Find comprehensive information on Sexually Transmitted Disease (STD) screening, including clinical documentation, medical coding, and healthcare guidelines. Learn about STD testing, diagnosis codes, and best practices for accurate and efficient documentation in a clinical setting. This resource covers essential information for healthcare professionals on proper coding and documentation for Chlamydia, Gonorrhea, Syphilis, HIV, and other STDs, ensuring accurate reporting and patient care. Explore resources for STD prevention, treatment, and patient education.
Also known as
Encounter for screening for STD
Screening for sexually transmitted diseases.
Enc for other screening exam
Encounter for other specified special screening examinations.
Enc for other preprocedural exam
Encounter for preprocedural examination, not elsewhere classified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the encounter for STD screening?
Yes
Specific STD suspected?
No
Do NOT use Z11 codes. Code the presenting problem.
When to use each related code
| Description |
|---|
| STD screening |
| Chlamydia infection |
| Gonorrhea infection |
Using unspecified STD codes (e.g., Z11.9) when a more specific diagnosis is documented leads to inaccurate data and rejected claims. ICD-10-CM, coding compliance.
Coding a suspected STD as confirmed without documented positive test results violates coding guidelines. Medical coding, healthcare compliance, risk adjustment.
Failure to use Z codes (e.g., Z11.3) for encounters solely for STD screening can lead to lost revenue and inaccurate reporting. CDI, medical billing, HCC coding.
Patient presents for sexually transmitted infection STI screening. The patient reports no specific symptoms or concerns but desires comprehensive STI testing as part of routine sexual health maintenance. Relevant social history includes new sexual partner within the past three months, consistent condom use reported. Past medical history is non-contributory to current presentation. Physical exam reveals no abnormalities. Plan includes laboratory testing for chlamydia, gonorrhea, syphilis, herpes simplex virus HSV, human immunodeficiency virus HIV, and hepatitis B and C. Patient education provided on safe sex practices, transmission risks, and the importance of regular STI screenings. Results will be reviewed upon completion and appropriate treatment initiated if indicated. Follow-up appointment scheduled to discuss results and address any questions. ICD-10 code Z11.3 Encounter for screening for sexually transmitted diseases is documented. CPT codes for laboratory tests performed will be documented upon completion of testing and reflected in the medical billing process. Patient understands the importance of partner notification if positive results are obtained.