Summary & Overview
HCPCS G9228: Chlamydia, Gonorrhea and Syphilis Screening Results Documented
HCPCS Level II code G9228 indicates that screening results for chlamydia, gonorrhea and syphilis are documented for a patient and that results are present for all three tests. Nationally, consistent documentation of STI screening results supports public health surveillance, quality measurement and preventive care initiatives; a standardized code for complete tri-screen documentation facilitates reporting and payor recognition of comprehensive STI screening workflows. Key payers in this context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare.
Readers will learn what HCPCS Level II code G9228 represents, how it is applied in ambulatory and outpatient settings, and the clinical context for reporting complete STI screening results. The publication presents benchmarks and coding guidance relevant to documentation practices, highlights policy considerations affecting reimbursement and quality reporting, and summarizes how payers handle STI screening documentation coding. Data not available in the input for associated taxonomies, specific ICD-10 pairings, detailed payer policy language, and service line breakouts.
Billing Code Overview
HCPCS Level II code G9228 documents that chlamydia, gonorrhea and syphilis screening results are present for all three tests. The code is reported when results for chlamydia, gonorrhea and syphilis screenings are all documented for a patient during the same encounter or reporting period.
Service Type: Infectious disease screening documentation / Sexually transmitted infection (STI) screening results reporting
Typical Site of Service: Outpatient clinics, primary care offices, sexual health clinics, community health centers, and other ambulatory care settings where STI screening and documentation occur
Clinical & Coding Specifications
Clinical Context
A sexually active 24-year-old patient presents to a primary care clinic for routine sexually transmitted infection (STI) screening as part of annual preventive care and after reporting new sexual partners. A clinician or nurse collects specimens for nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea from urine and/or genital swabs, and a serum sample for syphilis serology (RPR/treponemal confirmatory testing). Test orders are placed in the electronic health record, specimens are sent to the laboratory, and results return within 24–72 hours. The clinician documents all three screening results — chlamydia, gonorrhea, and syphilis — in the chart. Billing for the HCPCS Level II code G9228 is reported when documentation contains results present for all three screenings. Typical site of service is an outpatient clinic, community health center, or sexually transmitted infection clinic. The typical patient scenario includes asymptomatic screening, exposure notification follow-up, or routine preventive care for patients at risk of STIs. Specimen collection is performed by nursing staff or the clinician, and result documentation supports treatment decisions, partner services, and public health reporting if indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When documentation supports substantially greater work than typical for the visit involving counseling or additional coordination related to STI management. |