Who Is Covered

All Medicare beneficiaries

   • 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.

HCPCS/CPT Codes

86631 - Chlamydia antibody

86632 - Chlamydia igm antibody

87110 - Chlamydia culture

87270 - Chlamydia trachomatis antigen direction by immunofluorescent

87320 - Chylmd trach antigen direction by immunoassay

87490 - Chylmd trach direction by necleic acid direct probe

87491 - Chylmd trach direction by necleic acid amplified probe

87810 - Chylmd trach immunoassay w/optic

87590 - Neisseria gonorrhoeae direction by necleic acid direct probe

87591 - Neisseria gonorrhoeae direction by necleic acid amplified probe

87850 - Neisseria gonorrhoeae immunoassay w/optical

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 - Hepatitis B (hepatitis B surface antigen)

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-10-CM Codes

For screening for chlamydia, gonorrhea, and syphilis in women at increased risk for STIs who are not pregnant report:

   • Z11.3 and

   • Z72.89

For screening for syphilis in men at increased risk, report:

   • Z11.3 and

   • Z72.89

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

   • Z11.3, Z72.89 and

   • Z34.00, (Z34.80 or Z34.90), or (O09.90, O09.91, O09.92, or O09.93)

For screening for syphilis in pregnant women, report:

   • Z11.3, Z34.00 and

   • (Z34.80 or Z34.90) or (O09.90, O09.91, O09.92, or O09.93)

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

   • Z11.3, Z72.89 and

   • Z34.00, (Z34.80 or Z34.90), or (O09.90, O09.91, O09.92, or O09.93)

For screening for hepatitis B in pregnant women, report:

   • Z11.59 and

   • Z34.00, (Z34.80 or Z34.90), or (O09.90, O09.91, O09.92, or O09.93)

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

   • Z11.59, Z72.89 and

   • Z34.00, (Z34.80 or Z34.90), or (O09.90, O09.91, O09.92, or O09.93)

Note: For HIBC: No specific diagnosis code

Note: Contact local Medicare Administrative Contractor (MAC) for guidance

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

Medicare Beneficiary Pays

   • Copayment waived

   • Coinsurance waived

   • Deductible waived

References