ICD-10 Coding for Venereal Disease(A56.00, Z11.3)
Complete ICD-10-CM coding and documentation guide for Venereal Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Venereal Disease
A50-A64Primary Range
Infections with a predominantly sexual mode of transmission
This range includes all primary codes for sexually transmitted infections, which are the main focus for venereal diseases.
Encounter for screening for infectious and parasitic diseases
This range includes codes for screening encounters, which are relevant for asymptomatic patients undergoing routine testing.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A56.00 | Chlamydial infection of lower genitourinary tract, unspecified | Use when a confirmed diagnosis of chlamydial infection is made via laboratory testing. |
|
| Z11.3 | Encounter for screening for infections with a predominantly sexual mode of transmission | Use for asymptomatic patients undergoing routine STI screening. |
|
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 venereal disease screening
Essential facts and insights about Venereal Disease
Primary ICD-10-CM Codes for venereal disease
Decision Criteria
clinical Criteria
- Presence of dysuria and abnormal discharge with positive NAAT for Chlamydia trachomatis.
Applicable To
- Chlamydia trachomatis infection
Excludes
- Chlamydial infection of the eye (A71.0)
Clinical Validation Requirements
- NAAT positive for Chlamydia trachomatis
Code-Specific Risks
- Incorrect use for screening purposes without confirmed infection.
Coding Notes
- Ensure laboratory confirmation before coding as A56.00.
Z11.3 - Encounter for screening for infections with a predominantly sexual mode of transmission
Use for asymptomatic patients undergoing routine STI screening.
Applicable To
- Routine STI screening
Excludes
- Screening for HIV (Z11.4)
Clinical Validation Requirements
- Patient asymptomatic and undergoing routine screening.
Coding Notes
Do not use if an infection is confirmed; switch to the specific infection code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
High-risk sexual behavior
Z72.51Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Gonococcal infection of lower genitourinary tract, unspecified
A54.00Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Venereal Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A56.00.
Impact
Clinical: Leads to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific terms and test results., Follow documentation templates.
Impact
Reimbursement: Claims may be denied if incorrect codes are used., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on STI prevalence and treatment.
Mitigation Strategy
Use the specific STI code (e.g., A56.00) for confirmed infections.
Impact
Using Z11.3 for symptomatic patients or confirmed infections.
Mitigation Strategy
Educate staff on proper code usage and documentation.
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 Venereal Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Venereal Disease
Use these documentation templates to ensure complete and accurate documentation for Venereal Disease. These templates include all required elements for proper coding and billing.
STI Screening Visit
Specialty: Family MedicineRequired Elements
- Chief Complaint
- Sexual History
- Physical Exam
- Testing
- Assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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