Find information on Sexually Transmitted Diseases Screening including clinical documentation, medical coding, and healthcare guidelines. Learn about STD testing, STI diagnosis codes, sexual health screening, chlamydia testing, gonorrhea testing, syphilis testing, HIV testing, herpes testing, and trichomonas testing. This resource provides details on appropriate medical terminology, documentation best practices, and relevant coding for accurate billing and reporting of STD screenings.
Also known as
Encounter for STD screening
Routine screening for sexually transmitted diseases.
Syphilis and other treponemal infections
Screening may reveal syphilis or related infections.
Gonococcal infection
STD screening can detect gonococcal infections.
Chlamydial lymphogranuloma/infection
Chlamydial infections are often screened for as STDs.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the screening for a specific STD?
When to use each related code
| Description |
|---|
| STD screening, unspecified |
| Chlamydia infection screening |
| Gonorrhea infection screening |
Using unspecified STD codes (e.g., R11) when a more specific diagnosis is documented leads to inaccurate data and lost revenue.
Coding STDs based on suspected infection without confirmatory testing violates coding guidelines and compliance rules.
Failure to code all diagnosed STD coinfections impacts quality reporting, reimbursement, and patient care.
Patient presents for sexually transmitted infection STI screening. Risk factors discussed include sexual history, number of partners, and type of sexual activity. Patient reports no current symptoms such as genital discharge, dysuria, or genital lesions. Past medical history is significant for chlamydia infection treated five years prior. Social history includes tobacco use, occasional alcohol use, and denies illicit drug use. Allergies are none. Physical examination is unremarkable with no inguinal lymphadenopathy or genital abnormalities noted. Based on patient risk factors and request, screening for common STIs including chlamydia, gonorrhea, syphilis, and HIV is indicated. Laboratory orders placed for nucleic acid amplification testing NAAT of urine for chlamydia and gonorrhea, rapid plasma reagin RPR for syphilis, and fourth-generation HIV 12 antibodyantigen combination immunoassay. Patient education provided regarding safe sex practices, condom use, and the importance of partner notification and treatment. Patient advised to follow up for test results and further management as indicated. Diagnosis: Sexually transmitted diseases screening. ICD-10 code Z11.3.