ICD-10 Coding for Sexually Transmitted Infections(A56.01, Z11.3)
Complete ICD-10-CM coding and documentation guide for Sexually Transmitted Infections. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sexually Transmitted Infections
A50-A64Primary Range
Infections with a predominantly sexual mode of transmission
This range includes all primary codes for sexually transmitted infections, covering specific pathogens and conditions.
Encounter for screening for sexually transmitted infections
These codes are used for screening encounters when no symptoms are present.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A56.01 | Chlamydial infection of lower genitourinary tract | Use when Chlamydia trachomatis is confirmed via lab testing. |
|
| Z11.3 | Encounter for screening for infections with a predominantly sexual mode of transmission | Use for routine screening in asymptomatic individuals. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for Chlamydia
Essential facts and insights about Sexually Transmitted Infections
Primary ICD-10-CM Codes for sexually transmitted infection
Decision Criteria
clinical Criteria
- Positive NAAT for Chlamydia trachomatis
Applicable To
- Chlamydia trachomatis infection
Excludes
- Chlamydial infection of eye (A71.-)
Clinical Validation Requirements
- Positive nucleic acid amplification test (NAAT) for Chlamydia trachomatis
Code-Specific Risks
- Ensure specificity by confirming the organism and site.
Coding Notes
- Ensure documentation specifies the organism and method of confirmation.
Z11.3 - Encounter for screening for infections with a predominantly sexual mode of transmission
Use for routine screening in asymptomatic individuals.
Applicable To
- Screening for sexually transmitted infections
Excludes
- Screening for HIV (Z11.4)
Clinical Validation Requirements
- Documented risk factors or routine screening in asymptomatic patients
Coding Notes
Ensure documentation supports the absence of symptoms.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
High-risk heterosexual behavior
Z72.51Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Gonococcal infection of lower genitourinary tract
A54.00Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sexually Transmitted Infections to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A56.01.
Impact
Clinical: Leads to vague clinical data., Regulatory: May result in non-compliance with coding standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Always verify lab results before coding., Use the most specific code available.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use specific infection codes when symptoms are present.
Impact
Using screening codes for symptomatic patients.
Mitigation Strategy
Educate providers on proper code selection based on symptoms.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Sexually Transmitted Infections, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sexually Transmitted Infections
Use these documentation templates to ensure complete and accurate documentation for Sexually Transmitted Infections. These templates include all required elements for proper coding and billing.
Routine STI Screening
Specialty: Family MedicineRequired Elements
- Patient history
- Risk factors
- Screening tests ordered
- Results
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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