- Preventive Services Guide
- Medicare Preventive Services Resource Guide
- Alcohol Misuse and Counseling
- Annual Wellness Visit Screening
- Bone Mass Measurements
- Cardiovascular Disease Screening Tests
- Colorectal Cancer Screening
- Counseling to Prevent Tobacco Use
- Depression Screening
- Diabetes Screening
- Diabetes Self-Management Training
- Glaucoma Screening
- Hepatitis B Virus Screening
- Hepatitis B Virus Vaccine and Administration
- Hepatitis C Virus Screening
- Human Immunodeficiency Virus Screening
- Influenza Virus Vaccine and Administration
- Initial Preventive Physical Examination
- Intensive Behavioral Therapy for Cardiovascular Disease
- Intensive Behavioral Therapy for Obesity
- Lung Cancer Screening Counseling and Annual Screening for Lung Cancer with Low-Dose Computed Tomography
- Medical Nutrition Therapy
- Pneumococcal Vaccine and Administration
- Prolonged Preventive Services
- Prostate Cancer Screening
- Screening for Cervical Cancer with Human Papillomavirus Tests
- Screening for Sexually Transmitted Infections and HIBC to Prevent STIs
- Screening Mammography
- Screening Pap Tests
- Screening Pelvic Examinations
- Ultrasound Screening for Abdominal Aortic Aneurysm
- Vaccinations
- Related Articles
- Medicare Preventive Services Resource Guide
- The Annual Wellness Visit
- Medicare’s Annual Wellness Visit in Illinois: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Minnesota: Understanding the Benefit and Preventing Denials
- Medicare’s Annual Wellness Visit in Wisconsin: Understanding the Benefit and Preventing Denials
Preventive Services Guide
Screening for Sexually Transmitted Infections and HIBC to Prevent STIs
Table of Contents
- Screening for Sexually Transmitted Infections
- Coverage Criteria
- High/Increased Risk Factors
- High/Increased Risk Factors for Asymptomatic, Nonpregnant Adolescents and Adults (Hepatitis B)
- Frequency Limits
- HCPCS/CPT Coding
- ICD-10-CM Diagnosis Coding
- Who Can Perform?
- Applicable Places of Service
- Cost Sharing
- Reimbursement
- Nonparticipating Providers
- Common Claim Denial Reasons
- High Intensity Behavioral Counseling to Prevent Sexually Transmitted Infections
- Related Content
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.
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
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)
High/Increased Risk Factors for Asymptomatic, Nonpregnant Adolescents and Adults (Hepatitis B)
- Persons born in countries and regions with a high prevalence
- US born persons not vaccinated as infants whose parents were born in countries and regions with a high prevalence
- HIV positive persons
- Men who have sex with men
- IV drug use
- Household contact or sexual partners with HBV infections
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
- Women at increased risk
- 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
- Hepatitis B
- Annual screening for asymptomatic, nonpregnant adolescents and adults at high risk (have not received a hepatitis B vaccination)
- Pregnant women
- At the first prenatal visit
- Rescreening at the time of delivery with new or continuing risk factors
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
- G0499: HBV screening for asymptomatic, nonpregnant adolescents and adults at high risk
- 86704: Hepatitis B core antibody (HBcAb); total
- 86706: Hepatitis B surface antibody (HBeAb)
- 83740: Hepatitis B surface antigen (HBsAg)
- 83741: Hepatitis B surface antigen (HBsAg) neutralization
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
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
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
Cost Sharing
- Copayment/coinsurance waived
- Deductible waived
Reimbursement
- MPFS: Fee Schedule Lookup
Nonparticipating Providers
- Nonparticipating reduction applies
- Limiting charge provision applies
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
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
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
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
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
ICD-10-CM Diagnosis Coding
- Z72.89: Other problems related to lifestyle
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
Applicable Places of Service
- Physician’s office
- Off campus outpatient hospital
- On campus outpatient hospital
- Independent clinic
- State or local public health clinic
Cost Sharing
- Copayment/coinsurance waived
- Deductible waived
Reimbursement
- MPFS: Fee Schedule Lookup
Nonparticipating Providers
- Nonparticipating reduction applies
- Limiting charge provision applies
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
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
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services, Section170
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCDs) Manual, Chapter 1, Coverage Determinations, Part 4, Sections 200-310.1
- MLN® Educational Tool: Medicare Preventive Services
Revised 2/20/2024