A paper published last month by medical watchdog group Do No Harm warns state officials and health insurance providers that “Healthcare Providers May Skirt Coding Rules to Get Paid for Child Sex Changes,” as the title puts it. The document identifies potential ways that medical providers can falsify insurance codes to ensure payment for gender transition procedures to evade state legislation, and it also identifies organizations advising providers to do just that.

“Payors and regulators — particularly in states that restrict such interventions for minors — should remain vigilant for any misuse of endocrine or other medical ICD-10 codes to obtain reimbursement for sex-rejecting procedures,” the group urged. Medical providers use ICD-10 codes to denote various diagnoses for billing and reporting.

The ICD-10-CM Official Guidelines for Coding and Reporting require providers to “[c]ode to the highest level of specificity when supported by medical record documentation.” However, the paper alleges that medical providers often substitute vague codes, or even inaccurate ones, to conceal the nature of gender transition treatments.

For example, when medical providers are providing a minor with puberty blockers or cross-sex hormones, “the F64 family of codes representing gender identity disorders should be used,” the paper stipulates, such as “F64.9, Gender identity disorder, unspecified.” However, providers may associate their prescription with a different code, such as “E34.9 Endocrine disorder, unspecified,” to obscure the true nature of the treatment.

“Organizations such as WPATH, the Campaign for Southern Equality, Planned Parenthood, and QueerDoc have publicly promoted the use of non-F64 diagnosis codes in connection with so-called ‘gender-affirming care,’” the document explained.

“In its 2021 training materials, WPATH endorsed the application of endocrine-related ICD-10 diagnosis codes for sex change treatments and insurance reimbursement,” the paper listed, with greater specificity. Similarly, the Campaign for Southern Equality formerly published a fact sheet on its website, which provided a list of ‘insurance coding alternatives for trans healthcare,’ encouraging the use of these misleading codes to avoid scrutiny and obfuscate sex-denying medical interventions.”

Of the Campaign for Southern Equality’s guide, Dr. Eithan Haim testified before Congress in April 2025, “This guide is essentially a template for how to commit medical fraud. We should all remember that this is something that people go to prison for. This is a major deal.” While employed at Texas Children’s Hospital (TCH) in Houston, Haim observed the hospital providing gender transition procedures to minors, even while it publicly claimed it no longer did so. His observations led him to blow the whistle on the practice, and his testimony was backed up by Vanessa Sivadge, a former TCH nurse who was later fired for doing so.

Do No Harm also recorded apparent admissions of such false coding from practitioners of gender medicine. “Planned Parenthood of Southeastern Pennsylvania explicitly states that it uses endocrine disorder codes ‘in order to meet the needs of most insurance companies and patients’ and only ‘occasionally’ uses gender identity disorder codes,” it said. Additionally, “QueerDoc also notes on its website that ‘some providers use the code E34.9, Endocrine disorder, unspecified.’”

The paper also identified the reason why medical providers would run the risk of being charged with insurance fraud in order to falsify diagnostic records on gender transition procedures for minors. “Insurance coverage has been variable for medical procedures performed for the purpose of so-called ‘gender-affirming care’ for minors,” it stated. “Further, dozens of states now restrict Medicaid funding for sex-denying interventions for minors or restrict minors’ access to the procedures themselves.”

By way of reminder, they stated, “the rise of the child transgender industry over the past decade has relied, in no small part, on the financial incentives for physicians and hospitals to perform sex-denying medical interventions.” In other words, the transgender medical industry exists because of the potential for massive profits, and the industry cannot keep the profits flowing without access to insurance systems.

Do No Harm compiled a list of eight different ICD-10 diagnostic codes that could be used to mask gender transition procedures. The list includes:

• E23.0 Hypopituitarism
• E28.39 Other primary ovarian failure
• E29.1 Testicular hypofunction
• E30.1 Precocious puberty
• E34.8 Other specified endocrine disorders
• E34.9 Endocrine disorder, unspecified
• Z79.890 Hormone replacement therapy
• N62 Hypertrophy of breast

Some of these conditions are sex-specific, such as ovarian failure (for females) or testicular hypofunction (for males). So, if insurance records showed a male with an ovarian failure (E28.39) diagnosis, that would raise a lot of questions. But Do No Harm cautioned that even such a combination was not a slam-dunk case of fraud, as “sex markers in medical or pharmacy insurance claims data cannot always be trusted.” A trans-identifying female could have registered as a male with her insurance and still suffered from female-only conditions.

Other suspect conditions include hypopituitarism, which is a naturally occurring condition but could be caused by puberty blockers.

Again, precocious puberty occurs when children begin puberty at an excessively young age. However, “at the Children’s Hospital of Philadelphia [CHOP] between 2017 and 2024, 25 minors were diagnosed with central precocious puberty (CPP) between the ages of 10 and 18.” Such puberty is not precocious but normal. They noted “a similar suspicious spike … at Boston Children’s Hospital,” where “the hospital issued hundreds of first-time diagnoses of CPP to children aged 10 or older since 2015 … including at least one patient diagnosed at age 22.”

Do No Harm identified enough problems to raise red flags and prompt further questions. “These examples raise legitimate concern that endocrine-related ICD-10 codes are possibly being used on their own to obtain reimbursement for so-called ‘gender-affirming care,’” they warned. However, the process for systematically uncovering fraud is complicated enough that they did not perform a full study with a dataset.

As they explained, “one must review and correlate two separate insurance claims databases.” Next, “one needs to match prescription claims to office visit claims. … The narrower the timeframe between the prescription claim and office visit claim, the higher confidence in the association.” Then there is the complication that sex markers in insurance records cannot always be trusted. These statistical difficulties provide barriers to any systematic review to determine the extent of insurance fraud, even though Do No Harm points to ample anecdotal evidence to suggest that such fraud exists.

This is why their paper concludes by calling for greater “regulatory oversight and medical review.” They hope to move further toward a solution by enlisting others in the monumental research endeavor.

“Medical diagnosis codes are being subverted by gender ideologues to avoid proper reporting, hide their activism from scrutiny, and potentially commit fraud,” said Do No Harm chief medical officer Kurt Miceli. “Groups like WPATH have publicly promoted the use of misleading diagnosis codes, and our report exposes how providers have financial incentives to do so. By hiding transgender procedures behind codes meant for other conditions, providers are — at minimum — skirting guidelines and ethical standards.”