Department of Aging and Disability Services Approved Diagnostic Codes for Persons with Related Conditions

Transcription

1 Department of Aging and Disability Services Approved Diagnostic Codes for Persons with Related Conditions The following diagnostic codes are found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), 2006, and are recognized by the Department of Aging and Disability Services (DADS) as a related condition. In accordance with the Code of Federal Regulations, Title 42, , a related condition is a severe and chronic disability that: (A) is attributed to: i. cerebral palsy or epilepsy; or ii. any other condition, other than mental illness, found to be closely related to mental retardation because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with mental retardation, and requires treatment or services similar to those required for individuals with mental retardation; (B) is manifested before the individual reaches age 22; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in at least three of the following areas of major life activity: i. self-care; ii. understanding and use of language; iii. learning; iv. mobility; v. self-direction; and vi. capacity for independent living. A primary diagnosis by a licensed physician of a related condition may be required to meet eligibility for the following Medicaid programs: ICF/MR, CLASS, HCS, TxHmL, DBMD and CWP. Please refer to the applicable rules governing those programs for complete information regarding eligibility. Center for Policy and Innovation Page 1 of 9 May 1, 2009

2 Infectious and Parasitic Diseases ( ) 138 Late effects of acute poliomyelitis Neoplasm of the Brain ( ) 191 Malignant neoplasm of the brain 237 Neoplasm of uncertain behavior of endocrine glands and nervous system Neurofibromatosis (von Recklinghausen s Disease) Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders ( ) 243 Congenital hypothyroidism 244 Acquired hypothyroidism Unspecified hypothyroidism Hyperparathyroidism Lowe (-Terrey-MacLachlan) syndrome (oculocerebrorenal dystrophy) Lipidoses Other disorders of calcium metabolism (pseudohypoparathyroidism) Other disorders of purine and pyrimidine metabolism (Lesch-Nyhan syndrome) Mucopolysaccharidosis (Hunter s syndrome, Hurler s syndrome, Scheie s syndrome) Other specified disorders of metabolism Unspecified disorder of metabolism (enzymopathy NOS) DiGeorge s syndrome Diseases of the Blood and Blood-Forming Organs ( ) Primary thrombocytopenia Primary thrombocytopenia unspecified Congenital and hereditary thrombocytopenic purpura (congenital and hereditary thrombocytopenia; Thrombocytopenia with Absent Radi (TAR) syndrome Psychoses with Origin Specific to Childhood (299) Autistic disorder (childhood autism; infantile psychosis; Kanner s syndrome) Childhood disintegrative disorder Other specified pervasive developmental disorders (Asperger s disorder, atypical childhood psychosis; borderline psychosis of childhood) Unspecified pervasive developmental disorder (pervasive developmental disorder NOS) Gilles de la Tourettes Disorder (307.23) Tourette s disorder (motor-verbal tic disorder) Specific Nonpsychotic Mental Disorders - Due to organic brain damage ( ) Frontal lobe syndrome (lobotomy syndrome; postleucotomy syndrome [state]) Postconcussion syndrome Other specified nonpsychotic mental disorders following organic brain damage (postencephalitic syndrome) Unspecified non-psychotic mental disorder following organic brain damage Center for Policy and Innovation Page 2 of 9 May 1, 2009

3 Specific Delays in Development (315.9) Unspecified delay in development (developmental disorder NOS) Nervous System and Sense Organs ( ) Meningitis due to unspecified bacterium 323 Encephalitis, myelitis, encephalomyelitis Unspecified cause of encephalitis 330 Cerebral degenerations usually manifest in childhood Metachromatic leukodystrophy Other specified cerebral degenerations in childhood (Alper s disease or gray-matter degeneration; infantile necrotizing encephalomyelopathy; Leigh s disease; subacute necrotizing encephalopathy or encephalomyelopathy, Rett s syndrome) Pick s disease Communicating hydrocephalus Obstructive hydrocephalus Other cerebral degeneration Reye s syndrome Cerebral ataxia Cerebral degeneration, unspecified Paralysis agitans (Parkinson s disease) Secondary Parkinsonism Huntington s chorea Idiopathic torsion dystonia Symptomatic torsion dystonia (athetoid cerebral palsy) Friedreich s ataxia Other spinocerebellar diseases (ataxia-telangiectasia [Louis-Bar syndrome]) Spinal muscular atrophy, unspecified Kugelberg-Welander disease Unspecified disease of spinal cord 340 Multiple sclerosis Demyelinating disease of central nervous system, unspecified Spastic hemiplegia Hemiplegia, unspecified Diplegic (congenital diplegia) Infantile cerebral palsy, unspecified Quadriplegia and quadriparesis Paraplegia (paralysis of both lower limbs) Unspecified monoplegia Paralysis, unspecified Generalized non-convulsive epilepsy Generalized convulsive epilepsy Petit mal status Grand mal status Partial epilepsy, with impairment of consciousness (psychomotor epilepsy) Epilepsy, unspecified Cerebral cysts (arachnoid cyst) Center for Policy and Innovation Page 3 of 9 May 1, 2009

4 348.1 Anoxic brain damage Encephalopathy, not elsewhere classified Other specified disorders of nervous system Unspecified disorders of nervous system Trigeminal neuralgia Myasthenia gravis Congenital hereditary muscular dystrophy Hereditary progressive muscular dystrophy Other myopathies Profound impairment, both eyes Moderate or severe impairment, better eye, profound impairment lesser eye Legal blindness, as defined in U.S.A Conductive hearing loss Sensorineural hearing loss Mixed conductive and sensorineural hearing loss Deaf mutism, not elsewhere classifiable Other specified forms of hearing loss Unspecified hearing loss Cerebrovascular Disease ( ) 436 Acute, but ill-defined cerebrovascular disease 438 Late effects of cerebrovascular disease Arthropathies and Related Disorders ( ) Polymyositis Juvenile chronic polyarthritis Rheumatism, Excluding the Back ( ) Other specific muscle disorders (arthrogryposis) Congenital Anomalies ( ) Spina bifida with hydrocephalus Spina bifida without mention of hydrocephalus Encephalocele Reduction deformities of brain Congenital hydrocephalus Other specified anomalies of nervous system (familial dysautonomia; Riley-Day syndrome) Unspecified anomaly of brain, spinal cord, and nervous system Anomalies of cerebrovascular system (arteriovenous malformation of brain; cerebral arteriovenous aneurysm, congenital; congenital anomalies of cerebral vessels) [EXCLUDES ruptured cerebral (arteriovenous) aneurysm (430)] Larsen s syndrome 755 Other congenital anomalies of limbs Longitudinal deficiency, combined, involving humerus, radius, and ulna (complete or incomplete) Center for Policy and Innovation Page 4 of 9 May 1, 2009

5 Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete) Longitudinal deficiency, combined, involving femur, tibia, and fibula (complete or incomplete) Acrocephalosyndactyly (Apert s syndrome) Anomalies of skull and face bones (Hallerman-Streiff syndrome, craniosynostosis) Anomalies of spine, unspecified Osteogenesis imperfecta Conradi syndrome Down s syndrome Patau s syndrome Autosomal deletion syndromes Gonadal dysgenesis (Turner s syndrome) Klinefelter s syndrome Conditions due to anomaly of unspecified chromosome Tuberous sclerosis Prader-Willi syndrome Marfan syndrome Fragile X syndrome Other specified anomalies (Cornelia de Lange s syndrome, Seckel syndrome); Congenital malformation syndromes affecting multiple systems, NEC; Angelman s Syndrome; Cerebrocostomandibular syndrome) Certain Conditions Originating in the Perinatal Period ( ) Fetal alcohol syndrome Injury to spine and spinal cord Severe birth asphyxia Congenital rubella 779 Other and ill-defined conditions originating in the perinatal period Codes The following fifth digit sub-classification is for use with the appropriate codes in categories 800, 801, 803, 804, and : 0 unspecified state of consciousness 1 with no loss of consciousness 2 with brief (less than one hour) loss of consciousness 3 with moderate (1-24 hours) loss of consciousness and return to pre-existing conscious level 4 with moderate (1-24 hours) loss of consciousness 5 with prolonged (more than 24 hours) loss of consciousness, without return to pre-existing conscious level. Use the fifth-digit 5 to designate when a patient is unconscious and dies before regaining consciousness, regardless of the duration of the loss of consciousness 6 with loss of consciousness of unspecified duration 9 with concussion, unspecified Center for Policy and Innovation Page 5 of 9 May 1, 2009

6 Fracture of Skull ( ) Fracture of Vault of Skull (800) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: frontal bone and parietal bone Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Fracture of Base of Skull (801) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: fossa, sinus, anterior, ethmoid, middle, frontal, posterior, sphenoid bone, occiput bone, temporal bone, and orbital roof Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Other and Unqualified Skull Fractures (803) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: skull NOS and skull multiple NOS Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other unspecified nature Center for Policy and Innovation Page 6 of 9 May 1, 2009

7 Multiple Fractures Involving Skull or Face with Other Bones (804) (Requires fifth digit see chart on page 5 for codes and definitions) Closed without mention of intracranial injury Closed with cerebral laceration and contusion Closed with subarachnoid, subdural, and extradural hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with intracranial injury of other and unspecified nature Open without mention of intracranial injury Open with cerebral laceration and contusion Open with subarachnoid, subdural, and extradural hemorrhage Open with other and unspecified intracranial hemorrhage Open with intracranial injury of other and unspecified nature Intracranial Injury, Excluding Those with Skull Fracture ( ) Concussion (850) Includes: commotio cerebri With no loss of consciousness (concussion with mental confusion or disorientation, without loss of consciousness) With brief loss of consciousness (of consciousness for less than one hour) With moderate loss of consciousness (loss of consciousness for 1-24 hours) With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) With prolonged loss of consciousness, without return to pre-existing conscious level With loss of consciousness of unspecified duration Concussion, unspecified Cerebral Laceration and Contusion (851) (Requires fifth digit - see chart on page 5 for codes and definitions) Cortex (cerebral) contusion without mention of open intracranial wound Cortex (cerebral) contusion with open intracranial wound Cortex (cerebral) laceration without mention of open intracranial wound Cortex (cerebral) laceration with open intracranial wound Cerebellar or brain stem contusion without mention of open intracranial wound Cerebellar or brain stem contusion with open intracranial wound Cerebellar or brain stem laceration without mention of open intracranial wound Cerebellar or brain stem laceration with open intracranial wound Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound Other and unspecified cerebral laceration and contusion, with open intracranial wound Center for Policy and Innovation Page 7 of 9 May 1, 2009

8 Subarachnoid, Subdural, and Extradural Hemorrhage Following Injury (852) (Requires fifth digit see chart on page 5 for codes and definitions) Subarachnoid hemorrhage following injury without mention of open intracranial wound (middle meningeal hemorrhage following injury) Subarachnoid hemorrhage following injury with open intracranial wound Subdural hemorrhage following injury without mention of open intracranial wound Subdural hemorrhage following injury with open intracranial wound Extradural hemorrhage following injury without mention of open intracranial wound (epidural hematoma following injury) Extradural hemorrhage following injury with open intracranial wound Other and Unspecified Intracranial Hemorrhage Following Injury (853) (Requires fifth digit see chart on page 5 for codes and definitions) Without mention of open intracranial wound (cerebral compression due to injury, intracranial hematoma following injury, traumatic cerebral hemorrhage) With open intracranial wound Intracranial Injury of Other and Unspecified Nature (854) (Requires fifth digit see chart on page 5 for codes and definitions) Includes: Brain injury NOS; head injury NOS Without mention of open intracranial wound With open intracranial wound Open Wound of Head, Neck, and Trunk Open Wound of Ocular Adnex ( ) Laceration of skin of eyelid and periocular area Laceration of eyelid, full-thickness, not involving lacrimal passages Laceration of eyelid involving lacrimal passages Penetrating wound of orbit, without mention of foreign body Penetrating wound of orbit with foreign body in orbit Other specified open wounds of ocular adnexa Unspecified open wound of ocular adnexa Injury to Nerves and Spinal Cord ( ) Injury to Optic Nerve and Pathways (950) Optic nerve injury (second cranial nerve) Injury to optic chiasm Injury to optic pathways Injury to visual cortex Unspecified (traumatic blindness NOS) Injury to Other Cranial Nerves (951) Injury to oculomotor nerve (third cranial nerve) Injury to trochlear nerve (fourth cranial nerve) Center for Policy and Innovation Page 8 of 9 May 1, 2009

9 951.2 Injury to trigeminal nerve (fifth cranial nerve) Injury to abducens nerve (sixth cranial nerve) Injury to facial nerve (seventh cranial nerve) Injury to acoustic nerve (auditory nerve, eighth cranial nerve) Injury to accessory nerve (eleventh cranial nerve) Injury to hypoglossal nerve (twelfth cranial nerve) Injury to other specified cranial nerves (glossopharyngeal [ninth cranial] nerve; olfactory [first cranial] nerve; pneumogastric [tenth cranial] nerve; traumatic anosmia NOS; vagus [tenth cranial] nerve Injury to unspecified cranial nerve Spinal Cord Injury Without Evidence of Spinal Bone Injury (952) Cervical C1-C4 level with unspecified spinal cord injury (spinal cord injury, cervical region NOS) C1-C4 level with complete lesion of spinal cord C1-C4 level with anterior cord syndrome C1-C4 level with central cord syndrome C1-C4 level with other specified spinal cord injury (incomplete spinal cord lesion at C1-C4 level: NOS with posterior cord syndrome) C5-C7 level with unspecified spinal cord injury C5-C7 level with complete lesion of spinal cord C5-C7 level with anterior cord syndrome C5-C7 level with central cord syndrome C5-C7 level with other specified spinal cord injury (incomplete spinal cord lesion at C5-C7 level: NOS with posterior cord syndrome) Dorsal (thoracic) T1-T6 level with unspecified spinal cord injury (spinal cord injury, thoracic region NOS) T1-T6 level with complete lesion of spinal cord T1-T6 level with anterior cord syndrome T1-T6 level with central cord syndrome T1-T6 level with other specified spinal cord injury (incomplete spinal cord lesion at T1-T6 level: NOS with posterior cord syndrome) T7-T12 level with unspecified spinal cord injury T7-T12 level with complete lesion of spinal cord T7-T12 level with anterior cord syndrome T7-T12 level with central cord syndrome T7-T12 level with other specified spinal cord injury (incomplete spinal cord lesion at T7-T12 level: NOS with posterior cord syndrome) Lumbar Sacral Cauda equina Multiple sites of spinal cord Unspecified site of spinal cord Center for Policy and Innovation Page 9 of 9 May 1, 2009

10 Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of 10/1/07) ICD Code Acquired hypothyroidism 244 Acrocephalosyndactyly (Apert s syndrome) Acute, but ill-defined cerebrovascular disease 436 Angelman's Syndrome Anomalies of cerebrovascular system (arteriovenous malformation of brain; cerebral arteriovenous aneurysm, congenital; congenital anomalies of cerebral vessels) [EXCLUDES ruptured cerebral (arteriovenous) aneurysm (430)] Anomalies of skull and face bones (Hallerman-Streiff syndrome, craniosynostosis) Anomalies of spine, unspecified Anoxic brain damage Autistic disorder (childhood autism; infantile psychosis; Kanner s syndrome) Autosomal deletion syndromes C1-C4 level with anterior cord syndrome C1-C4 level with central cord syndrome C1-C4 level with complete lesion of spinal cord C1-C4 level with other specified spinal cord injury (incomplete spinal cord lesion at C1- C4 level: NOS with posterior cord syndrome) C1-C4 level with unspecified spinal cord injury (spinal cord injury, cervical region NOS) C5-C7 level with anterior cord syndrome C5-C7 level with central cord syndrome C5-C7 level with complete lesion of spinal cord C5-C7 level with other specified spinal cord injury (incomplete spinal cord lesion at C5- C7 level: NOS with posterior cord syndrome) C5-C7 level with unspecified spinal cord injury Cauda equina Cerebellar or brain stem contusion with open intracranial wound Cerebellar or brain stem contusion without mention of open intracranial wound Cerebellar or brain stem laceration with open intracranial wound Cerebellar or brain stem laceration without mention of open intracranial wound Cerebral ataxia Cerebral cysts (arachnoid cyst) Cerebral degeneration, unspecified Cerebral degenerations usually manifest in childhood 330 Cerebrocostomandibular syndrome Cervical Childhood disintegrative disorder Closed with cerebral laceration and contusion Closed with cerebral laceration and contusion Closed with cerebral laceration and contusion Closed with cerebral laceration and contusion Closed with intracranial injury of other and unspecified nature Closed with intracranial injury of other and unspecified nature Closed with intracranial injury of other and unspecified nature Closed with intracranial injury of other and unspecified nature 804.4

11 Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of ICD-9-10/1/07) 2006 Code Closed with other and unspecified intracranial hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with other and unspecified intracranial hemorrhage Closed with subarachnoid, subdural, and extradural hemorrhage Closed with subarachnoid, subdural, and extradural hemorrhage Closed with subarachnoid, subdural, and extradural hemorrhage Closed with subarachnoid, subdural, and extradural hemorrhage Closed without mention of intracranial injury Closed without mention of intracranial injury Closed without mention of intracranial injury Closed without mention of intracranial injury Communicating hydrocephalus Concussion, unspecified Conditions due to anomaly of unspecified chromosome Conductive hearing loss Congenital and hereditary thrombocytopenic purpura (congenital and hereditary thrombocytopenia; Thrombocytopenia with Absent Radi (TAR) syndrome Congenital hereditary muscular dystrophy Congenital hydrocephalus Congenital hypothyroidism 243 Congenital malformation syndromes affecting multiple systems, NEC Congenital rubella Conradi syndrome Cortex (cerebral) contusion with open intracranial wound Cortex (cerebral) contusion without mention of open intracranial wound Cortex (cerebral) laceration with open intracranial wound Cortex (cerebral) laceration without mention of open intracranial wound Deaf mutism, not elsewhere classifiable Demyelinating disease of central nervous system, unspecified DiGeorge s syndrome Dorsal (thoracic) Down s syndrome Encephalitis, myelitis, encephalitis 323 Encephalocele Encephalopathy, not elsewhere classified Epilepsy, unspecified Extradural hemorrhage following injury with open intracranial wound Extradural hemorrhage following injury without mention of open intracranial wound (epidural hematoma following injury) Fetal alcohol syndrome Fragile X syndrome Friedreich s ataxia Frontal lobe syndrome (lobotomy syndrome; postleucotomy syndrome [state]) 310.0

12 Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of ICD-9-10/1/07) 2006 Code Generalized convulsive epilepsy Generalized non-convulsive epilepsy 345 Gonadal dysgenesis (Turner s syndrome) Grand mal status Hemiplegia, unspecified Hereditary progressive muscular dystrophy Huntington s chorea Hyperparathyroidism Idiopathic torsion dystonia Infantile cerebral palsy, unspecified Injury to abducens nerve (sixth cranial nerve) Injury to accessory nerve (eleventh cranial nerve) Injury to acoustic nerve (auditory nerve, eighth cranial nerve) Injury to facial nerve (seventh cranial nerve) Injury to hypoglossal nerve (twelfth cranial nerve) Injury to oculomotor nerve (third cranial nerve) Injury to optic chiasm Injury to optic pathways Injury to other specified cranial nerves (glossopharyngeal [ninth cranial] nerve; olfactory [first cranial] nerve; pneumogastric [tenth cranial] nerve; traumatic anosmia NOS; vagus [tenth cranial] nerve Injury to spine and spinal cord Injury to trigeminal nerve (fifth cranial nerve) Injury to trochlear nerve (fourth cranial nerve) Injury to unspecified cranial nerve Injury to visual cortex Juvenile chronic polyarthritis Klinefelter s syndrome Kugelberg-Welander disease Laceration of eyelid involving lacrimal passages Laceration of eyelid, full-thickness, not involving lacrimal passages Laceration of skin of eyelid and periocular area Larsen s syndrome Late effects of acute poliomyelitis 138 Late effects of cerebrovascular disease 438 Legal blindness, as defined in U.S.A Lipidoses Longitudinal deficiency, combined, involving femur, tibia, and fibula (complete or incomplete) Longitudinal deficiency, combined, involving humerus, radius, and ulna (complete or incomplete) Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete) Lowe (-Terrey-MacLachlan) syndrome (oculocerebrorenal dystrophy) Lumbar 952.2

13 Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of ICD-9-10/1/07) 2006 Code Malignant neoplasm of the brain 191 Marfan syndrome Meningitis due to unspecified bacterium Metachromatic leukodystrophy Mixed conductive and sensorineural hearing loss Moderate or severe impairment, better eye, profound impairment lesser eye Mucopolysaccharidosis (Hunter s syndrome, Hurler s syndrome, Scheie s syndrome) Multiple sclerosis 340 Multiple sites of spinal cord Myasthenia gravis Neoplasm of uncertain behavior of endocrine glands and nervous system 237 Neurofibromatosis (von Recklinghausen s Disease) Obstructive hydrocephalus Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with cerebral laceration and contusion Open with intracranial injury of other and unspecified nature Open with intracranial injury of other and unspecified nature Open with intracranial injury of other and unspecified nature Open with intracranial injury of other unspecified nature Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with other and unspecified intracranial hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open with subarachnoid, subdural, and extradural hemorrhage Open without mention of intracranial injury Open without mention of intracranial injury Open without mention of intracranial injury Open without mention of intracranial injury Optic nerve injury (second cranial nerve) Osteogenesis imperfecta Other and ill-defined conditions originating in the perinatal period 779 Other and unspecified cerebral laceration and contusion, with open intracranial wound Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound Other cerebral degeneration Other congenital anomalies of limbs 755 Other disorders of calcium metabolism (pseudohypoparathyroidism) Other disorders of purine and pyrimidine metabolism (Lesch-Nyhan syndrome) Other myopathies 359.8

14 ICD Code Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of 10/1/07) Other specific muscle disorders (arthrogryposis) Other specified anomalies (Cornelia de Lange s syndrome, Seckel syndrome) Other specified anormalies of nervous system (familial dysautonomia; Riley-Day syndrome) Other specified cerebral degenerations in childhood (Alper's disease or gray-matter degeneration; infantile necrotizing encephalomyelopathy; Leigh's disease; subacute necrotizing encephalopathy or encephalomyelopathy, Rett's syndrome Other specified disorders of metabolism Other specified disorders of nervous system Other specified forms of hearing loss Other specified nonpsychotic mental disorders following organic brain damage (postencephalitic syndrome) Other specified open wounds of ocular adnexa Other specified pervasive developmental disorders (Asperger s disorder, atypical childhood psychosis; borderline psychosis of childhood) Other spinocerebellar diseases (ataxia-telangiectasia [Louis-Bar syndrome]) Paralysis agitans (Parkinson s disease) Paralysis, unspecified Paraplegia (paralysis of both lower limbs) Partial epilepsy, with impairment of consciousness (psychomotor epilepsy) Patau s syndrome Penetrating wound of orbit with foreign body in orbit Penetrating wound of orbit, without mention of foreign body Petit mal status Pick s disease Polymyositis Postconcussion syndrome Prader-Willi syndrome Primary thrombocytopenia Primary thrombocytopenia unspecified Profound impairment, both eyes Quadriplegia and quadriparesis Reduction deformities of brain Reye s syndrome Sacral Secondary Parkinsonism Sensorineural hearing loss Severe birth asphyxia Spastic hemiplegia Spina bifida with hydrocephalus Spina bifida without mention of hydrocephalus Spinal muscular atrophy, unspecified Subarachnoid hemorrhage following injury with open intracranial wound Subarachnoid hemorrhage following injury without mention of open intracranial wound (middle meningeal hemorrhage following injury) 852.0

15 Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of ICD-9-10/1/07) 2006 Code Subdural hemorrhage following injury with open intracranial wound Subdural hemorrhage following injury without mention of open intracranial wound Symptomatic torsion dystonia (athetoid cerebral palsy) T1-T6 level with anterior cord syndrome T1-T6 level with central cord syndrome T1-T6 level with complete lesion of spinal cord T1-T6 level with other specified spinal cord injury (incomplete spinal cord lesion at T1-T6 level: NOS with posterior cord syndrome) T1-T6 level with unspecified spinal cord injury (spinal cord injury, thoracic region NOS) T7-T12 level with anterior cord syndrome T7-T12 level with central cord syndrome T7-T12 level with complete lesion of spinal cord T7-T12 level with other specified spinal cord injury (incomplete spinal cord lesion at T7- T12 level: NOS with posterior cord syndrome) T7-T12 level with unspecified spinal cord injury Tourette s disorder (motor-verbal tic disorder) Trigeminal neuralgia Tuberous sclerosis Unspecified (traumatic blindness NOS) Unspecified anomaly of brain, spinal cord, and nervous system Unspecified cause of encephalitis Unspecified delay in development (developmental disorder NOS) Unspecified disease of spinal cord Unspecified disorder of metabolism (enzymopathy NOS) Unspecified disorders of nervous system Unspecified hearing loss Unspecified hypothyroidism Unspecified monoplegia Unspecified non-psychotic mental disorder following organic brain damage Unspecified open wound of ocular adnexa Unspecified pervasive developmental disorder (pervasive developmental disorder NOS) Unspecified site of spinal cord With brief loss of consciousness (of consciousness for less than one hour) With loss of consciousness of unspecified duration With moderate loss of consciousness (loss of consciousness for 1-24 hours) With no loss of consciousness (concussion with mental confusion or disorientation, without loss of consciousness) With open intracranial wound With open intracranial wound With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) With prolonged loss of consciousness, without return to pre-existing conscious level Without mention of open intracranial wound Without mention of open intracranial wound (cerebral compression due to injury, intracranial hematoma following injury, traumatic cerebral hemorrhage) 853.0

16 COMMISSIONER Eric M. Bost July 27, 2000 BOARD MEMBERS David Herndon Chair, Austin Carlela K. Vogel Vice Chair, Fort Worth Bill Jones Houston Anchi Ku Dallas Elizabeth D. Seale San Antonio Carole Woodard Houston To: Community Living Assistance and Support Services (CLASS) Providers Subject: Policy Clarification Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions This policy clarification transmits an updated list of ICD-9-CM Diagnostic Codes for Persons with Related Condtions. Attached is the updated list of ICD-9-CM codes that were added to the TDMHMR approved primary diagnoses of related conditions:! Edward's Syndrome (Trisomy: 18)! Bonnevie-Ullrich Syndrome If you have any questions, please contact Don Mann, CLASS Unit Manager, at 512/ Sincerely, [Signature on File] Becky Beechinor Assistant Deputy Commissioner Long Term Care Services BB:aa John H. Winters Human Services Complex 701 West 51st Street P.O. Box Austin, TX (512) Call your local DHS office for assistance.

17 COMMISSIONER Eric M. Bost April 15, 1999 BOARD MEMBERS David Herndon Chair, Austin Carlela K. Vogel Vice Chair, Fort Worth Bill Jones Houston Anchi Ku Dallas Elizabeth D. Seale San Antonio Carole Woodard Houston To: Community Living Assistance and Support Services (CLASS) Providers Subject: CLASS Policy Clarification No Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions Updated Related Conditions Eligibility Screening Instrument and Instructions Updated Procedures for Processing Levels-of-Care (LOC). This policy clarification transmits an updated list of ICD-9-CM Diagnostic Codes for Persons with Related Conditions, and replaces CLASS Provider Manual Form 3650-A/B Instructions, Attachment C and D. The updated procedures for processing LOCs should be added to the Form 3650-A/B Instructions under Transmittal and in Section 5200 of the CLASS Provider Manual until the manual revision is released. Attached is the updated list of ICD-9-CM Diagnostic Codes for Persons with Related Conditions, Attachment C, and a copy of Instructions, Related Conditions Eligibility Screening Instrument, Attachment D. Please note the following ICD-9-CM code that was added to the Texas Department of Mental Health and Mental Retardation (TDMHMR) approved primary diagnoses of related conditions: Other specified cerebral degeneration's in childhood Alper's disease or gray-matter degeneration Infantile necrotizing encephalomyelopathy Leigh's Disease Subacute necrotizing encephalopathy or encephalomyelopathy Rett's syndrome Anomalies of cerebrovascular system Arteriovenous malformation of brain Cerebral arteriovenous aneurysm, congenital Congenital anomalies of cerebral vessels EXCLUDES ruptured cerebral (arteriovenous) aneurysm (430) The Related Conditions Eligibility Screening Instrument and instructions has been updated to include a "not Applicable (N/A)" category in the screening instrument, N/A is circled only when the question does not apply to the individual due to his/her chronological age, personal preferences, or phase of life. An example of this is when young children will not have the motor skills to appropriately groom themselves without assistance. Due to the diversity of age ranges to be administered and assessed by the caseworkers and Registered Nurses you will need to be mindful of appropriate developmental tasks based on chronological age. In addition, the support routinely expected by a parent/caregiver, should not be scored as needing assistance. John H. Winters Human Services Complex 701 West 51st Street P.O. Box Austin, TX (512) Call your local DHS office for assistance.

18 CLASS Policy Clarification No April 15, 1999 Page 2 For example, a young child routinely requires some encouragement or reminders to perform ADL/IADL tasks and would not be given a score of 1 unless they demonstrated a developmental lag (i.e., these reminders should not be considered as requiring assistance unless abnormal or excessive for chronological age). Effective May 1, 1999, the procedure for processing an Initial, On-going, Denied and Purpose code E LOCs for CLASS is as follows:! The provider makes a copy of a blank Form 3650-A/B, Level-of-Care (this form is no longer available through the Texas Department of Human Services (TDHS) warehouse).! The provider completes Form 3650-A/B with a purpose code of 2 for an initial LOC and code 3 for an on-going or Purpose code E LOC and the Related Conditions Eligibility Screening Instrument to establish a LOC for a potential or on-going participant.! The provider mails both the completed forms to: Texas Department of Human Services Long Term Care Policy Attention: Vicki Munoz, Mail code W-519 P.O. Box Austin, Texas ! If the Form 3650-A/B or the Related Conditions Eligibility Screening Instrument is incomplete or the screening instrument is not included, it will be remanded back to the originator for corrections.! If the Form 3660-A/B is complete, Ms. Munoz will date stamp it and log the form in the LOC log book. For any questions concerning the LOC process, please contact your lead program specialist for your area. For any other questions, please contact Don Mann, CLASS Unit Manager, at (512) Sincerely, [Signature on File] Becky Beechinor Assistant Deputy Commissioner Long Term Care Programs BB:aa