Correctly Code This Asymptomatic STD Encounter
Question: If a patient is tested for a sexually transmitted disease (STD) but has no signs or symptoms, should I just code the visit as a screening? RCI Subscriber Answer: Yes. If the patient is showing no signs or symptoms at the visit, you should consider the test a screening and assign Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission) unless the provider was screening for human immunodeficiency virus (HIV) or human papillomavirus (HPV), which have their own separate encounter codes: Z11.4 (Encounter for screening for human immunodeficiency virus [HIV]) and Z11.51 (Encounter for screening for human papillomavirus (HPV)). Make note: If there is any mention of other exposure or suspected exposure within the physician’s documentation, other codes like Z20.6 (Contact with and (suspected) exposure to human immunodeficiency virus [HIV]), Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases), and Z20.89 (Contact with and (suspected) exposure to other communicable diseases) — or codes such as Z72.5- (High risk sexual behavior) or Z70.- (Counseling related to sexual attitude, behavior and orientation) — may be necessary in this scenario. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
