Patient with gender dysphoria is seen for psychotherapy today due to feelings of anxiety and high levels of stress. Patient was assigned female at birth but never felt comfortable with that identity, nor that of a male. Patient tells the psychotherapist that she prefers that people refer to her as “they” rather than she or he.

Some friends and family members are acceptable of patient’s situation, but some are not. This gives patient great stress having to go out in public and deal with people’s reactions. During the therapy session, patient expresses anxiety over menstruation and their changing body.

Discussion took place on how to reduce the dysphoria and how to talk to people about gender to relieve some of the anxiety. The session lasted 45 minutes.  Assign the CPT code.

See the answer and rationale here.

 

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