Preventive Services

Preventive Services Guide

Screening for Sexually Transmitted Infections and HIBC to Prevent STIs

Table of Contents

[Return to Top]

Screening for Sexually Transmitted Infections

If you are sexually active, getting tested for STDs is one of the most important things you can do to protect your health. Make sure you have an open and honest conversation about your sexual history and STD testing with your doctor and ask whether you should be tested for STDs.

[Return to Top]

Coverage Criteria

Medicare beneficiaries are covered for screening for STIs and HIBC to prevent STIs when meeting the following requirements:

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

[Return to Top]

High/Increased Risk Factors

  • Multiple sex partners
  • Using barrier protection inconsistently
  • Having sex under 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
  • Men having sex with men and engaged in high-risk sexual behavior (no age requirement)
  • IV drug use (for hepatitis B only)
  • Community social factors per USPSTF recommendations (chlamydia, gonorrhea and syphilis)

[Return to Top]

Frequency Limits

  • Chlamydia and Gonorrhea
    • Women at increased risk
      • Annual screening
    • Pregnant women 24 years old or younger
      • Initial screening when a pregnancy is confirmed
      • Repeated during the third trimester if high-risk sexual behavior has occurred since the initial screening test
    • Pregnant women who are at an increased risk
      • Initial screening when pregnancy is confirmed
      • Repeated during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Syphilis
    • One annual occurrence for women at increased risk who are not pregnant
    • One annual occurrence for men at increased risk
    • Pregnant women
      • Initial screening when a pregnancy diagnosis is known
      • Repeated during the third trimester if high-risk sexual behavior has occurred
      • At delivery if high-risk sexual behavior has occurred since screening

[Return to Top]

HCPCS/CPT Coding

  • Chlamydia
    • 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810
    • 87800 (combined chlamydia/gonorrhea test)
  • Gonorrhea
    • 87590, 87591, 87850
    • 87800 (combined chlamydia/gonorrhea test)
  • Chlamydia and Gonorrhea
    • 0353U: Infectious agent detection by nucleic acid (DNA), Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique, urine, vaginal, pharyngeal, or rectal, each pathogen reported as detected or not detected
    • 0402U: Infectious agent (sexually transmitted infection), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiplex amplified probe technique, vaginal, endocervical, or male urine, each pathogen reported as detected or not detected
  • Syphilis
    • 86592, 86593, 86780
  • Hepatitis B (Hepatitis B Surface Antigen)

[Return to Top]

ICD-10-CM Diagnosis Coding

  • Non-Pregnant and High-Risk Women (screening for chlamydia, gonorrhea, or syphilis)
    • Z11.3 and any of these: Z72.51, Z72.52, Z72.53, Z72.89
  • High-Risk Pregnant Women (screening for chlamydia, gonorrhea, or syphilis)
    • Z11.3 and any of these: Z72.51, Z72.52, Z72.53, Z72.89; and 1 of these: 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, O09.93
  • Pregnant Women (screening for syphilis)
    • Z11.3 and 1 of these: 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, O09.93
  • High-Risk Men (screening for syphilis)
    • Z11.3 and any of these: Z72.51, Z72.52, Z72.53, Z72.89
  • For proper ICD-10-CM coding, please review the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18 “Preventive and Screening Services”, Section 170.
    • Note: Some procedures require more than one diagnosis code to be reported

[Return to Top]

Who Can Perform?

Must be performed by a Medicare eligible primary care provider in a primary care setting.

  • General practice
  • Family practice
  • Internal medicine
  • Obstetrics/gynecology
  • Pediatric medicine
  • Geriatric medicine
  • Certified nurse midwife
  • Nurse practitioner
  • Certified clinical nurse specialist
  • Physician assistant

[Return to Top]

Applicable Places of Service

  • Physician’s office
  • Off campus outpatient hospital
  • On campus outpatient hospital
  • Independent clinic
  • State or local public health clinic
  • Independent laboratory

[Return to Top]

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

[Return to Top]

Reimbursement

[Return to Top]

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

[Return to Top]

Common Claim Denial Reasons

  • The information provided does not support the need for this service or item
  • Screening lab test was not ordered by the primary care provider
  • Invalid ICD-10-CM code

[Return to Top]

High Intensity Behavioral Counseling to Prevent Sexually Transmitted Infections

Coverage Criteria

Two individual 30 minute face-to-face counseling sessions are covered annually for the following Medicare beneficiaries:

  • All sexually active adolescents
  • Adults at increased risk for STIs

[Return to Top]

High/Increased Risk Factors

  • Multiple sex partners
  • Using barrier protection inconsistently
  • Having sex under influence of alcohol or drugs
  • Having sex in exchange for money or drugs
  • Having an STI within the past year
  • Men having sex with men and engaged in high-risk sexual behavior (no age requirement)
  • Community social factors

[Return to Top]

HIBC Components and Documentation

  • Education
  • Skills training
  • Guidance on how to change sexual behavior
  • Documentation must clearly support diagnosis of high risk for STIs and must clearly reflect components of service

[Return to Top]

HCPCS/CPT Coding

  • G0445: Semi-annual high-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior, 30 minutes

[Return to Top]

ICD-10-CM Diagnosis Coding

  • Z72.89: Other problems related to lifestyle

[Return to Top]

Who can perform?

Must be performed by a Medicare eligible primary care provider in a primary care setting.

  • General practice
  • Family practice
  • Internal medicine
  • Obstetrics/gynecology
  • Pediatric medicine
  • Geriatric medicine
  • Certified nurse midwife
  • Nurse practitioner
  • Certified clinical nurse specialist
  • Physician assistant

[Return to Top]

Applicable Places of Service

  • Physician’s office
  • Off campus outpatient hospital
  • On campus outpatient hospital
  • Independent clinic
  • State or local public health clinic

[Return to Top]

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

[Return to Top]

Reimbursement

[Return to Top]

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

[Return to Top]

Other Services

Can be performed on the same date of service as:

  • Annual wellness visit (AWV)
  • Evaluation and management service (E/M)
    • Must have significant and separately identifiable diagnosis code
    • Should not be billed when sole reason for visit is HIBC
  • During the global period for obstetrical care

[Return to Top]

Common Claim Denial Reasons

  • Service performed more frequently than allowed
  • ICD-10-CM code is not covered
  • Not covered when performed in this type of setting

[Return to Top]

Related Content

Revised 9/27/2024