Find information on high-risk sexual behavior diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about risk assessment, sexually transmitted infections, prevention strategies, patient education, and behavioral health interventions. This resource provides guidance for healthcare professionals on accurate coding and documentation of high-risk sexual behaviors in medical records, supporting appropriate patient care and public health reporting.
Also known as
High-risk sexual behavior
Diagnosis for individuals engaging in unprotected or risky sexual practices.
Sexual dysfunction, not elsewhere classified
Covers various sexual dysfunctions that may contribute to risky behavior.
Problems related to psychosocial circumstances
Includes social and environmental factors influencing high-risk behavior.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the encounter specifically for high-risk sexual behavior counseling/screening?
Yes
Is there a specific disease concern?
No
Do NOT code Z72.51. Code the presenting problem.
When to use each related code
| Description |
|---|
| High-risk sexual behavior |
| Unprotected sexual intercourse |
| Sexual dysfunction NOS |
Coding lacks specificity. Documentation must clearly define the high-risk behavior (e.g., unprotected sex, multiple partners) for accurate code assignment and billing.
Diagnosis based on patient-reported history without objective evidence. CDI should query for supporting documentation to validate the diagnosis for compliance.
Using Z codes (e.g., Z72.5, High-risk sexual behavior) without linking it to a primary diagnosis. This impacts risk adjustment and may lead to audit scrutiny.
Patient presents with concerns regarding high-risk sexual behavior. The patient reports engaging in unprotected sex, multiple sexual partners, and inconsistent condom use. These behaviors increase the patient's risk of sexually transmitted infections (STIs), including HIV, gonorrhea, chlamydia, and syphilis. Assessment includes a detailed sexual history, including the number of partners, frequency of sexual activity, type of sexual activity (oral, anal, vaginal), and history of STI diagnosis and treatment. The patient's understanding of safe sex practices and access to preventative resources, such as condoms and STI testing, were also evaluated. Diagnosis of high-risk sexual behavior is based on the patient's self-reported history and clinical assessment. Differential diagnoses considered include sexual compulsivity and other impulse control disorders. The treatment plan focuses on patient education regarding safe sex practices, including consistent and correct condom use, STI prevention, and the importance of regular STI testing. Referral for sexual health counseling and resources for STI testing and treatment will be provided. Patient education materials on safer sex practices, risk reduction strategies, and available community resources were also provided. Follow-up appointment scheduled to assess adherence to the treatment plan and address any further concerns.