Cracking the Code

Transgender Hysterectomy

When coding medical cases pertaining to transgender individuals, there is certain criteria that a provider must meet within their documentation for the patient to have the medical procedure fully covered by their insurance. There must be a final diagnosis in the provider’s documentation for gender dysphoria. The formal diagnosis is gender identity disorder (GID), which is when a person experiences significant gender dysphoria. If this information is missing, then it is highly likely that the encounter will result in a denial. Please be sure to read the provider’s documentation fully to ensure all important information is captured when reporting final diagnoses and procedures for that encounter.

Q: A 40-year-old transgender man enters an OBGYN office to have a FTM hysterectomy procedure completed. The patient consents to the procedure, and the surgeon proceeds with the operation. An incision is made in the abdomen, and DaVinci robotic camera is inserted for visualization. The uterus and cervix are dissected free from the bladder and surrounding tissues. Coagulation is achieved. The uterus and cervix are removed as well as the fallopian tubes and ovaries. The uterus weighs 205 g. Final diagnosis: gender dysphoria in adulthood.
A: F64.0, transsexualism
CPT 58571, laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
Reference: CPT Assistant 2012, page 13: Robotic assisted laparoscopic vaginal hysterectomy
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