Chlamydia, gonorrhea and syphilis screening results documented (report when results are present for all of the 3 screenings)
HCPCS code
Name of the Procedure:
Chlamydia, Gonorrhea, and Syphilis Screening Results Documented (G9228)
Summary
Routine screenings for sexually transmitted infections (STIs) like Chlamydia, Gonorrhea, and Syphilis involve laboratory tests to detect these infections. This procedure reports when results for all three screenings are present.
Purpose
The purpose of this procedure is to identify the presence of Chlamydia, Gonorrhea, and Syphilis infections in a patient. Early detection can lead to timely treatment and reduce the spread of these STIs. The goal is to ensure comprehensive STI screening and proper documentation of results for all three infections.
Indications
- Symptoms suggestive of STIs such as unusual discharge, pain during urination, sores, or rashes.
- Routine screening for sexually active individuals, especially those with multiple partners or new partners.
- Pregnant women as part of prenatal care.
- Individuals with a known exposure to an STI.
- Populations at higher risk, such as men who have sex with men (MSM).
Preparation
- No special preparation is typically required.
- Patients may need to avoid urination for at least one hour before a urine test.
- For certain tests, patients may need to avoid sexual intercourse or vaginal douching for 24 hours before the test.
- Any specific instructions will be provided by the healthcare provider based on the type of sample collected (e.g., urine, swab).
Procedure Description
Sample Collection:
- Urine sample: The patient collects the first part of the urine stream.
- Swab sample: A healthcare provider collects a sample from the affected area (vaginal, cervical, urethral, or rectal swab).
- Blood sample: A small blood sample is drawn for syphilis testing.
Laboratory Testing:
- The samples are sent to a laboratory where specific tests for Chlamydia, Gonorrhea, and Syphilis are performed.
Documentation:
- The results for all three screenings are documented in the patient's medical record once available.
Duration
- Sample collection typically takes a few minutes.
- Laboratory processing time can vary but generally takes a few days.
Setting
- This procedure is usually performed in a hospital outpatient clinic, a primary care office, or a specialized sexual health clinic.
Personnel
- Healthcare provider (e.g., nurse, primary care physician) performs the sample collection.
- Laboratory technicians conduct the analysis of the samples.
Risks and Complications
- Risks: Minimal; may include slight discomfort or minor bleeding at the sample collection site.
- Complications: Rare; possible infection at the sample collection site if not properly sanitized.
Benefits
- Early detection and treatment of STIs.
- Reduced risk of transmission to others.
- Prevention of potential complications related to untreated infections.
Recovery
- No recovery time is needed after sample collection.
- Patients can resume normal activities immediately.
- Follow-up may be required if test results are positive, potentially including further testing, treatment, and partner notification.
Alternatives
- Individual tests for each STI can be done separately if comprehensive screening is not necessary.
- Home testing kits are available but may not provide the same level of accuracy as tests done in a clinical setting.
Patient Experience
- Patients may feel anxious about the test results, but minimal discomfort is experienced during the sample collection.
- Health providers may discuss pain management and comfort measures to alleviate patient anxiety during sample collection.