Summary & Overview
CPT 55980: Gender-Affirming Genital Reconstructive Surgery
CPT code 55980 represents multi-stage surgical procedures for conversion of female anatomy to male anatomy, including hysterectomy, oophorectomy, genital tissue reshaping, and phalloplasty. This code is relevant nationally as demand for gender-affirming surgical services has grown and insurers and health systems refine coverage policies and care pathways for transgender and gender-diverse patients. Payment and coverage determinations for complex reconstructive services have implications for access to care, surgical planning, and facility resource allocation.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines how these payers approach coverage and authorization for multi-stage genital reconstruction, though specific payer criteria and allowance amounts vary.
Readers will learn the clinical scope represented by CPT code 55980, typical sites of service, common modifiers used with surgical billing, and where to look for related codes and diagnoses. The report also summarizes benchmarking considerations, typical utilization patterns for staged reconstructive surgery, and recent policy update themes affecting prior authorization and medical necessity reviews. Data not available in the input are noted where applicable.
Billing Code Overview
CPT code 55980 describes staged surgical procedures to convert female anatomy to male anatomy. The procedures can include removal of the uterus and ovaries (hysterectomy and oophorectomy), reshaping of genital tissue to appear more male, and construction of a penis (phalloplasty). This code captures complex, multi-stage gender-affirming genital reconstruction.
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Service type: Gender-affirming genital reconstructive surgery (multi-stage operative procedures)
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Typical site of service: Inpatient or outpatient surgical setting, often performed in hospitals or ambulatory surgery centers depending on procedure stage and patient needs.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 28-year-old transgender man presents for staged gender-affirming male chest and genital reconstruction. Prior to surgery he completed diagnostic evaluations, hormone therapy, and counseling. The planned operative pathway includes extirpation of the uterus and ovaries (total hysterectomy with bilateral salpingo-oophorectomy), vaginectomy or closure of vaginal canal, and staged phalloplasty with reconstruction of the neophallus and urethral lengthening. The clinical workflow begins with preoperative assessment (medical clearance, imaging as indicated, laboratory studies, and informed consent), followed by an inpatient or ambulatory surgical procedure under general anesthesia. Perioperative care includes intraoperative reconstruction by a multidisciplinary team (plastic/reconstructive surgeon, gynecologic surgeon, urologist as needed), postoperative monitoring for bleeding, infection, flap viability if applicable, pain control, and scheduled follow-up visits for staged revisions or prosthesis placement.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — default | Use when no special circumstance or modifier applies |
22 | Increased procedural services |