Welcome back to our blog! We hope you enjoyed Insurance 101 – Part 1, which introduced us to some basic insurance terminology. Now that we have covered the basics, today we will talk about insurance and surgeries.
Current Procedural Terminology:
This is also known as a CPT code. It is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. Essentially, it is a set of numbers and sometimes letters that providers and healthcare facilities use to bill your insurance company. Each procedure, medication, or order has a specific CPT code.
For transgender patients treated by Dr. Webb, the most common CPT codes we use are:
- 58570 – This is a laparoscopic total hysterectomy, also known as LTH
- This is removal of the uterus and the cervix
- 58571 – Laparoscopic total hysterectomy and bilateral salpingo oophorectomy, also known as LTH with BSO
- This is removal of the uterus, cervix, both fallopian tubes, and both ovaries
- 57110 – Vaginectomy
- In this procedure, the vaginal mucosa is removed (Look out for a future blog on this subject!)
INTERNATIONAL CLASSIFICATION OF DISEASE:
More commonly referred to as an ICD code. ICD codes are updated by the World Health Organization (WHO) every few years, and we are currently using ICD-10 codes. ICD codes are a classification of diseases and health conditions in the medical field.
Clinical Information for Gender Identity Disorder: A disorder characterized by a strong and persistent cross-gender identification (such as stating the desire to be the other gender or frequently passing as the other gender) coupled with persistent discomfort with his or her gender (manifested in adults, for example, as a preoccupation with altering primary and secondary gender characteristics through hormonal manipulation or surgery.)
The ICD-10 codes related to Gender Identity are:
- F64.0 – Transsexualism (As defined by the World Health Organization)
- WHO definition: “A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.”1
- F64.1 – Dual-role transvestism
- WHO definition: “The wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.” 1
- F64.2 – Gender identity disorder of childhood
- WHO definition: “A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual’s own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient.” 1
- F64.8 – Other gender identity disorders
- F64.9 – Gender identity disorder, unspecified
Also known as pre-certification. Your physician must obtain prior authorization from your health care provider before prescribing a specific medication for you or to performing a particular operation. Without this prior approval, your health insurance provider may not provide coverage, or pay for, your medication or operation, leaving you to cover some, or all, of the costs out of pocket.
Why Do Health Insurers Require Prior Authorization?
There are several reasons that a health insurance provider requires prior authorization.
Your health insurance company uses a prior authorization requirement as a way of keeping health care costs in check. It wants to make sure that:
- The service or drug you’re requesting is truly medically necessary.
- The service or drug follows up-to-date recommendations for the medical problem you’re dealing with.
- The drug is the most economical treatment option available for your condition. For example, Drug C (cheap) and Drug E (expensive) both treat your condition. If your doctor prescribes Drug E, your health plan may want to know why Drug C won’t work just as well. If you can show that Drug E is a better option, it may be pre-authorized. If there’s no medical reason why Drug E was chosen over the cheaper Drug C, your health plan may refuse to authorize Drug E.
- The service isn’t being duplicated. This is a concern when multiple specialists are involved in your care. For example, your lung doctor may order a chest CT scan, not realizing that, just two weeks ago, you had a chest CT ordered by your cancer doctor. In this case, your insurer won’t pre-authorize the second scan until it makes sure that your lung doctor has seen the scan you had two weeks ago and believes an additional scan is necessary.
- An ongoing or recurrent service is actually helping you. For example, if you’ve been having physical therapy for three months and you’re requesting authorization for another three months, is the physical therapy actually helping? If you’re making slow, measurable progress, the additional three months may well be pre-authorized. If you’re not making any progress at all, or if the PT is actually making you feel worse, your health plan might not authorize any further PT sessions until it speaks with your physician to better understand why he or she thinks another three months of PT will help you.
In effect, a pre-authorization requirement is a way of rationing health care. Your health plan is rationing paid access to expensive drugs and services, making sure the only people who get these drugs or services are the people for whom the drug or service is appropriate.
If you are planning your initial consult with Dr. Webb and would like to know if your insurance will cover hormone replacement therapy or lower surgery, you can use the information provided in this blog to find out. Call your insurance company and choose the option for coverage and benefits. Sometimes you will speak with an agent and you can provide him/her with the CPT and ICD-10 codes we listed above. The agent should be able to tell you if the procedure(s) is a covered benefit and if there are any exclusions or prior authorization requirements. You also want to make sure there are no exclusions for Gender Identity Disorder so make sure you ask the agent about this.
The insurance agent will likely have limited or no information about pricing for the procedures, but that is something we will cover after your initial consult when you meet with me, Kim. We hope this helps you prepare for your consult, please comment below with any suggestions or questions!
- The World Health Organization. http://apps.who.int/classifications/icd10/browse/2016/en#!/F64.0