Residents seek to rid insurance codes of pejorative language

Dr. Colbey Ricklefs recalled scrolling through the formal, static list of diagnosis codes, known as ICD-10, to find the appropriate one to associate with a patient's prescription. He couldn’t believe what he saw:  Pre-exposure prophylaxis against HIV (PrEP) was associated with a code that denoted “high-risk homosexual behavior.”

PrEP is a commonly used antiretroviral medication used by HIV-negative people to reduce the risk of HIV transmission.

Diagnosis codes are required to prescribe medicine or order a test; for example, a provider may use the code “pneumonia” to prescribe an antibiotic or “left arm fracture” to order an x-ray. The codes help ensure common understanding between medical providers, and also are necessary to apply insurance coverage, Ricklefs said. The diagnosis code that carries the descriptor “high-risk homosexual behavior” is one of the few codes universally accepted by insurance companies to cover the medication.

“What in the world does that mean,” he remembered thinking, looking at the code language.Ricklefs, a resident physician in family medicine at the University of Washington School of Medicine, recently chronicled his journey through insurance codes in the current edition of the Journal of Family Medicine.

First, the term “homosexual” is an antiquated and pejorative, Ricklefs said. The LGBTQ community does not use this language nor do national press publications; even Merriam-Webster now discourages its use. The term “high risk” was equally judgmental and vague, he added.

“Is it one partner, two or seven? What are we talking about here?” he wondered.

Eventually Ricklefs joined Dr. Nicolle Siegart,  a family medicine resident colleague, who was having difficulty finding a diagnosis code that applied insurance coverage to gender affirming care for transgender and gender-diverse patients. To prescribe gender-affirming hormones, Siegart found hat most insurance firms only accept the code whose static descriptor is “gender dysphoria.”

This term describes significant emotional distress resulting from a patient’s physical body not fitting with their gender identity. While this is an appropriate way to describe some patients’ experience, it cannot be universally applied to all transgender people. The designated descriptor for this diagnosis can lead to over-medicalizing transgender identities, noted Siegart, who works with patients who identify as transgender.

“This term really doesn’t universally describe the experience of transgender care or the transgender experience,” Siegart said.

Nonetheless, the code must be checked for insurance to be applied to the care. 

The two frustrated doctors pushed the issue further, drafting a resolution to advocate for state-run insurance to remove the requirement that these and other stigmatizing diagnosis codes be used.

Their resolution was approved last year by the Washington Academy of Family Physicians, the American Academy of Family Physicians, and the American Medical Association. The goal is to remove the requirement that insurance companies use these descriptions, and also to collaborate with governing bodies that develop the ICD codes.

That next step will be for the World Health Organization to modify its language in ICD codes in future iterations so it can be adopted by governing authorities in the United States.

That step, both doctors concede, might take a while.

“It’s out of our hands at this point,” said Ricklefs, as changes with the insurance companies and regulatory agencies will have to be made at state and national levels.

But it is a start, and was worth the effort, Siegart added.

“Patients have more access to charts more than ever before, including access to seeing their doctors being forced to use this stigmatizing terminology in their medical records. There has been a historic amount of medical mistrust with this community, and the last thing we want to do is make it worse by using these diagnosis codes” Siegart said. “True, diagnosis codes are tedious things to change, but I see this as a step of partnering with our patients.”

Written by Barbara Clements - 253-740-5043, bac60@uw.edu

For details about UW Medicine, please visit http://uwmedicine.org/about.