STI Screening Under Medicare

STI Screening Under Medicare

The Centers for Disease Control and Prevention (CDC) estimates nearly 20 million new, sexually transmitted infections (STI) occur every year in the United States, accounting for almost $16 billion in healthcare costs. Medicare covers STI screenings for chlamydia, gonorrhea, syphilis, and hepatitis B once every 12 months, or at certain times during pregnancy. Certain conditions must be met, however.

Screening for Chlamydia and Gonorrhea

The CDC reported a 1.5 percent increase in chlamydia cases from 2012 to 2013. Those eligible for screening include:

  • Pregnant women age 24 years or younger when a pregnancy diagnosis is known, with repeat screening during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Pregnant women who are at increased risk for STIs when a pregnancy diagnosis is known, with repeat screening during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Women at increased risk for STIs, annually

Screening for Syphilis

The CDC reported a 10 percent increase in syphilis cases, predominantly among gay and bisexual men, and a 4 percent increase in congenital syphilis from 2012 to 2013. Beneficiaries eligible for screening include:

  • Pregnant women when a pregnancy diagnosis is known, with repeat screening during the third trimester and at delivery if high-risk sexual behavior has occurred since the previous screening test
  • Men and women at increased risk for STIs, annually

Screening for Hepatitis B

The CDC reported a 5.3 percent increase in acute hepatitis B cases from 2012 to 2013. Those eligible for screening include:

  • Pregnant women at the first prenatal visit when the diagnosis of pregnancy is known, with rescreening at time of delivery for those with new or continuing risk factors.

CMS identifies the following as behaviors/factors putting individuals at high risk for STIs:

  • Multiple sex partners
  • Using barrier protection inconsistently
  • Having sex under the influence of alcohol or drugs
  • Having sex in exchange for money or drugs
  • Age (24 years of age or younger, and sexually active women for chlamydia and gonorrhea)
  • Having an STI within the past year
  • IV drug use (for hepatitis B only)
  • Men having sex with men and engaged in high-risk sexual behavior, regardless of age

Screening for HIV

The CDC reported an overall stabilization of new HIV infections diagnosed annually in the United States, at 50,000 cases. Under a separate national coverage determination (NCD 210.7), Medicare covers a maximum of one, annual voluntary HIV screening for beneficiaries:

  • Between the ages of 15 and 65, without regard to perceived risk
  • Younger than 15 or older than 65 who are at increased risk for HIV infection, as defined by USPSTF guidelines (see below)

Pregnant women have different coverage parameters. A maximum of three voluntary HIV screenings for pregnant Medicare beneficiaries is covered:

  1. When the diagnosis of pregnancy is known;
  2. During the third trimester; and
  3. At labor, if ordered by the woman’s clinician.

HIV Risk Factors

The USPSTF identifies the following individuals at high risk for HIV infection:

  • Men who have had sex with men after 1975
  • Men and women having unprotected sex with multiple partners
  • Past or present injection drug users
  • Men and women who exchange sex for money or drugs, or have sex partners who do
  • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users
  • Persons being treated for sexually transmitted diseases
  • Persons with a history of blood transfusion between 1978 and 1985
  • Persons who request an HIV test despite reporting no individual risk factors, as this group is likely to include individuals not willing to disclose high-risk behaviors

In addition to individual risk factors, community social factors — such as high prevalence of STIs in the community populations — are considered in determining high/increased risk for chlamydia, gonorrhea, and syphilis, and for recommending high-intensity behavioral counseling.

Diagnosis Coding

Claims for STI screening should include the appropriate screening diagnosis code, such as ICD-10-CM code Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission (ICD-9-CM code V74.5 Screening examination for venereal disease) or Z11.59 Encounter for screening for other viral diseases (ICD-9-CM V73.89 Special screening examination for other specified viral diseases) with the screening lab tests.

Diagnosis codes Z72.51 High risk heterosexual behavior, Z72.52 High risk homosexual behavior and Z72.53 High risk bisexual behavior (ICD-9-CM V69.8 Other problems related to lifestyle) indicate the beneficiary is at high or increased risk for STIs.

Diagnosis codes Z34.0x Encounter for supervision of normal first pregnancy (ICD-9-CM V22.0 Supervision of normal first pregnancy), Z34.8x Encounter for supervision of other normal pregnancy (ICD-9-CM V22.1 Supervision of other normal pregnancy), or O09.9x Supervision of high risk pregnancy, unspecified (ICD-9-CM V23.9 Supervision of unspecified high-risk pregnancy) are to be used in addition to the above coding, when appropriate.

The Medicare Claims Processing Manual (publication 100-3, chapter 18, section 130) indicates that you should list diagnosis code V73.89 as primary and V69.8 as secondary for high/increased risk beneficiaries, which crosswalk to ICD-10-CM Z11.4 Encounter for screening for human immunodeficiency virus (HIV) as primary, and Z72.51, Z72.52, or Z72.53 as secondary.

The following examples include only coding for laboratory services, and do not include coding for the office visit or specimen collection.

Example 1: A 66-year-old female presents to her primary care physician with sores around her mouth. Her social history indicates multiple heterosexual risk factors for STIs and HIV, categorizing her as high risk. The physician orders a rapid HIV 1/2 screen, immunoassay screens for chlamydia and gonorrhea, and a qualitative syphilis screen.

Procedure coding is: G0435, 86592, 87810, 87850. ICD-10-CM coding is: Z11.4, Z72.51, Z11.3

Example 2: A male Medicare beneficiary presents to his primary care physician with penile warts and requests an STI screen. His physician provides counseling, prescribes medications, and orders chlamydia and gonorrhea screens by polymerase chain reaction, a rapid HIV test, and a qualitative syphilis test.

Procedure coding is: G0435, 86592, 87491, 87591. ICD-10-CM coding is: Z11.4, Z11.3.

This article is not meant as a replacement for Medicare guidance. Always refer to the respective payer guidelines for specific instructions in each case.

Procedure Coding

Common CPT® codes associated with STI screening include:

Chlamydia

86631 Antibody; Chlamydia

86632 Antibody; Chlamydia, IgM

87110 Culture, chlamydia, any source

87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis

87320 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis

87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique

87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique

87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique

87810 Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis

Gonorrhea

87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, direct probe technique

87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, amplified probe technique

87850 Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhea

87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique

Syphilis

86592 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)

86593 Syphilis test, non-treponemal antibody; quantitative

86780 Antibody; Treponema pallidum

Hepatitis B

87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)

87341 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) neutralization

HIV (Medicare HCPCS Level II)

G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening

G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening

G0435 Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening

Resources:

CDC, “CDC Face Sheet – Reported STDs in the United States 2013 National
Data for Chlamydia, Gonorrhea, and Syphilis,” Dec. 2014:
www.cdc.gov/nchhstp/newsroom/docs/std-trends-508.pdf

CDC, HIV Prevention in the United States, Expanding the Impact:
www.cdc.gov/nchhstp/newsroom.HIVFactSheets/Progress/Trends.htm

CDC, Prevention of HIV/AIDS, Viral Hepatitis, STDs, and TB Through Health Care.
Nov. 7, 2014: www.cdc.gov/nchhstp/PreventionThroughHealthCare/Index.htm

CDC, Table 3.1 Reported cases of acute hepatitis B, nationally and by state –
United States, 2009-2013: www.cdc.gov/hepatitis/statistics/2013surveillance/
index.htm#tabs-801937–1

CMS, Pub. 100-03, CR 7610, Transmittal 141, Jan. 26, 2012

CMS, Decision Memo for Screening for Sexually Transmitted Infections (STIs)
and High-Intensity Behavioral Counseling (HIBC) to prevent STIs (CAG-00246N).
Nov. 8, 2011: www.cms.gov/medicare-coverage-database/details/nca-decision-
memo.aspx?NCAId=250

CMS, NCD for Screening for HIV Infection (210.7): www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=335&ncdver=1&bc=AAAAgAAAAAAA&

CMS, pub. 100-03, chapter 1, section 210.7, Dec. 8, 2009

CMS, pub. 100-04, chapter 18, section 130, July 6, 2010

OIG, “OIG Compliance Program Guidance for Clinical Laboratories,” 63 FR 163 45079

Palmetto GBA, Lab Guidelines, Feb. 27, 2012:
www.palmettohealth.org/bodylab.cfm?id=2181&action=list&startingrow=38


 

Frank Mesaros, MPA, MT(ASCP), CPC, is a member of the Harrisburg, Pa., local chapter and CEO of Trusent Solutions, LLC, a management consulting firm specializing in the laboratory industry. Trusent provides revenue stream integrity services to regional laboratories, hospital based laboratories, and physician office based laboratories.

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One Response to “STI Screening Under Medicare”

  1. Jen says:

    Can you please clarify the ICD-10 coding in this article? If you code from an ICD-10-CM book, the proper code for screening for chlamydia is Z11.8 NOT Z11.3. We are interested in an answer to this because we are an independent lab billing for these services.

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