Coding, Classification & Reimbursement

Gender Reassignment Surgery (Male to Female)

  • 1.  Gender Reassignment Surgery (Male to Female)

    Posted 07-12-2018 08:32

    Good morning! We have an interesting case that we would like to get your opinion on.


    We have a gender reassignment surgery (male to female) case that needs discussion. This is a male patient that is a female on his driver's license and with his insurance company. He came to our facility to have a scrotectomy, bilateral orchiectomy and a partial penectomy. He also had a vaginoplasty with a graft and a clitroplasty. The problem we are having is coding the penectomy. Since this patient is registered as a female and lists female on her driver's license, we are not able to assign the male to female procedure codes. We were wondering if anyone else has encountered this sort issue and if so, what did you do to work around it?


    Rachel L Pratt, RHIT, CDIP, CCS

    Inpatient Coding Supervisor


    Health Information

    525 East 100 South Suite 3810

    Salt Lake City, UT, 84102 | 810-721-0548 (office)| 810-223-1090 (cell)




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  • 2.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 07-13-2018 09:42
      |   view attached
    ​Hi Rachel-
    I attended a webinar back in April speaking about transgender issues and billing presented by Advize Health. I have attached it for everyone . Maybe you can find something in this presentation that would be helpful.


    Christina Donahue-Taylor
    Section Head-Coding


  • 3.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 07-13-2018 19:46
    Currently, I temporarily change the sex of the patient in the system and we then assign the codes. After the coding is completed I change the sex back to the original.  So far this has been working for us.

    Chrystel Barron
    Coding Education Instructor
    Cleveland Clinic Health System

  • 4.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 27 days ago
    Did you have any issues with audits because the sex was changed just to assign the codes, and then changed back?

    We have a patient who is transitioning from Female to Male. The patient identifies as a Male but still has female organs. Admitted for procedures on female organs. Epic is not allowing the procedures to be coded because patient is listed as Male in the system. ​ Is this how you were able to get around this (by changing the sex for coding and then changing it back)?

    Charlene Koroby RHIT, CCS
    Coding Supervisor

  • 5.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 07-14-2018 08:40

    There is very little Official Guidance on how to code these procedures.  I believe you are supposed to use the Root Operation Creation.

    From, "Creation procedures are captured in the general anatomical regions body system, Table 0W4. The body part values are M-Perineum, Male and N-Perineum, Female. These body part values pertain to the current gender of the patient. The qualifier identifies the body part that is created, either vagina or penis."  In this case it is the female body parts that are being created.

    I can find no official information on what all the Root Creation includes.  Does it include the resection of the original body parts?  I have never coded one of these cases.  I checked the 2016 AHIMA Trainer's Manual and it really does not provide complete details on how to code the cases other than a separate code should be assigned for the harvest of any material used for autografts.  I have always assumed Creation includes the removal of the original body parts.

    There should be detailed guidance provided in the PCS Official Guidelines for the Root Operation Creation.  I would imagine the proper gender value would be associated based on the above instructions and the edits conform accordingly.  In this case the correct gender should be male.  Without official guidance any other advice, including mine, is speculative.

    Lawrence Barr

  • 6.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 07-15-2018 13:58
    Edited by Judy Bielby 07-15-2018 14:02
    The third character of the ICD-10-PCS Medical and Surgical Section code defines the root operation, or objective of the procedure.  It appears as though you are not assigning the correct codes if you are assigning separate codes for various components of the procedure.  The objective of the procedure you described meets the ICD-10-PCS root operation Creation.  Components of a procedure would not be coded separately as per OCG B3.1b. If tissue is harvested from a different procedure site for graft then it would be coded separately in accordance with OCG B3.9.

    As noted in Chapter 25 Section 75.1 of the Medicare Claims Processing Manual, the patient's sex is recorded at admission, outpatient service, or start of care.1 Given the information that I find in regards to this procedure, it makes the most sense to me that the sex at birth would be reported in this field.  In the case you describe it would be Male.  In some cases it might be Undetermined.

    Contact the specific payer for billing advice. Also review the Official UB-04 Data Specifications Manual. For example, if applicable, it might be necessary to report Condition Code 45 for ambiguous gender.

    The following references might be of interest.  In two of the websites below, you will find that the terms sex and gender are not necessarily regarded as synonymous terms.


    1. Chapter 25 of Medicare Claims Processing Manual


    Judy Bielby
    Clinical Assistant Professor
    University of Kansas Medical Center

  • 7.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 07-16-2018 06:05
    I agree with Judy, gender undertermine is the direction I will go.This is a sensitive issue so accurate documentation and coding is key. 
    Great job Judy. Good question to think a out.
    Good morning. 

  • 8.  RE: Gender Reassignment Surgery (Male to Female)

    Posted 19 days ago

    I coded at a facility that performed "hermaphrodite surgery."  These patients are born with ambiguous genitalia.  A short time after birth, the parents decide if the infant is going to be raised as a male or female.  At the appropriate time, surgeons perform the procedures necessary to comply with the parents wishes.  The procedures performed are always contrary to the patients assigned gender.  Changing the gender value specifically for billing then back again after bill submission was the process used.

    Lawrence Barr