Taking a Closer Look at the June ICD-10 Coding Challenge

July 20, 2015 / By Sue Belley, RHIA


A 37-year old male with a long-standing history of the diagnosis of gender identity disorder is currently undergoing counseling and medical therapy in an effort to work toward physically modifying his body to better match his psychological gender identity. The patient is scheduled to undergo an orchiectomy penectomy and surgical construction of a vagina in the near future.

Assign the ICD-10-CM code for the diagnosis of gender identity disorder.

What ICD-10-PCS code will be used for the procedure of a surgical construction of a vagina using autologous tissue procedure for this patient? Diagnosis Code

F64.1 Gender identity disorder in adolescence and adulthood

Root Operation



The recent news coverage of a former Olympic gold medalist and media figure who transitioned from male to female provides the opportunity to understand how sex reassignment surgery is captured in ICD-10-PCS. The root operation, Creation, is assigned when a new genital structure that does not physically take the place of a body part is created.

This root operation is only used for sex change operations such as the creation of a vagina in a male or the creation of a penis in a female. In this scenario, the procedure code that would be assigned for the creation of a vagina in a male patient is 0W4M070. Some of you assigned code 0W4N071 which is incorrect; this code indicates that a penis is being created in a male patient. Use the 7th character qualifier for the codes in this table to help you assign the correct code for they identify the genital organ that was created during the surgery.

The diagnosis code for gender identify disorder is F64.1, Gender identity disorder in adolescence and adulthood. Some of you assigned an additional code – Z87.890, Personal history of sex reassignment. This code would not be assigned during the encounter when sex reassignment surgery was performed. This code would, however, be assigned for any subsequent encounters.

Sue Belley is a project manager with the consulting services business of 3M Health Information Systems.

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