Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire policy or relevant Local Coverage Determinations) as if they are covered. When billing Medicare for services that are statutorily non-covered, such as Gender Reassignment Surgery when specific criteria are not met or a national coverage determination does not apply, the GY modifier (Item or service statutorily excluded, or does not meet the definition of a Medicare benefit) should be appended to the service code. For services voluntarily elected by the beneficiary that are not covered, the GX modifier (Notice of liability issued, voluntary) or GA modifier (Waiver of liability on file) may be appropriate if an Advance Beneficiary Notice (ABN) was signed. Proper modifier usage is crucial for billing compliance and to avoid claims denials for transgender healthcare coverage.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Indications and Limitations of Coverage: Gender Reassignment Surgery

Understanding Gender Dysphoria: Diagnosis and Medical Necessity

Gender Identity Disorder (GID) was an earlier diagnostic term now largely replaced by “gender dysphoria” in clinical practice, particularly within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Gender dysphoria describes the significant distress an individual experiences due to a marked incongruence between their experienced or expressed gender and their assigned gender at birth. It is crucial to understand that while it has a psychiatric classification, gender dysphoria is not classified as a mental illness. Instead, it is recognized as a complex medical condition with significant implications for an individual’s psychological well-being and overall health, necessitating medical and surgical interventions for some. The medical necessity for gender-affirming care, including Medicare gender affirmation surgery, is rooted in alleviating this distress and improving the individual’s quality of life and functional outcomes. This understanding is key when considering CMS guidelines for gender-affirming care and transgender healthcare coverage.

Diagnostic Criteria for Gender Dysphoria (DSM-5)

In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) are met. The criteria include:

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
   • A marked incongruence between one’s experienced/expressed gender and primary and/or sex characteristics; OR
   • 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; OR
   • A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
   • A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR
   • A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR
   • 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; AND
2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Pre-Surgical Requirements and the Gender-Affirming Care Pathway

Gender Reassignment Surgery (GRS), often referred to as gender affirmation surgery, is a significant component of a comprehensive, multidisciplinary treatment approach for gender dysphoria. It is not a standalone procedure but a complex process that demands careful coordination among various medical, psychiatric, and surgical specialists. The overarching goal is to achieve optimal psychological, behavioral, functional, and medical outcomes for the individual. Prior to GRS, candidates typically undergo important medical and psychological evaluations and often engage in a period of medical therapies and real-life experience to confirm that surgery is the appropriate and medically necessary treatment choice. These prerequisites, often based on professional standards like those from the World Professional Association for Transgender Health (WPATH), are crucial for transgender healthcare coverage and include:

• Comprehensive Psychological Evaluation: Assessments by mental health professionals specializing in gender identity to confirm the diagnosis of gender dysphoria, evaluate mental health stability, and assess readiness for surgery.
• Hormone Therapy: A period of continuous hormone therapy (e.g., 6-12 months) under medical supervision, unless medically contraindicated. This helps to achieve physical changes that align with the affirmed gender and is often a prerequisite for surgical eligibility.
• Real-Life Experience (RLE): A period of living in a gender role congruent with the affirmed gender (e.g., 12 months), allowing individuals to experience and adjust to their affirmed gender identity in daily life before irreversible surgical steps are taken.
• Medical Clearance: General medical evaluations to ensure the patient is a suitable candidate for major surgery, addressing any co-morbid conditions.

Thorough documentation of these evaluations and therapies is critical for supporting the medical necessity of GRS and facilitating potential reimbursement, especially given the complexities of gender dysphoria treatment costs.

Medicare Coverage Evolution and Specific Criteria for GRS

Historically, Gender Reassignment Surgery (GRS) was largely excluded from Medicare coverage. Prior to March 27, 2014, the Centers for Medicare & Medicaid Services (CMS) specifically excluded GRS from reimbursement. However, the landscape of transgender healthcare coverage has evolved. While a blanket national coverage determination (NCD) for GRS remains complex and often non-existent for routine coverage (as noted in NCD 160.27 regarding gender dysphoria treatment), certain procedures and services related to gender affirmation may be covered through local coverage determinations (LCDs) or specific Medicare Advantage plans when deemed medically necessary and when specific criteria are met.

Key considerations for potential Medicare coverage for GRS procedures after May 30, 2014, when an LCD or plan policy is applicable, include:

• A confirmed diagnosis of gender dysphoria (DSM-5 criteria).
• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and to consent to treatment.
• Absence of mental health conditions that would contraindicate surgery, or if present, they must be well-controlled.
• Completion of required real-life experience (RLE), typically 12 months, during which the individual consistently lives in a gender role congruent with their affirmed gender.
• Completion of a period of continuous hormone therapy, typically 6-12 months, under medical supervision, unless medically contraindicated.
• Letters of support from qualified mental health professionals recommending surgery, often one or two depending on the specific procedure.
• Patient must be of legal age (18 or older).

It is critical for providers to meticulously document that all applicable criteria are met and to verify the specific coverage policies of the patient’s Medicare plan or local jurisdiction, as CMS guidelines for gender-affirming care can vary significantly at the local level. Providers should consult official CMS guidance on claim adjustments and relevant LCDs.

ICD-10 and CPT Codes for Gender Reassignment Surgery and Related Care

Accurate coding is paramount for proper billing of gender affirmation surgery and related services, particularly when navigating gender dysphoria treatment costs and potential Medicare gender affirmation surgery reimbursement. Providers must ensure that diagnostic codes (ICD-10-CM) align with the documented medical necessity for procedures (CPT codes).

Common ICD-10-CM Codes for Gender Dysphoria:

• F64.1 – Dual role transvestism (less common for GRS, but related to gender identity)
• F64.0 – Transsexualism (older diagnostic term, still encountered in records)
• F64.9 – Gender identity disorder, unspecified (use when specific type not documented)
• Z87.890 – Personal history of sex reassignment (for post-operative patients and follow-up care)

Example CPT Codes for Gender Reassignment Surgery (GRS) Procedures:

Note: These are examples and specific codes vary based on the exact procedure performed. Always verify the most current and appropriate codes with official coding resources and payer guidelines.

• 55970 – Intersex surgery; male to female (often used for vaginoplasty procedures)
• 55980 – Intersex surgery; female to male (often used for phalloplasty/metoidioplasty procedures)
• 19303 – Mastectomy, simple, complete (commonly used for chest masculinization)
• 19316 – Mastopexy (for breast augmentation in feminization, if medically indicated)
• 31580 – Laryngoplasty, for laryngeal stenosis, with graft, or with tracheotomy; with stent; reconstruction of larynx, single stage (for voice feminization surgery, e.g., vocal cord shortening)
• 14040-14041 – Adjacent tissue transfer or rearrangement, face/scalp (can be applicable for components of facial feminization/masculinization surgeries)

For diagnostic evaluations, hormone therapy management, and psychological support prior to and following surgery, standard Evaluation and Management (E/M) codes (e.g., 99202-99215 for office visits) and psychiatric service codes (e.g., 90832-90839 for psychotherapy) would be applicable, billed according to medical necessity.