diagnosis code that has a gender identifier automatically added to it of ‘F’ for female, it’s going to be automatically denied. No one’s going to see it on the payer side since the system is going to immediately capture and deny it,” Kelley explains. “Modifier KX is supposed to be a kind of go-to modifier that we put on the claim and procedure. For instance, maybe it’s an injection, and KX lets the system know that there is a mismatch, which we did on purpose. The payer can process the claim as normal.”

Still, Kelley notes, modifier KX is not the complete solution, “It’s not quite that hero modifier everyone hoped it would be because it’s used for so many different things. Payers are still processing it in very different ways. In the Washington Medicaid system, this modifier directs the claim to a different fee schedule in their system. So, it doesn’t always immediately bypass those gender claim-edit rules.”

When a claim is denied, it places a burden on the patient, who often must help correct the denial. “The best case scenario is that the patient will never know about the initial denial. They may get an EOB [explanation of benefits] from their payer that lets them know something is denied, but from my point of view, the best case scenario is they will never hear from me at all or receive a bill or phone call,” Kelley states. “I will do anything and everything to find the policy for their payer and make any needed corrections based on the documentation and why they came in to make sure their claim is processed correctly.”

There is one area in which patients have to intervene and advocate for themselves. “Those situations primarily have to do with gender-mismatch denials,” Kelley shares. “A patient may update their information, like their gender identifier or identity, with the provider. The provider then updates the electronic health record [EHR]. But if the patient hasn’t updated the information appropriately with their insurance company, when we send that information out, we still may get denials that we can’t bypass. In those cases, the patient has to reach out to their insurance company to get their information updated. This is becoming more of a problem today and will in the future than it has in the past, unfortunately. We have laws being passed in certain states, like Tennessee and Florida, that keep people from updating their gender identity on their state ID cards or birth certificates. They can’t even list ‘X’ if they are nonbinary. If an insurance company requires that supportive documentation, patients in those states might not be able to provide any kind of proof or documentation to the payer that updates their gender identity. We then have an EHR that doesn’t match the information the insurance company has, and we can’t get anything covered.”

In some situations, individuals may be forced to come out to their employers if their insurance is through their jobs and the employer updates their insurance information. “Oftentimes, employers require documentation, and we’re back to that legal ID card or birth certificate that shows that individual’s mismatched gender,” Kelley continues. “In those instances, patients have to be involved and not in a small way. Instead, it can be a whole life-changing way that impacts every aspect of their environment as opposed to simply calling the insurance company and making a little change.”

Other issues that can arise in gender-affirming health care are in the documentation for procedures that might not be deemed medically necessary. “As someone is preparing for vaginoplasty [vaginal construction], hair removal may not be deemed medically necessary but cosmetic instead. Still, it’s required before the procedure can take place,” Kelley explains. “So, you’ve got a patient who’s paying out of pocket for a cosmetic procedure in order to get to their actual medical procedure.”

Kelley believes that the field of gender-affirming health care is changing so rapidly that for providers and health information professionals, it can feel like it’s impossible to keep pace. “The state laws are changing so quickly,” she says. “I recently checked on the transgender legislation tracker, and there are 485 active antitransgender bills being floated in our country. So many of these will affect health care, and I can’t even imagine what coding and documentation in this field will look like in a year or even two years because you just never know what will be allowed. We’ve got states who are passing laws asserting that adults and minors cannot receive gender-affirming HRT, and then those go to the courts a month later, which say adults can receive care but also need to see a mental-health practitioner. Then, with children, that has to go to court. It becomes a back-and-forth that happens every few months. And that is just one example. To help resolve this, providers are trying to be as creative as possible in terms of selecting diagnosis codes for procedures to ensure that the patient gets the health care that they need covered under their health insurance. But payers are also becoming more aware. It can be heartbreaking and frustrating. Still, we are doing everything we can because we know these patients are at high risk for mental health disorders like anxiety and depression, and it’s worth putting in the time and effort to figure out how best we can support them.”

— Susan Chapman, MA, MFA, PGYT, is a Los Angeles–based freelance writer and editor.

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign website. https://www.hrc.org/resources/sexual-orientation-and-gender-identity-terminology-and-definitions
2. What is gender dysphoria? American Psychiatric Association website. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
3. Transgender and nonbinary identities. Planned Parenthood website. https://www.plannedparenthood.org/learn/gender-identity/transgender
4. What it means to be non-binary. LGBT Foundation website. https://lgbt.foundation/help/what-it-means-to-be-non-binary/. Updated January 9, 2024.
5. Health & Human Services Office of Population Affairs. Gender-affirming care and young people. https://opa.hhs.gov/sites/default/files/2023-08/gender-affirming-care-young-people.pdf
6. Therapy and the KX modifier. Palmetto GBA website. https://www.palmettogba.com/palmetto/rr.nsf/DIDC/TRZEFX3G47~eServices%20Portal~
   Electronic%20Comparative%20Billing%20Report%20(eCBR). Published December 6, 2023.