ICD-10 Code for Asymptomatic STI Screening Without Known Exposure
For an asymptomatic patient with no known exposure seeking STI screening, use ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission).
Primary Code Selection
- Z11.3 is the appropriate code for routine STI screening in asymptomatic individuals without documented exposure 1
- This code specifically covers encounters where the patient is requesting screening for sexually transmitted infections as a preventive measure 1
Alternative Codes Based on Clinical Context
If Risk Factors Are Present
While the patient reports "no known exposure," if you identify risk factors during history-taking, consider these additional codes:
- Z72.51 - High-risk heterosexual behavior (if applicable based on sexual history) 2
- Z72.52 - High-risk homosexual behavior (for men who have sex with men) 2
- Z72.53 - High-risk bisexual behavior 2
- Z20.2 - Contact with and exposure to infections with a predominantly sexual mode of transmission (if partner history suggests potential exposure) 3, 2
For Specific Screening Contexts
- Z11.4 - Encounter for screening for human immunodeficiency virus (HIV), if HIV testing is specifically requested 1
- Z11.59 - Encounter for screening for other viral diseases, if hepatitis screening is included 1
Important Coding Considerations
Documentation Requirements
- The medical record should clearly document that the patient is asymptomatic and presenting specifically for screening purposes 3, 1
- Document any risk factors identified during sexual history, as this supports the medical necessity of screening 3, 1
- Note that screening recommendations vary by age, with sexually active individuals under 25 years having the highest STI prevalence rates 1
Common Pitfalls to Avoid
- Do not use disease-specific codes (such as A54.9 for gonorrhea or A74.9 for chlamydia) unless laboratory results confirm infection 4, 2
- Avoid using Z20.6 (Contact with and exposure to HIV) unless there is documented HIV exposure, as this code implies known contact 2
- Do not code symptoms if the patient is truly asymptomatic; symptom codes (R30-R39 for genitourinary symptoms) should only be used when symptoms are present 2
Insurance and Reimbursement Context
- Screening codes like Z11.3 typically align with preventive care benefits under the Affordable Care Act, which mandates coverage for STI screening in high-risk populations without cost-sharing 3, 1
- Many insurers require documentation of risk factors (age under 25, multiple partners, new partner, inconsistent condom use) to justify screening frequency beyond annual intervals 3, 1
- For patients requiring more frequent screening (every 3-6 months), such as men who have sex with men with multiple partners or HIV-infected individuals, document specific high-risk behaviors to support medical necessity 1, 5