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HCPCS/CPT Codes

86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 – Chlamydia

87590, 87591, 87850 – Neisseria gonorrhoeae

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

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

86593 - Syphilis test, non-treponemal, quantitative

86780 – Treponema pallidum

87340, 87341 – Hepatitis B (hepatitis B surface antigen)

G0445 - Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior, 30 minutes

ICD-9-CM (ICD-10-CM) Codes

Z11.3, Z72.89, Z72.51, Z72.52, Z72.53, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, and O09.93

For screening for chlamydia, gonorrhea, and syphilis in women at increased risk for STIs who are not pregnant report V74.5 (Z11.3) and V69.8 (Z72.89)

For screening for syphilis in men at increased risk, report V74.5 (Z11.3) and V69.8 (Z72.89)

For screening for chlamydia and gonorrhea in pregnant women at increased risk for STIs, report:

V74.5 (Z11.3), V69.8 (Z72.89); and

V22.0 (Z34.00), V22.1 (Z34.80 or Z34.90), or V23.9 (O09.90, O09.91, O09.92, or O09.93)

For screening for syphilis in pregnant women, report:

V74.5 (Z11.3), V22.0 (Z34.00); and

V22.1 (Z34.80 or Z34.90) or V23.9 (O09.90, O09.91, O09.92, or O09.93)

For screening for syphilis in pregnant women at increased risk for STIs, report:

V74.5 (Z11.3), V69.8 (Z72.89); and

V22.0 (Z34.00), V22.1 (Z34.80 or Z34.90), or V23.9 (O09.90, O09.91, O09.92, or O09.93)

For screening for hepatitis B in pregnant women, report:

V73.89 (Z11.59); and

V22.0 (Z34.00), V22.1 (Z34.80 or Z34.90), or V23.9 (O09.90, O09.91, O09.92, or O09.93)

For screening for hepatitis B in pregnant women at increased risk for STIs, report:

V73.89 (Z11.59), V69.8 (Z72.89); and

V22.0 (Z34.00), V22.1 (Z34.80 or Z34.90), or V23.9 (O09.90, O09.91, O09.92, or O09.93)

For HIBC: No specific diagnosis code

Contact local Medicare Administrative Contractor (MAC) for guidance

Who Is Covered

Certain Medicare beneficiaries who are:

Sexually active adolescents and adults at increased risk for STIs; and
Referred for this service by a primary care provider and provided by a Medicare-eligible primary care provider in a primary care setting

NOTE: More information on covered beneficiaries and a definition of “increased risk for STIs” can be found in the Medicare National Coverage Determinations Manual, Publication 100-03, Chapter 1 , Section 210.10.

Frequency

One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant
One annual occurrence of screening for syphilis in men at increased risk
Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening
One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs
One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence at delivery if at continued increased risk for STIs
Up to two 20-30 minute, face-to-face HIBC counseling sessions annually

Beneficiary Pays

Copayment/coinsurance waived
Deductible waived

Other Notes

For more information about increased risk for STIs and covered Medicare beneficiaries, refer to the Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 210.10.