ICD-10 Coding for STI Exposure(Z20.2, Z20.6)
Complete ICD-10-CM coding and documentation guide for STI Exposure. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to STI Exposure
Z20-Z29Primary Range
Contact with and (suspected) exposure to communicable diseases
This range includes codes for exposure to communicable diseases, including sexually transmitted infections and HIV.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z20.2 | Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission | Use when a patient has been exposed to a sexually transmitted infection through sexual contact. |
|
| Z20.6 | Contact with and (suspected) exposure to HIV | Use for patients exposed to HIV, such as through needle-stick injuries or sexual contact with an HIV-positive partner. |
|
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 STI exposure
Essential facts and insights about STI Exposure
Primary ICD-10-CM Codes for soft tissue injury exposure
Decision Criteria
clinical Criteria
- Patient reports unprotected sexual contact with a known STI-positive partner.
Applicable To
- Exposure to sexually transmitted infections
Excludes
- HIV exposure (Z20.6)
Clinical Validation Requirements
- Documented sexual contact with an infected partner
- High-risk sexual behavior
Code-Specific Risks
- Incorrectly coding as lifestyle problem (Z72.89)
Coding Notes
- Ensure documentation specifies the type of exposure and risk factors.
Z20.6 - Contact with and (suspected) exposure to HIV
Use for patients exposed to HIV, such as through needle-stick injuries or sexual contact with an HIV-positive partner.
Applicable To
- Exposure to HIV
Excludes
- Exposure to other sexually transmitted infections (Z20.2)
Clinical Validation Requirements
- Documented exposure to an HIV-positive individual
- Needle-stick injury from an HIV-positive source
Coding Notes
Ensure proper sequencing with Z20.6 as the primary code for HIV exposure scenarios.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting STI Exposure to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z20.2.
Impact
Clinical: Potential for missed diagnosis and inadequate patient care., Regulatory: Non-compliance with documentation standards., Financial: Risk of claim denials due to insufficient documentation.
Mitigation Strategy
Ensure comprehensive sexual history is documented., Include all relevant test results and risk factors.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records and epidemiological data.
Mitigation Strategy
Ensure Z20.2 is used for documented STI exposure.
Impact
Inadequate documentation of exposure details.
Mitigation Strategy
Implement standardized templates for documenting exposure scenarios.
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 STI Exposure, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for STI Exposure
Use these documentation templates to ensure complete and accurate documentation for STI Exposure. These templates include all required elements for proper coding and billing.
Primary Care PrEP Visit
Specialty: Primary CareRequired Elements
- Patient's sexual history
- HIV test results
- Renal function monitoring
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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