Revenue Cycle Insider

Don’t forget to consider prolonged service codes when warranted.

When a patient is diagnosed with a sexually transmitted infection (STI), your provider may need to prescribe medications, counsel the patient, and even offer care to the patient’s sexual partner. But in some instances, the patient will simply get an STI screening, without any symptoms or firm diagnosis at all.

Reporting these situations can be fraught with coding challenges, whether the diagnosis is confirmed and simple or based on risk factors alone. Read on for more information on getting your STI coding correct the first time.

Evaluate Diagnosis Code Options

One of the biggest challenges for encounters to test for STIs involves which diagnosis code to use. There are several scenarios that you might encounter. Patients with STIs may present with symptoms, or they might simply request a screening due to other concerns.

In cases where patients have symptoms but test negative for an STI, you should code the visit with the diagnosis representing their symptoms. For instance, if a patient presents with vulvar itching, report ICD-10-CM code L29.2 (Pruritis vulvae).

If the patient has no symptoms but the provider performs a screening and a diagnosis isn’t confirmed, use the appropriate Z code, such as Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission), in most cases. The exception would be if 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)).

Depending on your physician’s documentation, other encounter codes, such as the contact and suspected exposure codes 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 come into play in this scenario.

If the patient tests positive for an STI, report the code for the confirmed diagnosis, such as A56.02 (Chlamydial vulvovaginitis). 

Lean Into the Office Visit Codes

You’ll report an evaluation and management (E/M) code for some STI encounters, depending on whether your documentation warrants it. For instance, if the provider spends time asking the patient about their sexual history, counseling the patient, and examining the patient before performing lab testing for an STI, you should be able to support a code from the 99202-99215 (Office or other outpatient visit for the evaluation and management …) series.

You should also report the corresponding lab test code, depending on the test performed. For instance, you might report 87491 (Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique) for chlamydia testing.

Keep in mind that if your E/M service is prolonged — for instance, if a patient and their partner have a lot of questions about the STI you’ve diagnosed them with — you can report prolonged service codes to reflect the extra time spent with the patient. You’d report +99417 (Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service) along with the applicable E/M code.

If you’re coding based on medical decision making (MDM), be sure and take any prescription management decisions into account when calculating MDM. For instance, if the provider is evaluating the difference between metronidazole and clindamycin to treat bacterial vaginosis, they can count that toward the number of diagnoses or management options considered when pinpointing the MDM level.

Remember Preventive Service Codes

For patients who are concerned about getting an STI but don’t currently have any symptoms, you may instead report a preventive medicine code such as 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …), depending on your documentation.

Example: A 23-year-old patient presents because she is planning to be sexually active for the first time. She asks the provider for information about how to prevent an STI. The provider spends 45 minutes discussing prevention strategies with the patient, and you report 99403 for this visit.

Medicare Covers Screening Under G0445

Medicare covers high-intensity behavior counseling (HIBC) to prevent STIs “for all sexually active adolescents and for adults at increased risk for STIs,” the Centers for Medicare & Medicaid Services (>CMS) says. The national coverage determination (NCD) is rooted in the United States Preventive Services Task Force (USPSTF) recommendations for STIs.

If you’re billing Medicare for this service, report G0445 (High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes).

The high/increased risk individual sexual behaviors indicated by USPSTF include any of the following:

• 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 for women for chlamydia and gonorrhea)
• Having an STI within the past year
• Intravenous (IV) drug use (hepatitis B only)
• For men: men having sex with men (MSM) and engaged in high-risk sexual behavior, but no regard to age

In addition to individual risk factors, physicians should consider community social factors such as high prevalence of STIs in the community populations when determining whether a patient is at high/increased risk for STIs and when recommending HIBC.

CMS notes that you can report G0445 “on the same date of service as an annual wellness visit, evaluation and management service, or during the global billing period for obstetrical care, but only one HIBC may be paid on any one date of service.”

Torrey Kim, Contributing Writer, Raleigh, North Carolina