Find information on STD screening, testing, and diagnosis codes. Learn about sexually transmitted infection screening guidelines, clinical documentation requirements, and relevant medical coding terminology like ICD-10 codes for STIs, laboratory testing procedures, and preventative healthcare measures. This resource provides details on chlamydia testing, gonorrhea testing, syphilis testing, HIV testing, herpes testing, and other STD panels for accurate diagnosis and treatment. Explore resources for healthcare professionals, including information on patient education and best practices for STD screening in clinical settings.
Also known as
Encounter for screening for STD
Routine examination for sexually transmitted diseases.
Syphilis and other treponemal infections
Includes codes for screening and diagnosis of syphilis.
Gonococcal infection
Includes codes for screening and diagnosis of gonorrhea.
Chlamydial lymphogranuloma venereum
Includes codes related to chlamydia infections, often screened for with other STDs.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the screening encounter for a specific STD?
Yes
Which STD is being screened for?
No
Is it a general STD screening?
When to use each related code
| Description |
|---|
| STD Screening |
| Chlamydia |
| Gonorrhea |
Coding with unspecified codes (e.g., Z11.3) when a more specific diagnosis is documented leads to inaccurate data and potential underpayment. Impacts CDI, medical coding, and healthcare compliance.
Billing individual STD tests when a panel or combination code is appropriate can violate billing guidelines. Medical coding, compliance, and CDI specialists must address this.
Failing to code relevant risk factors (e.g., Z72.89) for STD screening can impact risk adjustment and quality reporting. Affects coding accuracy and healthcare compliance.
Q: What are the most current CDC recommended STD screening guidelines for asymptomatic adolescents and young adults in primary care settings?
A: The CDC recommends annual chlamydia and gonorrhea screening for all sexually active women under 25 years old, as well as older women with risk factors such as new or multiple partners. For men, routine screening is not recommended except for men who have sex with men (MSM). MSM should be screened at least annually for syphilis, chlamydia, and gonorrhea, and more frequently (e.g., every 3-6 months) if engaging in high-risk behaviors. HIV screening is recommended at least once for all adolescents and adults aged 13-64. Explore how these guidelines can be integrated into your practice to improve patient outcomes and consider implementing routine risk assessment discussions during annual wellness visits. Learn more about the specific risk factors that necessitate more frequent STD testing.
Q: How can I differentiate between various genital ulcerative diseases like herpes, syphilis, and chancroid in a clinical setting to ensure accurate diagnosis and treatment?
A: Differentiating between genital ulcers requires a thorough clinical evaluation including patient history, physical examination, and laboratory testing. Herpes simplex virus (HSV) typically presents with painful, vesicular or ulcerative lesions. Syphilis, specifically primary syphilis, presents with a painless chancre, often accompanied by regional lymphadenopathy. Chancroid, less common in the United States, causes painful genital ulcers with associated tender inguinal lymphadenopathy. Darkfield microscopy, serologic tests (RPR, TP-PA for syphilis; HSV serology), and PCR testing can confirm the diagnosis. Consider implementing point-of-care testing for syphilis and HSV where available to expedite treatment. Learn more about the specific diagnostic criteria for each condition to enhance your differential diagnosis process.
Patient presents for sexually transmitted disease (STD) screening. Reason for visit includes concerns regarding potential exposure to sexually transmitted infections (STIs), routine sexual health checkup, or partner notification of a positive STD test. Patient reports (or denies) symptoms such as genital discharge, burning with urination, genital sores or ulcers, pelvic pain, abnormal vaginal bleeding, or testicular pain. Relevant sexual history obtained, including number of partners, type of sexual activity (vaginal, anal, oral), and condom use. Past medical history reviewed, including prior STDs, allergies, and current medications. Physical examination performed, noting any relevant findings such as genital lesions, lymphadenopathy, or abdominal tenderness. Laboratory tests ordered for chlamydia, gonorrhea, syphilis (RPR), HIV, herpes simplex virus (HSV), human papillomavirus (HPV) as indicated by patient history and risk factors. Patient education provided on safe sex practices, risk reduction strategies, and the importance of partner notification and treatment. Treatment plan discussed, including potential medications for positive STD results and follow-up testing. Patient verbalized understanding of risks, benefits, and potential complications of STD testing and treatment. Follow-up appointment scheduled for test results review and initiation of treatment if necessary. Diagnosis: STD screening. ICD-10 code Z11.3. CPT codes for laboratory tests performed documented separately.