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Official Description

Intersex surgery; male to female

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 55970 refers to intersex surgery specifically aimed at transitioning from male to female genitalia. This surgical intervention involves the use of plastic surgery techniques to reconstruct male genital structures into female anatomical features. The process is designed to align the physical characteristics of the individual with their gender identity, providing a means for those undergoing gender transition to achieve a body that reflects their gender identity. The surgery may involve various techniques, including the removal of male genitalia and the creation of female genital structures, which can include the formation of a neovagina and the construction of external female genitalia. This procedure is a critical component of gender-affirming care for individuals seeking to transition from male to female, addressing both physical and psychological aspects of gender dysphoria.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The indications for performing intersex surgery, specifically male to female transition surgery, include the following:

  • Gender Dysphoria Individuals experiencing significant distress or discomfort due to a mismatch between their assigned male sex at birth and their identified female gender.
  • Desire for Gender Affirmation Patients seeking surgical intervention to align their physical appearance with their gender identity, enhancing their psychological well-being and social functioning.
  • Persistent Identification as Female Individuals who have consistently identified as female and wish to undergo surgical procedures to reflect this identity.

2. Procedure

The procedure for male to female intersex surgery involves several critical steps, each designed to facilitate the transformation of male genitalia into female genitalia. The following outlines the procedural steps:

  • Step 1: Anesthesia Administration The procedure begins with the administration of anesthesia to ensure the patient is comfortable and pain-free throughout the surgery. This may involve general anesthesia or regional anesthesia, depending on the specific surgical plan and patient needs.
  • Step 2: Surgical Incision The surgeon makes incisions in the appropriate anatomical locations to access the male genital structures. This step is crucial for the subsequent reconstruction and must be performed with precision to minimize scarring and optimize aesthetic outcomes.
  • Step 3: Removal of Male Genitalia The next step involves the careful removal of the male genitalia, including the penis and scrotum. This step is performed with attention to preserving surrounding tissues that may be used in the reconstruction of female genital structures.
  • Step 4: Creation of Neovagina The surgeon constructs a neovagina using the existing tissue, which may involve the inversion of penile skin or the use of grafts from other areas of the body. This step is essential for creating a functional and aesthetically pleasing vaginal canal.
  • Step 5: Construction of External Female Genitalia The final step involves the reconstruction of external female genitalia, including the labia and clitoris. This is achieved through meticulous surgical techniques to ensure proper form and function, allowing for sexual sensation and aesthetic appearance.

3. Post-Procedure

Post-procedure care for patients undergoing male to female intersex surgery is critical for recovery and includes several key considerations. Patients are typically monitored in a recovery area until they are stable and can be safely discharged. Pain management is an essential aspect of post-operative care, and patients may be prescribed analgesics to manage discomfort. Additionally, patients are advised on wound care to prevent infection and promote healing. Follow-up appointments are necessary to assess healing, address any complications, and provide ongoing support for the patient's transition process. Patients may also receive guidance on sexual health and function as they adjust to their new anatomy.

Short Descr SEX TRANSFORMATION M TO F
Medium Descr INTERSEX SURG MALE FEMALE
Long Descr Intersex surgery; male to female
Status Code Carriers Price the Code
Global Days YYY - Carrier Determines Whether Global Concept Applies
PC/TC Indicator (26, TC) 9 - Not Applicable
Multiple Procedures (51) 9 - Concept does not apply.
Bilateral Surgery (50) 9 - Concept does not apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 9 - Concept does not apply.
Co-Surgeons (62) 9 - Concept does not apply.
Team Surgery (66) 9 - Concept does not apply.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 118 - Other OR therapeutic procedures, male genital
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
GC This service has been performed in part by a resident under the direction of a teaching physician
Date
Action
Notes
2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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