TL;DR: The Centers for Medicare & Medicaid Services modified NCD 352 governing STI screening and High-Intensity Behavioral Counseling (HIBC) coverage under Medicare, with an effective date of February 7, 2026. Here's what billing teams need to know.
This CMS STI screening coverage policy update affects providers who bill Medicare for chlamydia, gonorrhea, syphilis, and hepatitis B screening, as well as HIBC services. NCD 352 in the Medicare system has been modified — and while the clinical scope stays rooted in USPSTF Grade A and B recommendations, the administrative details matter for your billing team. This policy does not list specific CPT or HCPCS codes in the updated document, which creates a real documentation gap you need to address now.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs |
| Policy Code | NCD 352 |
| Change Type | Modified |
| Effective Date | February 7, 2026 |
| Impact Level | Medium |
| Specialties Affected | OB/GYN, Family Medicine, Internal Medicine, Infectious Disease, Preventive Medicine, Laboratory |
| Key Action | Audit your STI screening and HIBC billing practices against the updated NCD 352 criteria before submitting claims with dates of service on or after February 7, 2026 |
CMS STI Screening Coverage Criteria and Medical Necessity Requirements 2026
The Centers for Medicare & Medicaid Services bases this coverage policy on USPSTF Grade A and B recommendations. That's the statutory anchor. Under §1861(ddd) of the Social Security Act — codified at 42 CFR §410.64 — CMS covers additional preventive services when they meet three tests: reasonable and necessary for prevention or early detection of illness or disability, recommended with a Grade A or B by the USPSTF, and appropriate for Medicare Part A or Part B beneficiaries.
CMS has determined that evidence supports coverage for four specific infections: chlamydia, gonorrhea, syphilis, and hepatitis B. Coverage also extends to HIBC for STI prevention. Medical necessity under NCD 352 is tied directly to patient population criteria — not just a diagnosis code on the claim.
The medical necessity criteria break down by infection:
| # | Covered Indication |
|---|---|
| 1 | Chlamydia (non-pregnant): Sexually active women aged 24 and younger, or older non-pregnant women at increased risk |
| 2 | Chlamydia (pregnant): Pregnant women aged 24 and younger, or older pregnant women at increased risk |
| 3 | Gonorrhea: Sexually active women — including pregnant women — at increased risk |
| 4 | Syphilis: All pregnant women, plus all persons at increased risk |
| 5 | Hepatitis B: Pregnant women at their first prenatal visit |
| 6 | HIBC: All sexually active adolescents, and adults at increased risk for STIs |
The phrase "at increased risk" does real work here. Your documentation must support that designation. CMS has not published a single exhaustive definition of "increased risk" in this NCD — that determination runs through clinical judgment and, in some cases, MAC-level guidance. If your local Medicare Administrative Contractor has issued a related local coverage determination (LCD), that guidance applies alongside this NCD.
Prior authorization is not listed as a requirement under this NCD for covered preventive STI screening. But that does not mean your claims will sail through. Medical necessity documentation is still the primary defense against a claim denial. If your documentation doesn't establish the patient population criteria above, expect a denial on that basis.
Reimbursement for these services falls under Medicare Part B as additional preventive services. The screening tests must use FDA-approved or FDA-cleared laboratory tests. That's not optional — it's a coverage condition. If your lab is using a test that lacks FDA clearance, the claim isn't covered regardless of the patient's risk profile.
CMS STI Screening Exclusions and Non-Covered Indications
This NCD does not extend to every STI. The scope is limited to chlamydia, gonorrhea, syphilis, and hepatitis B. Other sexually transmitted infections — HIV, HPV, herpes simplex, trichomonas — are not covered under NCD 352. Those may fall under separate Medicare coverage policies or local coverage determinations.
Screening in populations outside the defined criteria is not covered. A routine chlamydia screen on a non-pregnant woman over 24 with no documented risk factors does not meet medical necessity under this NCD. Bill that without supporting documentation and you're setting up a denial.
HIBC is covered for sexually active adolescents and adults at increased risk. General sexual health counseling outside of HIBC's defined high-intensity format — or counseling for patients who don't meet the increased-risk criteria — does not fall under this policy's coverage.
Coverage Indications at a Glance
| Indication | Population | Status | Notes |
|---|---|---|---|
| Chlamydia screening | Sexually active non-pregnant women ≤24 | Covered | Must use FDA-approved/cleared lab test |
| Chlamydia screening | Non-pregnant women >24 at increased risk | Covered | Document increased risk in the record |
| Chlamydia screening | Pregnant women ≤24 | Covered | Must use FDA-approved/cleared lab test |
| Chlamydia screening | Pregnant women >24 at increased risk | Covered | Document increased risk in the record |
| Gonorrhea screening | Sexually active women at increased risk (including pregnant) | Covered | Risk documentation required |
| Syphilis screening | All pregnant women | Covered | No increased-risk qualifier needed for pregnant women |
| Syphilis screening | All persons at increased risk | Covered | Document increased risk |
| Hepatitis B screening | Pregnant women, first prenatal visit | Covered | Timing matters — first prenatal visit only |
| HIBC to prevent STIs | All sexually active adolescents | Covered | High-intensity behavioral counseling format required |
| HIBC to prevent STIs | Adults at increased risk | Covered | Must meet increased-risk criteria |
| STI screening — other infections (HIV, HPV, etc.) | Any | Not Covered under NCD 352 | Covered under separate Medicare policies if at all |
| Chlamydia or gonorrhea screening — women >24, no documented risk | Non-pregnant women without risk factors | Not Covered | Medical necessity not established |
CMS STI Screening Billing Guidelines and Action Items 2026
The policy does not list specific CPT or HCPCS codes. That's the most frustrating part of this update for billing teams. You need to verify which codes your MACs currently accept for these services before claims with dates of service on or after February 7, 2026 go out the door.
Here's what to do:
| # | Action Item |
|---|---|
| 1 | Pull your MAC's LCD and billing guidelines for STI screening. NCD 352 sets the national floor. Your MAC may have an LCD that specifies which CPT and HCPCS codes are accepted for chlamydia, gonorrhea, syphilis, and hepatitis B screening under Medicare. Check Novitas, NGS, CGS, WPS, or whichever contractor covers your region. Do this before February 7, 2026. |
| 2 | Audit your documentation templates for "increased risk" language. Every covered indication except syphilis in pregnant women and HIBC in adolescents requires increased-risk documentation. If your EHR templates don't capture that designation explicitly, update them now. A clean claim starts with clean documentation. |
| 3 | Confirm your lab's FDA clearance status for each test type. Coverage under NCD 352 requires FDA-approved or FDA-cleared laboratory tests. If you outsource your lab work, get written confirmation from your lab partner that the tests used for chlamydia, gonorrhea, syphilis, and HBV screening carry FDA clearance. Keep that on file. |
| 4 | Review your HIBC billing for format compliance. HIBC is not routine counseling. It's a specific high-intensity format. If your providers are billing HIBC codes for brief or moderate-intensity counseling encounters, that's a medical necessity mismatch. Work with your clinical team and compliance officer to confirm that what's being billed aligns with what's being delivered. |
| 5 | Check your preventive services billing workflow for hepatitis B. The coverage for HBV screening applies to pregnant women at their first prenatal visit. Timing is a coverage condition. If HBV screening is being billed at a later prenatal visit without a documented reason for the delay, you face denial risk. Audit your prenatal billing workflows. |
| 6 | Talk to your compliance officer if you're billing HIBC at high volume. The "increased risk" standard for adults is not bright-line. If your team is applying it broadly, get your compliance officer to review the claim selection criteria. A pattern of HIBC claims without consistent increased-risk documentation is an audit target. Don't wait for a review to discover the gap. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for STI Screening Under NCD 352
This policy update does not list specific CPT, HCPCS, or ICD-10 codes. This is a real limitation in the current document and the most significant operational gap for billing teams.
The absence of enumerated codes in the policy does not mean STI screening billing is code-agnostic. It means the code-level specifics live at the MAC level, in LCD guidance and contractor-specific billing articles. Until CMS publishes an updated code list for NCD 352, the source of truth for which codes to bill is your MAC's documentation.
What to do instead of relying on the NCD for codes:
- Pull your MAC's billing article for preventive STI screening
- Cross-reference CPT codes for chlamydia NAAT, gonorrhea NAAT, syphilis serology, HBsAg testing, and HIBC counseling codes against your MAC's accepted code list
- If your MAC has not published LCD-level guidance, contact your MAC's provider outreach line and request code-level guidance in writing
If your billing team needs specific code guidance and can't get it from the MAC quickly, loop in your billing consultant before submitting claims under this updated policy.
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