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Posted By Deborah Roorda on 01-14-2019, 10:37:01 in Ob-Gyn
My doctor saw a transgender female to male, who is 3-4 yrs of testosterone injections but is having irregular uterine bleeding. Patient has not had surgery yet due to finances. Medication was changed and patient scheduled for return visit and ultrasound to check endometrial stripe. The physician coded just F64.0- Transsexualism . I don't that should be the only code. I know the irregular uterine bleeding needs to addressed. Also, how do I code her return visit? Is there some information on how to code this transition/situation?
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Posted By Melanie Witt on 01-14-2019, 14:20:18
There is no advice out there for transgender coding in the AHA Coding Clinic with regard to diagnosis, but if this patient's insurance identifies the patient as female and your physician is treating the patient for the irregular periods, that is the only diagnosis that should appear on the claim (and yes, you should bill for the return visit). If the patient's insurance has decided to identify the patient as male, the primary Dx is still the irregular periods and the secondary the F64.0 code, but remember that the physician is not treating this patient for being transgender, but rather treating the patient for a medical condition that is associated with being physically female.
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