Mudança de sexo

(Responde Fernando Lopes)


Quando um doente é admitido para mudança de sexo o diagnóstico principal deverá ser o da patologia que justifica este procedimento. Por exemplo:
F64 Gender identity disorders 
F64.0 Transsexualism
Gender identity disorder in adolescence and adulthood
Gender dysphoria in adolescents and adults 
F64.1 Dual role transvestism Use additional code to identify sex reassignment status (Z87.890) 
Excludes1: gender identity disorder in childhood (F64.2) 
Excludes2: fetishistic transvestism (F65.1) 
F64.2 Gender identity disorder of childhood
Gender dysphoria in children 
Excludes1: gender identity disorder in adolescence and adulthood (F64.0) 
Excludes2: sexual maturation disorder (F66) 
F64.8 Other gender identity disorders
Other specified gender dysphoria 
F64.9 Gender identity disorder, unspecified
Gender dysphoria, unspecified
Gender-role disorder NOS
 
A variável administrativa 'sexo' (1=masculino, 2=feminino) vai estar em contradição com o procedimento a realizar, o que irá despoletar o alerta de 'conflito de sexo', o qual, como é evidente, terá de ser validado/ultrapassado para que o episódio possa ser agrupado.
Não deverá ser necessário alterar esta variável como alguém já fez:
We have a gender reassignment surgery (male to female) case that needs discussion. This is a male patient that is a female on his driver's license and with his insurance company. He came to our facility to have a scrotectomy, bilateral orchiectomy and a partial penectomy. He also had a vaginoplasty with a graft and a clitroplasty. The problem we are having is coding the penectomy. Since this patient is registered as a female and lists female on her driver's license, we are not able to assign the male to female procedure codes. We were wondering if anyone else has encountered this sort issue and if so, what did you do to work around it?  
-> Currently, I temporarily change the sex of the patient in the system and we then assign the codes. After the coding is completed I change the sex back to the original.  So far this has been working for us. (Coding, Classification & Reimbursement: Gender Reassignment Surgery (Male to Female))
 
O SIMH deve estar preparado para reconhecer estas situações.
Medicare and most insurance carriers require that all Part A claims for transgender inpatient and outpatient services include condition code 45 (Ambiguous Gender Category) in order to avoid being denied. This condition code is to be used by providers to let the fiscal intermediary know that the gender/procedure or gender/diagnosis conflict is not a mistake and that the sex-related edit should be ignored, according to the Medicare Claims Processing Manual.  (Understanding Gender Dysphoria and Gender Reassignment Procedures)
 
Os colegas que têm estas cirurgias no seu hospital poderão dizer como estão a lidar com estas questões.  
Poderia pensar-se no valor 3=sexo indeterminado mas isso deve estar reservado para os casos de hermafroditismo, o que não é o caso nas admissões para mudança de sexo:
 
Q56 Indeterminate sex and pseudohermaphroditism 
Excludes1: 46,XX true hermaphrodite (Q99.1)
androgen insensitivity syndrome (E34.5-)
chimera 46,XX/46,XY true hermaphrodite (Q99.0)
female pseudohermaphroditism with adrenocortical disorder (E25.-)
pseudohermaphroditism with specified chromosomal anomaly (Q96-Q99)
pure gonadal dysgenesis (Q99.1) 
Q56.0 Hermaphroditism, not elsewhere classified
Ovotestis 
Q56.1 Male pseudohermaphroditism, not elsewhere classified
46, XY with streak gonads
Male pseudohermaphroditism NOS 
Q56.2 Female pseudohermaphroditism, not elsewhere classified
Female pseudohermaphroditism NOS 
Q56.3 Pseudohermaphroditism, unspecified 
Q56.4 Indeterminate sex, unspecified
Ambiguous genitalia
 
 
Num novo episódio para um segundo tempo cirúrgico poderia pensar-se num código Z de Aftercare como, por exemplo:
 
Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system
 
mas, no caso aqui descrito de "internado para remover útero e ovários" dever-se-á ter em atenção as limitações dos códigos Z:
 
Chapter 21 Factors influencing health status and contact with health services (Z00-Z99)
When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
 
o que leva a pensar na utilização, outra vez, do diagnóstico principal da doença de base que justifica a mudança de sexo.
 
Não esquecer que existe um código para assinalar em episódios posteriores a história de mudança de sexo:
Z87.890 Personal history of sex reassignment
 
Quanto à codificação dos procedimentos, Tudo dependerá de cada caso.
Eis uma lista (que não verifiquei) encontrada em healthx.com:
 
0U5J0ZZ Destruction of Clitoris, Open Approach
0U5JXZZ Destruction of Clitoris, External Approach
0U9J00Z Drainage of Clitoris with Drainage Device, Open Approach
0U9J0ZZ Drainage of Clitoris, Open Approach
0U9JX0Z Drainage of Clitoris with Drainage Device, External Approach
0U9JXZZ Drainage of Clitoris, External Approach
0UBJ0ZX Excision of Clitoris, Open Approach, Diagnostic
0UBJ0ZZ Excision of Clitoris, Open Approach
0UBJXZX Excision of Clitoris, External Approach, Diagnostic
0UBJXZZ Excision of Clitoris, External Approach
0UCJ0ZZ Extirpation of Matter from Clitoris, Open Approach
0UCJXZZ Extirpation of Matter from Clitoris, External Approach
0UMJXZZ Reattachment of Clitoris, External Approach
0UNJ0ZZ Release Clitoris, Open Approach
0UNJXZZ Release Clitoris, External Approach
0UQG0ZZ Repair Vagina, Open Approach
0UQJ0ZZ Repair Clitoris, Open Approach
0UQJXZZ Repair Clitoris, External Approach
0UTG0ZZ Resection of Vagina, Open Approach
0UTG4ZZ Resection of Vagina, Percutaneous Endoscopic Approach
0UTG7ZZ Resection of Vagina, Via Natural or Artificial Opening
0UTG8ZZ Resection of Vagina, Via Natural or Artificial Opening Endoscopic
0UTJ0ZZ Resection of Clitoris, Open Approach
0UTJXZZ Resection of Clitoris, External Approach
0UTM0ZZ Resection of Vulva, Open Approach
0UTMXZZ Resection of Vulva, External Approach
0UUJ07Z Supplement Clitoris with Autologous Tissue Substitute, Open Approach
0UUJ0JZ Supplement Clitoris with Synthetic Substitute, Open Approach
0UUJ0KZ Supplement Clitoris with Nonautologous Tissue Substitute, Open Approach
0UUJX7Z Supplement Clitoris with Autologous Tissue Substitute, External Approach
0UUJXJZ Supplement Clitoris with Synthetic Substitute, External Approach
0UUJXKZ Supplement Clitoris with Nonautologous Tissue Substitute, External Approach
0VR90JZ Replacement of Right Testis with Synthetic Substitute, Open Approach
0VRB0JZ Replacement of Left Testis with Synthetic Substitute, Open Approach
0VRC0JZ Replacement of Bilateral Testes with Synthetic Substitute, Open Approach
0VTS0ZZ Resection of Penis, Open Approach
0VTS4ZZ Resection of Penis, Percutaneous Endoscopic Approach
0VTSXZZ Resection of Penis, External Approach
0VUS07Z Supplement Penis with Autologous Tissue Substitute, Open Approach
0VUS0JZ Supplement Penis with Synthetic Substitute, Open Approach
0VUS0KZ Supplement Penis with Nonautologous Tissue Substitute, Open Approach
0VUS47Z Supplement Penis with Autologous Tissue Substitute, Percutaneous Endoscopic Approach
0VUS4JZ Supplement Penis with Synthetic Substitute, Percutaneous Endoscopic Approach
0VUS4KZ Supplement Penis with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach
0W4M070 Creation of Vagina in Male Perineum with Autologous Tissue Substitute, Open Approach
0W4M0J0 Creation of Vagina in Male Perineum with Synthetic Substitute, Open Approach
0W4M0K0 Creation of Vagina in Male Perineum with Nonautologous Tissue Substitute, Open Approach
0W4M0Z0 Creation of Vagina in Male Perineum, Open Approach
0W4N071 Creation of Penis in Female Perineum with Autologous Tissue Substitute, Open Approach
0W4N0J1 Creation of Penis in Female Perineum with Synthetic Substitute, Open Approach
0W4N0K1 Creation of Penis in Female Perineum with Nonautologous Tissue Substitute, Open Approach
0W4N0Z1 Creation of Penis in Female Perineum, Open Approach
 
 
Bibliografia:
Understanding Gender Dysphoria and Gender Reassignment Procedures
Gender Reassignment Surgery - Clinical UM Guideline
Transgender Code and Billing
Sex Reassignment Surgery -  Clinical UM Guideline 
Taking a Closer Look at the June ICD-10 Coding Challenge