Individuals may seek gender affirmation services to make their voice and/or other aspects of their communication congruent with their gender identity and/or gender expression. Speech-language pathologists (SLPs) provide expertise in safely modifying the voice. According to The Report of the 2015 U.S. Transgender Survey [PDF] voice therapy is the second most common reported medical intervention, behind hair removal, for transgender individuals assigned male at birth. SLPs who serve this population should be specifically educated and appropriately trained to do so.
The following information focuses on policies related to reimbursement and coding for voice therapy related to gender affirmation services for transgender and gender diverse people.
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Laws related to gender identity are constantly evolving. Title VII of the 1964 Civil Rights Act, a federal regulation, prohibits discrimination in any federally funded program on the basis of race, color, sex, or national origin. This includes any public or private facility, such as a hospital, clinic, nursing home, public school, university, or Head Start program that receives federal financial assistance, such as grants, training, use of equipment, and other assistance.
According to Section 1557 of the Patient Protection and Affordable Care Act (ACA), which is the primary anti-discrimination provision of the ACA, a health plan or health insurer that receives federal financial assistance from the Department of Health and Human Services (HHS) cannot categorically exclude all services related to gender affirmation and/or make coverage decisions in a manner that results in discrimination against a transgender or gender diverse individual (i.e., deny a claim or impose limitations or restrictions on any health service).
In addition, the Health Insurance Portability and Accountability Act (HIPAA) protects the disclosure of information about a patient’s sexual orientation and gender identity.
As of 2021, 21 states plus the District of Columbia have affirmative coverage for gender affirmation-related care for Medicaid, and 22 states plus the District of Columbia have coverage requirements for private payers. Although some coverage may be provided for voice therapy related to gender affirmation, there can be barriers to accessing it.
Seek legal counsel if you have questions or concerns regarding the impact of federal or state law on the reimbursement of voice therapy for gender affirmation-related care.
SLPs should keep in mind that there is significant variability in coverage for services related to gender affirmation. Such services may be covered with the medical diagnosis of "gender dysphoria." According to The Report of the 2015 U.S. Transgender Survey[PDF], nearly 25% of respondents reported having experienced challenges with insurance regarding services related to gender. Often, current laws only mention specific services, such as gender affirmation surgery or hormone therapy
Always verify payer coverage policies before beginning to provide voice therapy services for transgender; or gender diverse people. Payers may use an evolving variety of terms to describe gender affirmation services, including but not limited to, gender reassignment, transgender voice services and gender dysphoria evaluation and treatment.
Effective August 30, 2016, the Centers for Medicare & Medicaid Services (CMS) determined that no national coverage determination (NCD) is appropriate at this time forgender affirmation surgery and gender dysphoria. Instead, coverage determinations will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis. Coverage for voice therapy for transgender and gender diverse people may be available under Medicare. Absent specific Medicare guidance regarding voice therapy for gender reassignment services (Medicare’s current terminology), SLPs should verify coverage with the local MAC and follow the Medicare Physician Fee Schedule (MPFS), generally accepted coding guidelines, and national Medicare policies as outlined in Medicare manuals, such as the Medicare Benefit Policy Manual.
As of 2021, 21 state Medicaid agencies, plus the District of Columbia, have affirmative coverage laws for gender affirmation-related care. The majority of Medicaid agencies that cover care tend to cover gender affirmation surgery, hormone therapy, and mental health treatment. However, a case could be made for voice therapy based on medical necessity.
The following state Medicaid agencies cover gender affirmation-related care but do not mention whether voice therapy is a covered or non-covered service: California, Colorado, Connecticut, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Washington, and Wisconsin.
The following state Medicaid agencies exclude coverage for voice therapy for gender affirmation services: District of Columbia, Maryland, and Vermont.
SLPs should contact their Medicaid agency for guidance on the following questions:
As of 2021, the following states have affirmative coverage for medically necessary gender affirmation-related care for private insurance: California (vocal training is an example of a covered service), Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, and Washington.
Like Medicaid, very few state laws mention coverage for voice therapy for transgender or gender diverse people. However, many of the state laws prohibit insurers from denying or excluding medically necessary services related to the diagnosis of gender dysphoria. Therefore, a case could be made for voice therapy coverage.
For example, BlueCross Blue Shield of North Carolina covers medically necessary voice therapy as part of the overall treatment for gender dysphoria.
It is important to check with each private insurer regarding coverage for voice therapy.
SLPs should contact private insurers for guidance on the following questions:
Each claim that is submitted to a payer for reimbursement of voice therapy should include both International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes to report the patient’s medical and treating diagnosis, and Current Procedural Terminology (CPT® American Medical Association) codes to report the services provided by the SLP.
The following information follows basic coding principles. SLPs should consult the payer if clarification of coding or coverage is needed regarding a specific case.
The R49 series of ICD-10-CM codes is used to report voice and resonance disorders and may be used in conjunction with ICD-10-CM codes related to gender dysphoria when providing voice therapy as part of gender affirmation services.
Specific diagnosis codes related to gender dysphoria are found in the F64 series for gender identity disorders. There is also a code used to report a personal history of sex reassignment (Z87.890). SLPs should always consult the medical record or referring physician to confirm the appropriate medical diagnosis code for gender dysphoria.
Although payers often refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, American Psychiatric Association) criteria when establishing a medical diagnosis of gender dysphoria, ICD-10-CM codes are used on claims for reimbursement, unless otherwise specified by the payer. HIPAA requires use of the ICD-10-CM for health care billing and recordkeeping.
A detailed list of ICD-10-CM codes for gender dysphoria and voice disorders [PDF] is available on ASHA’s website.
There are no CPT codes specific to gender affirmation-related voice therapy. Coding for evaluation and treatment is accomplished using the same CPT codes, regardless of the patient’s medical or treating diagnosis. CPT codes typically used by SLPs to report voice services include 92524 (Behavioral and qualitative analysis of voice and resonance) and 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder). A full list of CPT codes related to the evaluation and treatment of voice and communication disorders is available on ASHA’s CPT coding webpage.
In 2014, Medicare updated its National Coverage Determination (NCD) for Gender Dysphoria and Gender Reassignment Surgery to provide coverage for medically necessary services related to gender transition such as gender reassignment surgery. The categorical exclusion of coverage of transition-related surgery was invalidated, meaning that coverage decisions for transition-related care will be made on an individual basis like all other services under Medicare.