PrEP’aring for Impact: Implicit Bias and Imperfect Billing Codes

Colbey Ricklefs, MD, MPH

Fam Med. 2023;55(2):123-124.

DOI: 10.22454/FamMed.2023.352793

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“Honestly, I mostly just wanted to ask about getting on PrEP,” the patient mentioned. He was establishing care with my clinic during my intern year after moving from across the country. As part of that move, he and his long-term partner had broken up after many years together. Now that he was single again, he was eager to explore the opportunities his new city had to offer him.

Truthfully, I was also excited. I chose family medicine because I wanted to work with all genders, all ages, and all pathologies; but I also chose family medicine because of the unique opportunities for sexual and reproductive health. I read about preexposure prophylaxis to HIV (PrEP) during my medical school years, but rarely saw it used. Now, as a fresh new intern, the opportunity to prescribe had walked through the clinic doors.

“I think it’s a great idea,” I told him, “but tell me a bit more.” He elaborated that he identified as gay, and he was sexually active with infrequent male partners, always using condoms as protection. He wanted to start PrEP because he had heard about it from friends who were on it. He heard how easy it was to take, and he wanted the reassurance it would provide him in his sexual encounters. He was on board with the requisite HIV screenings every 3 months, and he assured me he would have no problem taking the medication every day. He was a great candidate for PrEP, and I pended the order for a 90-day supply the medication.

Before I could submit the prescription, I had to associate it with a billing code. I had seen billing codes associated with other patients in the past, including Z72.52: “high-risk homosexual behavior.” It made me cringe every time I saw it, and now that I was the one to assign the billing code, I could not help but to think about how much it really did not fit him. After all, he told me he was just being responsible and proactive. His partners were infrequent, and he used condoms all the time; and even if he did not, who am I to judge him as “high risk”? Furthermore, I took offense with the term “homosexual” being used in the medical record, especially for someone who did not use the term to self-identify. “Homosexual” is increasingly frequently viewed as an offensive term and I would never call someone this in person, so why would I “diagnose” him as such?

At the same time, I wanted to ensure his insurance company would cover the prescription, and knew there had to be certain codes affiliated in order for him to receive coverage. With the patient still in the room, I did a quick web search to explore other options. Among the choices I found “high-risk heterosexual behavior” and “high-risk bisexual behavior,” neither of which applied to his identity. “Contact with and (suspected) exposure to HIV” felt inappropriate as well because he had not been in known contact. The options were not great, so I went back to what I had seen associated in the past: “high-risk homosexual behavior.”

I paused and thought about my next move. “Just an FYI,” I said, “more of an insurance thing, but the system makes me select an option here in order to prescribe PrEP today. The options aren’t great, but this one is particularly bad.”

I watched as his eyes narrow in on the selected text on my screen. He read the term “high-risk homosexual behavior,” and gave a slight laugh.

“These are terrible codes, and I’m sorry,” I said to him. I found myself overapologizing to him on behalf of myself, the clinic, indeed the field of medicine, that this was the diagnosis to which I was limited. I thought back on the courage it took him just to come in to the clinic today, and how patients who identify as sexual and gender minorities already often feel marginalized and alienated by their providers.

I was stuck between making sure his medication would be covered and trying to maintain a therapeutic relationship with him. In no way did I want invalidate his identity, yet I felt the system was forcing me to diagnose him as “homosexual.” In no way did I want to make him feel judged, yet I felt the system was forcing me to label him as “high risk.” Did him identifying as gay singularly make him high risk? In the world of billing codes, the apparent answer was yes; the implicit bias in this code was palpable. It felt reductive to his humanity; and I wondered why this was one of the hoops we make patients jump through as they seek autonomy over their sexual health.

“It’s okay,” he said. “I understand that it’s just part of PrEP.” He was right to an extent: “high-risk homosexual behavior” is a common billing code, but it should not be. These diagnosis codes are often imperfect, but never before did I find myself having a moral objection to one.

We came to a mutual agreement to use this code that day, mostly because as an intern I was not aware of what more I could do. He understood that I was just ticking all the boxes, even if the boxes were biased and it meant assigning a label that neither of us felt was right.

Fortunately, that diagnosis code did not serve as a barrier and he has returned every 3 months for PrEP follow-up. I have since changed his diagnosis code to the far more generic Z79.899 (“on preexposure prophylaxis for HIV”), but I wonder if I would have ever had the chance to explain myself if I had never addressed the words “high-risk homosexual behavior” written on his medical record. How might that have impacted his perception of receiving PrEP? Would he have ever returned at all?

He deserved better than that. All of our patients do.

Lead Author

Colbey Ricklefs, MD, MPH

Affiliations: Family Medicine Residency Program, Harborview Family Medicine Clinic, University of Washington, Seattle, WA

Corresponding Author

Colbey Ricklefs, MD, MPH


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