CurrentIndependence AdministratorsPolicy N/A

Chlamydia Screening — Coverage Criteria

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Covers chlamydia screening as a preventive service for sexually active females (including pregnant) age 24 and younger, and for older females at increased risk based on sexual history or other listed risk factors.

Policy Summary

PayerIndependence Administrators

PolicyChlamydia Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument patient age, sexual activity status, and any listed risk factors or pregnancy/increased-risk diagnosis codes when billing for chlamydia screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≤24age group covered routinely

risk-basedolder females covered if increased risk

8 CPT

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CurrentIndependence AdministratorsPolicy N/A

Chlamydia Screening — Coverage Criteria

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Policy Summary

PayerIndependence Administrators

PolicyChlamydia Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument patient age, sexual activity status, and any listed risk factors or pregnancy/increased-risk diagnosis codes when billing for chlamydia screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≤24age group covered routinely

risk-basedolder females covered if increased risk

8 CPT

Coverage Criteria

Covered Populations

Covered when ALL of the following are met

Routine young sexually active females: Sexually active females age 24 years and youngerage <= 24

Includes pregnant females

Older females at increased risk: Older sexually active females whose sexual history reveals new or persistent risk factors since the last negative test resultpresence of one or more listed risk factors

Risk factors include: new sex partner; more than one sex partner; sex partner with concurrent partners; sex partner with an STI; inconsistent condom use when not mutually monogamous; history of or current STI; exchange of sex for money or drugs

Coding and diagnosis linkage for preventive coverage

Covered testing codes when billed with appropriate diagnoses

Code linkage: CPT codes 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 and specimen handling code 99000 are covered as a preventive service when reported in conjunction with an appropriate pregnancy diagnosis code or increased-risk diagnosis codebilling with appropriate diagnosis codes

Certain CPTs (listed above) will only be covered as preventive when billed with an appropriate pregnancy or increased-risk diagnosis

Pregnancy/increased-risk diagnosis examples: Examples include A50.01, A50.02 and multiple Z-codes relevant to screening and high-risk behavior (eg, Z11.2, Z11.3, Z20.2, Z72.51–Z72.53, Z86.19, Z91.42, Z00/Z01 series, R87.811, R87.820, R87.821)presence of listed diagnosis codes

Policy lists specific ICD-10 and HCPCS encounter/behavior codes as examples

The following CPT/procedure codes are covered as a preventive chlamydia screening only when billed in the appropriate clinical context: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 (testing codes) and 99000 (specimen handling). Coverage as a preventive service for these CPTs is limited to claims reported in conjunction with an appropriate pregnancy diagnosis code or an increased-risk diagnosis code as enumerated in the policy.

CPT codes listed for chlamydia screening will not be paid as a preventive service outside of the scenarios above; ensure the claim includes the applicable pregnancy or increased-risk diagnosis code when requesting preventive screening coverage.

Coding and Billing

Covered CPT/Procedure Codes for screeningCPTCovered

86631	Antibody; Chlamydia
86632	Antibody; Chlamydia, IgM
87110	Culture, chlamydia, any source
87270	Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis
87320	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA] qualitative or semiquantitative, multiple step method; chlamydia trachomatis
87490	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
87491	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
87810	Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
99000	Handling and/or conveyance of specimen for transfer from the office to a laboratory

Associated Diagnosis/HCPCS/FindingsICD-10

A50.01	Early congenital syphilitic oculopathy
A50.02	Early congenital syphilitic osteochondropathy
R87.811	Vaginal high risk human papillomavirus (HPV) DNA test positive
R87.820	Cervical low risk human papillomavirus (HPV) DNA test positive
R87.821	Vaginal low risk human papillomavirus (HPV) DNA test positive
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings
Z00.121	Encounter for routine child health examination with abnormal findings
Z00.129	Encounter for routine child health examination without abnormal findings
Z01.411	Encounter for gynecological examination (general) (routine) with abnormal findings

1–10 of 20

1/2

Age threshold — 24 years or younger

Age thresholdSexually active females age 24 years and younger (includes pregnant females)

Applies toSexually active females (includes pregnant)

Older femalesCovered if sexual history reveals new or persistent risk factors since last negative test

Provider Actions and Billing Guidance

Prior Authorization

Prior authorization — Not required for listed screening codes when billed appropriately

No prior authorization requirement is stated; the listed CPT/procedure codes are identified as covered when billed in the appropriate screening context.

Covered CPT/procedure codes: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, and specimen handling 99000

Denial Risk

Provider billing action — link CPT to appropriate diagnosis

When reporting preventive chlamydia screening, use only the policy‑listed CPT codes and report an associated pregnancy or increased‑risk diagnosis code to qualify for preventive coverage; CPTs billed without the required diagnosis linkage may not be paid as preventive services.

Covered CPTs: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810; specimen handling 99000 when reported in conjunction with screening

Background

Chlamydia is a sexually transmitted bacterial infection for which screening seeks to identify asymptomatic infection and prevent complications and further transmission. This policy endorses screening when clinically indicated and specifies the covered testing codes and the billing contexts (pregnancy or increased-risk diagnoses) required for preventive service coverage.

Definitions

Increased risk definition — listed risk factors

New sex partnerIndividual who has a new sex partner

Multiple partnersIndividual with more than one sex partner

Partner with concurrent partnersIndividual who has a sex partner with concurrent partners

Partner with an STIIndividual who has a sex partner who has a sexually transmitted infection

Inconsistent condom useInconsistent condom use for individuals who are not in a mutually monogamous relationship

History or current STIHistory of or current diagnosis for sexually transmitted infection

Exchange of sex for money/drugs