A64, Unspecified sexually transmitted disease
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be submitted with an appropriate covered diagnosis code (ICD-10-CM) that corresponds to the indications listed in the Coding Information; reimbursement is not allowed for services billed with non-covered diagnoses.
- Services must be submitted in accordance with the relevant criteria outlined in the Coverage Policy, including covered diagnosis and/or procedure code(s) (policy instruction: 'reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s). Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy').
- For asymptomatic screening indications, documentation should support high-risk behavior, high-risk condition or high-risk experience when used as the basis for testing (examples of supporting ICD-10 codes provided in the Coding Information: Z72.51-Z72.53, Z11.4, Z20.6, pregnancy-related Z-codes, sexual abuse codes T74.xx/T76.xx, etc.).
Key Coverage Criteria
- Nucleic acid pathogen testing for certain sexually transmitted infections is considered medically necessary for EITHER: (1) asymptomatic individual with any of the following: high-risk behavior (e.g., exposure to possible infected partner); high-risk condition (e.g., pregnancy, HIV infection); high-risk experience (e.g., assault); chlamydia screening in sexually active individual; gonorrhea screening in sexually active individual; human papillomavirus (HPV) cervical cancer screening; OR (2) symp [...]
- Nucleic acid testing for Candida species when criteria in the policy are met (CPTs listed e.g., 87480, 87481). Covered Candida-related diagnoses include pulmonary candidiasis, vulvovaginal candidiasis, candidal meningitis, candidal endocarditis, candidal sepsis, candidal esophagitis, candidal enteritis and other candidiasis sites, and associated screening/high-risk Z-codes (examples: B37.1, B37.31, B37.5, Z11.4, Z71.7, Z72.51-Z72.53).
- Nucleic acid testing for Chlamydia trachomatis when policy criteria are met (CPTs listed e.g., 87490,87491,87492). Covered diagnoses include chlamydial infections and related presentations (examples: A56.x, A64, cervicitis, urethritis, cystitis, pelvic inflammatory disease, sexual abuse encounter codes, pregnancy-related codes, and screening Z-codes).
- Nucleic acid testing for Gardnerella vaginalis when policy criteria are met (CPTs listed e.g., 81513,87510,87511). Covered diagnoses include bacterial vaginosis / vaginitis related codes and pregnancy/HIV/high-risk codes listed in the Coding Information.
- Nucleic acid testing for genital herpes (HSV types 1 & 2) when criteria met (CPTs listed e.g., 87528,87529). Covered diagnoses include anogenital herpes, viral meningitis/encephalitis, keratitis/ocular herpes, mucocutaneous herpes infections, and related Z-codes and transplant/immunocompromised status codes.
- Nucleic acid testing for HSV types 1 & 2 and Varicella zoster virus (VZV) panel when criteria are met (CPT listed e.g., 0527U). Covered diagnoses include HSV and VZV related diagnoses as listed in Coding Information (herpes, zoster, encephalitis/meningitis, ocular zoster, etc.).
1 Active Policy
CIGNA-0530, Nucleic Acid Pathogen Testing
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.