Edition 1: Medicare’s Coverage for Sexually Transmitted Infections Screening Tests[1],[2]

Edition 1: Medicare’s Coverage for Sexually Transmitted Infections Screening Tests[1],[2]

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Medicare now provides coverage for screening of sexually transmitted infections (STIs) as well as coverage for high intensity behavioral counseling (HIBC) to prevent STIs. The screening tests that will be covered are for Chlamydia, Gonorrhea, Syphilis and Hepatitis B.

 

Chlamydia and Gonorrhea Screening

Chlamydia and Gonorrhea screening tests are only indicated for the following beneficiaries:

  • Pregnant women who are 24 years old or younger when the diagnosis of pregnancy is known then repeat testing during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Pregnant women who are at increased risk for STIs when the diagnosis of pregnancy is known then repeat testing during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Women at increased risk for STIs annually

The following CPT3 codes are covered for Chlamydia and Gonorrhea screening:

  • 86631 Antibody Chlamydia
  • 86632 Antibody, Chlamydia , IgM
  • 87110   Culture, Chlamydia, any source
  • 87270 Infectious agent antigen detection by Immunofluorescent technique; Chlamydia trachomatis
  • 87320 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis
  • 87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
  • 87491     Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
  • 87810 Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
  • 87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
  • 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique
  • 87850 Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae
  • 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique (used for combined Chlamydia and Gonorrhea testing)

 

The following ICD-9-CM4 codes should be utilized for Chlamydia and Gonorrhea screening:

  • For claims for women at increased risk for STIs:
    • 5   Special screening examinations for bacterial and spirochetal diseases; venereal disease

AND

  • 8 Other problems related to lifestyle
    • For claims for pregnant women at increased risk for STIs use the two codes listed above as well as one of the following:
      • 0 Supervision of normal first pregnancy
      • 1 Supervision of other normal pregnancy
      • 9 Unspecified high-risk pregnancy

 

Syphilis Screening

Syphilis screening tests are only indicated for the following beneficiaries:

  • Pregnant women who are at increased risk for STIs when the diagnosis of pregnancy is known then repeat testing during the third trimester if high-risk sexual behavior has occurred since the initial screening test
  • Men and women at increased risk for STIs annually

 

The following CPT codes are covered for Syphilis screening:

  • 86592 Syphilis test, non-treponemal antibody; qualitative (eg. VDRL, RPR, ART)
  • 86593 Syphilis test, non-treponemal antibody; quantitative
  • 86780 Antibody; Treponema palidum

 

The following ICD-9-CM codes should be utilized for Syphilis screening:

  • For claims for men and women at increased risk for STIs:
    • 5   Special screening examinations for bacterial and spirochetal diseases; venereal disease

AND

  • 8 Other problems related to lifestyle
    • For claims for pregnant women:
  • 5   Special screening examinations for bacterial and spirochetal diseases; venereal disease

AND one of the following:

  • 0 Supervision of normal first pregnancy
  • 1 Supervision of other normal pregnancy
  • 9 Unspecified high-risk pregnancy
    • For claims for pregnant women at increased risk for STIs:
  • 5   Special screening examinations for bacterial and spirochetal diseases; venereal disease

AND

  • 8 Other problems related to lifestyle

AND one of the following:

  • 0 Supervision of normal first pregnancy
  • 1 Supervision of other normal pregnancy
  • 9 Unspecified high-risk pregnancy

 

Hepatitis B (hepatitis B surface antigen) Screening

Hepatitis B screening tests are only covered for the following beneficiaries:

  • Pregnant women at the first prenatal visit when the diagnosis of pregnancy is known and then rescreening at time of delivery for those with new or continuing risk factors.

 

The following CPT codes are covered for Hepatitis B screening:

  • 87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAg)
  • 87341 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAg) neutralization

 

The following ICD-9-CM codes should be utilized for Hepatitis B screening:

  • For claims for pregnant women:
    • 89 Special screening for other specified viral diseases

AND one of the following

  • 0 Supervision of normal first pregnancy
  • 1 Supervision of other normal pregnancy
  • 9 Unspecified high-risk pregnancy
    • For claims for pregnant women at increased risk for STIs:
  • 89 Special screening for other specified viral diseases

                  AND

  • 8 Other problems related to lifestyle

AND one of the following

  • 0 Supervision of normal first pregnancy
  • 1 Supervision of other normal pregnancy
  • 9 Unspecified high-risk pregnancy

 

High/increased risk sexual behavior for STIs is determined by the primary care provider by assessing the patient’s sexual history which is part of any complete medical history, typically part of an annual wellness visit or prenatal visit and considered in the development of a comprehensive prevention plan.

 

High Intensity Behavioral Counseling (HIBC)

Medicare will also cover up to two individual 20 to 30 minute counseling sessions annually for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting.

 

The following HCPCS code is to be used for HIBC:

  • G0445 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; performed semi-annually, 30 minutes

 

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[1] https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=250

2 Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services

3 CPT 2013

4 ICD-9-CM 2013

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