Gastroenterology Coding Alert

Pronoun mismatches can lead to denials.

Here are a few things you and your practice can do to ensure your trans patients feel comfortable and cared for when they come for medical treatment.

Acknowledge The Importance of Language

First, let’s identify a few commonly misunderstood terms.

Transgender: People who identify as transgender, or trans, have a gender identity that does not match the conventional expectations of the sex they were assigned at birth.

Gender identity: Gender identity is not limited to male/female or masculine/feminine; people may identify as nonbinary (not identifying with either the male or female gender), genderfluid, genderqueer, etc. Gender identity is wholly separate from sexual orientation and sexuality.

Intersex: People who are intersex can have a wide range of congenital variations in internal and external biology, hormone levels, and chromosome composition, which may not fit into stereotypical conceptions of male and female bodies.

Gender dysphoria: In terms of diagnoses, gender dysphoria replaced the term gender identity disorder in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 2000. Trans people who seek medical care may be seeking gender affirmation surgery, hormone replacement, or facial feminization surgery. These services are all aspects of medical transition; social transition is also part of many transgender people’s lived experience and includes acknowledgement of their gender, like using the correct pronouns.

“If you’re unsure what pronouns a person uses, ask them. If you, like all of us, make mistakes, don’t sweat it. Quickly acknowledge the mistake, correct yourself, and move on. Don’t dwell and don’t try to explain why you misgendered them,” said Trent Stechschulte, vice president and general counsel for I Am Boundless in Columbus, Ohio, in an AAPC Collaborative Compliance Conference presentation. “Demonstrate that you and your department value care for all,” Stechschulte continued.

Be Aware of Social Determinants of Health

Inequality has real effects on transgender people, including higher rates of unemployment and underemployment than other demographics, as well as housing insecurity and homelessness and other public health concerns — effects that are amplified by racism. Many transgender people report experiencing harassment and/or discrimination in the workplace, leading to being passed over for promotions or being terminated because of their gender identity.

Additionally, 29 percent of transgender people live in poverty versus 16 percent of non-transgender people, and 41 percent of transgender people have reported attempting suicide versus the national average of 5 percent, Stechschulte said. Many transgender women, especially transgender women of color, are HIV positive or are at risk of acquiring HIV.

Many of these situations can be considered social determinants of health (SDoH) and can be recorded and reported accordingly.

In terms of coverage of care, 22 percent have no health insurance coverage, and 29 percent of trans adults reported being denied services by a doctor or provider even with insurance; 32 percent of trans people of color do not have health insurance.

Although some payers cover gender affirming care, many set limits below the cost of the procedures or require lengthy prior authorization processes where some patients fall through the cracks, Stechschulte said. As many as 50 percent of transgender patients also feel like they need to educate their providers on the care they require, according to a study Stechschulte quoted.

These realities can lead to more self-reported negative experiences with providers.

Respect Gender Identity to Remain In Compliance

Gender mismatches on claims can create a lot of issues at both the provider and reimbursement levels, Stechschulte said.

“We found that 21 percent of transgender individuals have updated their identification forms with their providers,” Stechschulte said. This creates problems down the line, such as claims being denied, but also things like post-visit summaries with the wrong gender listed. For many trans people, misgendering can fall on a spectrum somewhere between aggravating and traumatizing.

The Affordable Care Act includes antidiscrimination provisions for U.S. healthcare — Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in a wide variety of healthcare programs and activities, which typically include hospitals, health clinics, community centers, rehab centers, and for doctors and other providers who receive federal funding, said Karen Owens, partner at Coppersmith Brockelman PLC in Phoenix, in the same presentation.

These regulations were initially passed during the Obama Administration, rewritten during the Trump Administration with the specific intention of not enforcing protections for trans patients, and are currently awaiting possible litigation for further adjustments to ensure care proposed by the Biden Administration, Owens said.

The proposed changes would prevent covered entities from withholding care based on a patient’s sex assigned at birth, like prostate cancer screenings for trans women or gynecological or obstetrical care for trans men.

Don’t Forget About Workplace Safety

Don’t forget to extend the same sensitivity, awareness, and accommodations to trans colleagues as you do to patients.

“Discrimination has no place in your workplace. Make meaningful policies around gender identity in expression, train staff, provide them with educational materials, ensure you supplement your sexual harassment policies with gender identity and expression language,” Stechschulte said.

“Transgender employees have a right not to be harassed. This is well-established in the courts. Sex-based harassment is unlawful when it’s severe or widespread and an employer does not take steps to stop it. That is the well-established law,” Owens said. “Sex-based harassment can include jokes or derogatory comments about transgender people, or repeated or intentional use of the wrong name or pronouns.”