Gender Rules and ICD 10-CM F64.0

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Gender Rules and ICD 10-CM F64.0


Date Issued: 10/15/2019

In 2016, the HHS Office for Civil Rights (OCR) published a final rule that is intended to promote non-discrimination of certain populations, including obtaining health coverage and health benefits. This communication is specific to the Centers for Medicare & Medicaid Services release of new ICD-10-CM code F64.0 for “transsexualism,” which is effective as of Oct. 1, 2016.


EmblemHealth has always been supportive of the LGBT (lesbian, gay, bisexual, and transgender) community. Moving to include gender affirmation/reassignment surgery in our plans is consistent with other changes we have made to better serve the needs of the LGBT community.


As of Oct. 1, 2016, EmblemHealth has instructed all claim editing systems and vendors to turn off all gender-based rules. In addition, all facility claims reported with condition codes 45 and all professional claims reported with ICD-10 CM diagnosis codes F64.0; transsexualism, F64.1; gender dysphoria, F64.8; other gender identity disorders, F64.9 gender identity disorder, unspecified, Z87.890; personal history of sex reassignment and/or reporting modifier KX will exclude the claim from gender-conforming editing.