Ask the Experts About LGBT Health
Q: Billing codes for transgender patients
I have completed genital reconstructive surgeries (GRS). All paperwork from birth certificate forward has had the gender marker changed. I continue to see the same endocrinologist since first starting. I had private insurance and had no problems with them paying both for the endocrinology visits and AndroGel for several years. I have just gone on Medicare (I am 68) and purchased supplemental plans (part b and drugs). I went to a senior advisor before purchasing to be sure my medications, including AndroGel would be covered. It would require prior approval (PA), but would be covered. I have not been able to get the AndroGel covered. I have called and written to my doctor asking if he was ethically bound to code me as transsexual even though now I am legally male. That question was never answered. His nurse says that she tried "rewording" the PA several ways, but as to what was written, I don't know (I had to switch to testosterone shots). Today I got a lab test order from my doctor's office. The diagnosis was always just drug monitoring in the past, now it is saying TRANS-SEXUALISM (ICD-302.50). Friends say their doctors use hypogonadism. Is it time for a change in doctors? There is a rumor he doesn't want to take any more trans patients. Is it a matter of choice as to how he codes me? Thanks.
A: Response from Dr. Raney
Hello. There is no standard diagnosis code for transgender patients who are getting hormone treatments, and therefore it is up to the provider to choose the code. For patients who have completed genital reconstructive surgeries (that is, they are no longer "transitioning" to male or female), it is very common to list their diagnosis code as hypogonadism or hormone disorder. This is because after surgeries are completed, the patients are simply having a lack of sex hormone treated. Your doctor could choose one of these codes and does not have to code your diagnosis as trans-sexualism.
The diagnosis of trans-sexualism on you chart, however, may not be the reason you cannot get AndroGel covered. It is more likely that the formulary offered under your Medicare plan may reject AndroGel because of its expense compared to generic drugs (about $300 a month compared to $50 for 6 months of injectable testosterone). Therefore, a diagnosis change on your chart may not make any change to the hormone treatment coverage.
If possible, we recommend that you do pursue finding a new physician who you feel you can trust, and who will make you feel comfortable and heard. Depending on where you live, you may be able to find an endocrinologist who works well with transgender patients, or even an internal medicine doctor who has experience with transgender health. It sounds like you have some friends who may be able to refer you. Good luck.
Ruben Hopwood, MDiv and Alex Gonzalez, MD, with Pat Raney, MD
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Forum Experts
 Harvey J. Makadon, MD is Clinical Professor of Medicine at Harvard Medical School and Director of Education and Training at The Fenway Institute at Fenway Health in Boston. He is a member of the Division of General Medicine at Beth Israel Deaconess Medical Center and is the lead editor of The Fenway Guide to LGBT Health, published by the American College of Physicians in 2007. He has long been involved in developing both educational and clinical programs to serve gay, lesbian, bisexual and transgender populations.  Patricia Raney, MD, is a staff physician at Fenway Health in Boston, Massachusetts. She is a graduate of the University of Massachusetts Medical School and is Board Certified in Family Medicine. Her clinical interests include women's health and wellness, primary care, preventive care and the health concerns of lesbians, bisexual women and transgender people. On a more personal note, she is an avid stone carver. |
