Find information on Venereal Disease Screening, including STD testing, STI diagnosis, sexually transmitted infection treatment, and clinical documentation guidelines. This resource covers medical coding for venereal diseases, healthcare protocols for STD screening, and information on laboratory testing for sexually transmitted infections. Learn about appropriate diagnostic codes, billing procedures, and best practices for documenting venereal disease diagnoses in patient records.
Also known as
Infections with a predominantly sexual mode of transmission
Covers syphilis and other venereal diseases like chlamydia, gonorrhea.
Special screening examination for infectious and parasitic diseases
Encompasses screening for various infectious diseases, including some STIs.
Symptoms and signs involving the digestive system and abdomen
May be relevant for some STI symptoms like abdominal pain or discomfort.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the screening encounter for syphilis?
Yes
Syphilis confirmed?
No
Is the screening for gonorrhea?
When to use each related code
| Description |
|---|
| Venereal disease screening |
| Chlamydia infection |
| Gonorrhea infection |
Using unspecified codes like R11 when a more specific diagnosis is documented leads to inaccurate reporting and lost revenue.
Coding a venereal disease screening as a confirmed diagnosis without supporting documentation poses compliance risks and claim denials. Use Z11.3.
Failing to code the specific site or type of VD (e.g., syphilis, gonorrhea) results in undercoding and affects quality metrics.
Patient presents for venereal disease screening (VD screening, STD testing, STI screening) due to [reason for screening, e.g., new sexual partner, routine checkup, concerns about exposure, specific symptoms]. Patient reports [sexual history relevant to risk assessment, e.g., number of partners, type of sexual activity, condom use]. Physical examination reveals [relevant findings or "unremarkable"]. Based on patient history and risk factors, the following tests were ordered: [list tests, e.g., Chlamydia trachomatis test, Neisseria gonorrhoeae test, syphilis test (RPR, VDRL), HIV test, herpes simplex virus (HSV) testing, hepatitis B and C testing, Trichomonas vaginalis test]. Patient education provided regarding safe sex practices, transmission of STIs, and the importance of follow-up. Results will be discussed with the patient upon their availability. Diagnosis: Z11.3 (Encounter for screening for sexually transmitted diseases). Differential diagnoses include [list potential alternative diagnoses if applicable, e.g., urinary tract infection, candidiasis]. Plan: Await laboratory results. Patient will be contacted for follow-up and treatment if necessary. Counseling on risk reduction and prevention strategies will be reinforced.