Internal Medicine Coding Alert

Question: Our internal medicine physician recently saw a 25-year-old female patient in our practice. He suspected that this patient had high risk sexual behavior and had been exposed to a sexually transmitted disease and performed a Pap smear. What diagnosis code(s) should I report for this encounter?

Indiana Subscriber

Answer: Since your internist was suspecting that the patient had high risk sexual behavior, you should report the diagnosis from one of these ICD-10 codes based on which gender her sexual partner(s) is:

• Z72.51 (High risk heterosexual behavior)
• Z72.52 (High risk homosexual behavior)
• Z72.53 (High risk bisexual behavior)

Since your clinician also suspected that the patient had been exposed to a sexually transmitted disease, you will also have to report Z20.2 (Contact with and [suspected] exposure to infections with a predominantly sexual mode of transmission) as a secondary diagnosis code.

Although Z72.5- does not specifically mention what “high risk sexual behavior” amounts to, Medicare lists several high risk factors that can be taken into account when reporting Z72.51 related to screening pap smears for cervical or vaginal cancer. These factors include:

• Early onset of sexual activity (under 16 years of age)
• Multiple sexual partners (five or more in a lifetime)
• History of sexually transmitted disease (including HIV infection)
• Fewer than three negative or any Pap smears within the previous seven years
• DES (diethylstilbestrol) -- exposed daughters of women who took DES during pregnancy.

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