Kentucky Medically Frail Medical Condition Guide v5 for Providers Supplement to the Kentucky Medically Frail Provider Attestation Form

Transcription

1 Page 1 f 9 Kentucky Medically Frail Medical Cnditin Guide v5 fr Prviders Supplement t the Kentucky Medically Frail Prvider Attestatin Frm This Guide is a reference t Medicaid Prviders and Clinicians as they cmplete the Kentucky Medically Frail Prvider Attestatin frm fr determinatin f pssible medically frail members. PLEASE NOTE: In several instances, the Guide requires that the prvider wh is cmpleting the attestatin dcument infrmatin abut hw a diagnsis is being managed fr the Member. Fr example: If a member has substance use disrder, the prvider must dcument the setting f treatment (e.g. inpatient, hspital based care), whether the member has experienced an verdse, r is participating in a recvery prgram. If a member is diagnsed with Majr Depressive Disrder (categry B11), the prvider must dcument whether the patient is being treated with anti-depressant medicatin, and list the names f all such current medicatins. If a member is diagnsed with Diabetes, the prvider must dcument whether the patient has experienced cmplicatins such as neurpathy, renal cmplicatins, r retinpathy. Multiple behaviral health r physical health diagnses listed require infrmatin regarding medicatins used in the member s treatment t accurately determine whether the individual is medically frail. The Prvider r Clinician may include additinal details r answer questins regarding each cnditin as directed in Sectin IV Additinal Cmmentary f the Attestatin frm. This list is intended t be cmprehensive, but a Member may still have ther significant cnditins nt listed here, which may qualify as medically frail. Fr thse cnditins and circumstances, please prvide details regarding the cnditin in the Sectin IV Additinal Cmmentary sectin f the Attestatin frm. Include diagnsis, treatment, hspitalizatin, disability, prgnsis, and impact t ADLs. Medical Cnditin Grupings: the fllwing categries crrespnd t the Kentucky Medically Frail Prvider Attestatin frm, Sectin IV Medical Cnditins A. thrugh N. A. Substance Use Disrders (excluding tbacc and cannabis) Prvide details t include type(s) f drugs abused (except fr tbacc and cannabis), treatment plans including inpatient, any verdse, current cunseling, recvery/abstinence date, and impact t the ADLs described in Sectin III f the prvider attestatin. Include details in Sectin IV f Attestatin. A1 Member has had at least ne inpatient r residential Substance Use Disrder (SUD) treatment episde, at least ne Intensive Outpatient Prgram (IOP) service, r a partial hspitalizatin service fr SUD treatment within the last 6 mnths. A2 Member has had at least ne drug verdse requiring medical care within the last 6 mnths

2 Page 2 f 9 A3 Member is participating in a vluntary substance use disrder recvery prgram within the last 6 mnths. Please indicate name and lcatin f prgram, length f time in prgram, and status in Sectin IV. A4 Member has met criteria fr substance use disrder within the last 6 mnths, but has nt had a residential SUD stay, Intensive Outpatient Prgram (IOP), r partial hspitalizatin AND Member des nt participate in any vluntary substance abuse recvery prgram AND B. Mental Disrders Member has nt had an verdse requiring medical treatment in last 6 mnths Prvide details t include diagnsis f severe mental illness (SMI), date f diagnsis, current treatment, Rx, hspitalizatin, and impact t ADLs. B1 Serius suicidal act with clear expectatin f death in the last six mnths, OR B2 Persistent danger f severely hurting self r thers (e.g. recurrent vilence), in the last six mnths OR B3 Grss impairment in cmmunicatin (e.g. largely incherent r mute), OR B4 Sme danger f hurting self r thers (e.g. suicide attempts withut clear expectatin f death; frequently vilent; manic excitement), in the last six mnths OR B5 Inability t functin in almst all areas (e.g. stays in bed all day; n jb, hme, r friends), in the last six mnths OR B6 Serius impairment in cmmunicatin r judgment (e.g. smetimes incherent, acts grssly inapprpriately, suicidal preccupatin), OR B7 Behavir is cnsiderably influenced by delusins r hallucinatins B8 Majr impairment in several areas, such as wrk r schl, family relatins, judgment, thinking, r md (e.g. depressed man avids friends, neglects family, and is unable t wrk; child frequently beats up yunger children, is defiant at hme, and is failing at schl), in the last six mnths OR B9 Biplar disrder, severe, OR B10 Dementia, requiring hspitalizatin (fr dementia) in the last 12 mnths, OR B11 Majr Depressive Disrder (MDD), severe with recurrent psychtic symptms, and taking tw (2) r mre antidepressants, OR B12 Mental disrders due t physilgical cnditins, requiring hspitalizatin in the last 12 mnths due t the mental disrder, OR B13 Severe psychtic disrders, taking tw (2) r mre antipsychtics, OR B14 Schizphrenia B15 Biplar disrder, mderate, OR B16 Dementia, requiring hspitalizatin in the last 24 mnths due t dementia, OR B17 Develpmental disrder: delayed speech and language, OR B18 Intellectual Disabilities, including autism and Rett s, OR

3 Page 3 f 9 B19 Majr Depressive Disrder (MDD), severe, recurrent, and taking at least ne antidepressant, OR B20 Mental disrders due t physilgical cnditins, requiring hspitalizatin in the last 24 mnths due t the mental disrder, OR B21 Pst-traumatic stress disrder (PTSD), chrnic B22 Cyclthymic disrder, OR B23 Dysthymic disrder, OR B24 Mental disrders due t physilgical cnditins, nt requiring hspitalizatin, OR B25 Pst-traumatic stress disrder (PTSD), unspecified r acute in the last 12 mnths C. Cancer C1 Malignant neplasm, currently underging chemtherapy r radiatin therapy, r requiring surgery, OR C2 Stage 3-4 (distal) malignancy, active systemic cancer C3 Malignant neplasm, nt underging chemtherapy r radiatin therapy, nt requiring surgery in last 6 mnths, OR C4 Stage 2 cancer C5 Stage 1, excluding basal and squamus cell cancers D. Cardiac and Circulatry System D1 Athersclersis, with cardiac surgery in the past 12 mnths, OR D2 Carctatin f Arta (unperated), OR D3 Pulmnary emblism, OR D4 Severe disrders f veins, lymphatic vessels, arteries, arteriles and capillaries, treated with at least ne anticagulant, OR D5 Tw r mre Rx, including diuretic and at least ne ace inhibitr, ARB, r beta blcker, due t ne r mre f the fllwing cnditins: D6 Unstable Angina Cardiac arrest, heart failure, OR Chrnic ischemic heart disease, OR Cngestive heart failure (CHF), OR Dilated cardimypathy, OR Ischemic cardimypathy, OR Fr members with any f the fllwing diagnses D7-D43, prvide Rx in details fr anticagulant, antiarrhythmic, beta blcker, r CA channel blcker.: D7 Artic r tricuspid valve insufficiency r stensis, OR D8 Atrial (AFib) ventricular fibrillatin, OR D9 Angina, OR D10 Arrhythmia, OR

4 Page 4 f 9 D11 Athersclertic heart disease f crnary artery w angina pectris, OR D12 Atrial flutter, unspecified, OR D13 AV Blck all types, OR D14 Cardimypathy, OR D15 Cerebral ischemic incident, trans-ischemic attack with n residuals, n impairment, OR D16 Chrdae tendineae rupture, OR D17 Chrnic ttal cclusin f crnary artery, OR D18 Crnary artery dissectin, OR D19 Endcarditis, OR D20 Fascicular blcks bi, tri, all types, OR D21 Left bundle branch blck, OR D22 Lng QT syndrme, OR D23 Mitral valve disrder, stensis, OR D24 Mycarditis r Pericarditis, OR D25 Papillary muscle rupture, OR D26 Pulmnary valve disrders, stensis, OR D27 Right bundle branch blck, OR D28 Severe disrders f veins, lymphatic vessels, arteries, arteriles and capillaries, OR D29 Sick Sinus Syndrme (SSS), OR D30 Taktsub syndrme, OR D31 Thrmbsis, OR D32 Ventricular r parxysmal tachycardia, flutter D33 Aneurysm, OR D34 Athersclersis withut cardiac surgery in the past 12 mnths, OR D35 Chrnic ischemic heart disease, unspecified, OR D36 Crnary artery aneurysm, OR D37 Parxysmal atrial fibrillatin, OR D38 Pericardial effusin (nninflammatry), OR D39 Pericardium disease, unspecified, OR D40 Pre-excitatin syndrme, OR D41 Silent mycardial ischemia, OR D42 Supraventricular tachycardia, OR D43 Unspecified atrial fibrillatin E. Digestive System E1 Alchlic liver disease with ascites, OR E2 Barrett s esphagus with high grade dysplasia E3 Esphageal varices, OR

5 Page 5 f 9 E4 Hepatic failure, OR E5 Hepatitis: Type B r Type C, viral, with at least ne antiretrviral Rx; symptmatic, OR E6 Liver Cirrhsis, fibrsis, OR E7 Txic liver disease with chrnic active hepatitis, OR E8 Ascites, OR F. Endcrine System E9 Autimmune hepatitis, OR E10 Barrett s esphagus with lw grade dysplasia, OR E11 Chrnic pancreatitis. Prvide details regarding symptms, Rx, any surgery, and date f diagnsis, OR E12 Crhn s Disease, symptmatic, with ne r mre Rx. Prvide details regarding symptms, Rx, any surgery, and date f diagnsis, OR E13 Granulmatus hepatitis, OR E14 Hepatitis Type C with n antiretrviral Rx, symptmatic. Prvide details regarding symptms, date f diagnsis, treatment plan, and if liver functin impairment, OR E15 Liver abscess, OR E16 Phlebitis f prtal vein, OR E17 Ulcerative Clitis, symptmatic, with ne f mre Rx. Prvide details regarding symptms, Rx, any surgery, and date f diagnsis E18 Clitis, nninfective gastrenteritis, OR E19 Crhn s Disease, asymptmatic, n cmplicatins, OR E20 Hepatitis, with n retrviral Rx, asymptmatic, OR E21 Hepatitis Type A, D, and E, OR E22 Inflammatry liver disease, OR E23 Nnalchlic steathepatitis (NASH), OR E24 Ulcerative Clitis, asymptmatic, n cmplicatins F1 Amylidsis, OR F2 Barth Syndrme, OR F3 Cushing s Syndrme (primary endcrinpathy), OR F4 Diabetes Mellitus Type I r Diabetes Type II with TWO r mre cmplicatins t include: pr cntrl w/ HbA1C > 8, peripheral neurpathy, renal cmplicatins, retinpathy, amputatin, insulin pump, heart disease, r strke, OR F5 Disrders f purine and pyrimidine metablism, eg: Lesch-Nyhan Syndrme, OR F6 Lipid strage diseases, OR F7 Nephrgenic Diabetes Insipidus, OR F8 Severe prtein calrie malnutritin, OR F9 Smith-Lemli-Opitz Syndrme F10 Cushing s Syndrme (drug induced), OR

6 Page 6 f 9 F11 Diabetes Mellitus Type I r Diabetes Type II with ONE cmplicatin t include: HbA1C > 8%, peripheral neurpathy, renal cmplicatins, retinpathy, amputatin, insulin pump, heart disease, r strke F12 Diabetes Mellitus Type I r Diabetes Type II with n cmplicatins, HbA1C < 6.5% G. Geniturinary System G1 Chrnic kidney disease r ESRD, dialysis dependent, OR G2 Chrnic renal tubul-interstitial disease, OR G3 Glmerular diseases with nephrtic syndrmes, OR G4 Plycystic kidney with impaired renal functin G5 Chrnic kidney disease, stage 2 4, nt n dialysis G6 Chrnic kidney disease, stage 1 H. Hematlgical Disrder I. Infectius Disease H1 A.I.D.S., OR H2 Aplastic anemia, OR H3 Bld cltting disrders, OR H4 Bne marrw failure syndrmes, OR H5 Cagulatin Defect r deficiency, OR H6 Erythrblastpenia, OR H7 Hemphilia, OR H8 Hereditary hemlytic anemias, OR H9 Human Immundeficiency Virus (HIV), OR H10 Nezelf s syndrme, OR H11 Sarcidsis, OR H12 Sickle cell disrder, OR H13 Tay Sachs, OR H14 Thalassemia, OR H15 Thrmbphilia H16 Activated Prtein C Resistance I1 I2 I3 I4 I5 Meningitis, if current, r if recvered but with residuals, disability, r neurlgical deficits, OR Prtzal Diseases, if current r active, OR Leprsy (Hansen s Disease) Meningitis, if recvered and n residuals r neurlgical deficit, OR Prtzal Diseases, recvered, n residuals J. Musculskeletal System J1 Algneurdystrphy, OR

7 Page 7 f 9 J2 J3 J4 J5 J6 Ankylsing Spndylitis, OR Ostemalacia, OR Ostenecrsis, OR Osteprsis with current pathlgical fracture, histry f fracture Osteprsis with n histry f fracture K. Nervus System K1 Alzheimer s Disease, OR K2 Amytrphic lateral sclersis (ALS), OR K3 Anencephaly and similar malfrmatins, OR K4 Ataxia, OR K5 Bublar Palsy, OR K6 Bullus Disrders, OR K7 Cerebral infarctin, with residuals, OR K8 Cerebral palsy with neurlgic impairment such as spastic plegia r hemiplegia, intellectual disability, may need durable medical equipment, OR K9 Chiari Malfrmatin, OR K10 Cngenital hydrcephalus, malfrmatins f the spinal crd, r malfrmatins f the nervus system, OR K11 Degenerative disease f the basil ganglia, OR K12 Demyelinating Diseases with debilitating symptms, including multiple sclersis, plyneurpathy, Guillain-Barre, OR K13 Diseases f the central nervus system, includes: bacterial meningitis, pli, rabies, encephalitis, current with residuals r deficits, OR K14 Dwn Syndrme, if disabled, OR K15 Epilepsy with recurrent seizures, taking tw r mre anticnvulsant Rx, OR K16 Extrapyramidal mvement disrders, OR K17 Familial Dysautnmia, OR K18 Guillain-Barre, OR K19 Huntingtn s Disease, OR K20 Hydrcephalus, OR K21 Intracranial abscess, present, OR K22 Meningima, if symptmatic, unperated, OR K23 Micrcephaly, OR K24 Multiple Sclersis, with debilitatin, impaired functin, OR K25 Muscular Dystrphy, OR K26 Myneural junctin disrder, OR K27 Parkinsn s Disease, OR

8 Page 8 f 9 K28 Plyneurpathies, severe with debilitatin, OR K29 Pst Pli Syndrme, OR K30 Quadriplegia, OR K31 Spastic Paraplegia, OR K32 Spinal Abscess, OR K33 Spina Bifida, OR K34 Traumatic Brain Injury (TBI), with paralysis, debilitatin, residuals K35 Cerebral infarctin, with residuals, OR K36 Cerebral palsy, functinal but with sme neurlgic impairment, OR K37 Dwn Syndrme, OR K38 Epilepsy, mderate, taking ne anticnvulsant Rx, OR K39 Idipathic prgressive neurpathy, OR K40 Multiple Sclersis, symptmatic, underging treatment, OR K41 Neurleptic Syndrme, OR K42 Plyneurpathies, mderate with sme debilitatin, determine cause, OR K43 Traumatic Brain Injury (TBI), withut paralysis, mild debilitatin r residuals K44 Cerebral infarctin, n residuals, recvered, OR K45 Cerebral palsy, n functinal impairment issues, OR K46 Encephalitis, recvered and n residuals, OR K47 Epilepsy, mild, under cntrl, OR K48 Hereditary and idipathic neurpathies, unspecified, OR K49 Multiple Sclersis, asymptmatic, n treatment, OR K50 Plyneurpathy, mild, OR K51 Subarachnid hemrrhage, nn-traumatic, n residuals L. Respiratry System L1 Brnchiectasis requiring supplemental xygen, OR L2 COPD requiring supplemental xygen, OR L3 Cystic Fibrsis, OR L4 Diseases f the pleura, mderate r severe, requiring supplemental xygen, OR L5 Emphysema requiring supplemental xygen, OR L6 Interstitial Pulmnary Diseases, OR L7 Other cnditin requiring supplemental xygen. Please give details f cnditin, OR L8 Pulmnary hypertensin, primary, OR L9 Severe lung diseases due t external agents, such as asbests, OR L10 Tuberculsis, active L11 Brnchiectasis, nt requiring supplemental xygen, OR L12 COPD, unspecified, nt requiring supplemental xygen, OR

9 Page 9 f 9 M. Skin Disrder N. Other L13 Idipathic interstitial pulmnary disease, OR L14 Emphysema and nt requiring supplemental xygen, OR L15 McLed s syndrme, OR L16 Severe persistent asthma L17 Brnchitis, simple, chrnic, unspecified, OR L18 Tuberculsis, nt active r arrested, OR L19 Hyptensin idipathic r rthstatic M1 Epidermlysis bullsa acquisita, OR M2 Systemic cnnective tissue disrders. Please give details f cnditin, and if any disability, OR M3 Sclerderma M4 Lupus, mild symptms M5 Lupus, n symptms, n debilitatin N1 Gangrene, OR N2 Hspice, current fr any cnditin, OR N3 Transplant: pending rgan transplant, ther than crnea (if nt blind), OR N4 Ostmy current N5 Transplant: < 1-year pst transplant, n cmplicatins r residual debilitatin N6 Transplant: > 1 year, n cmplicatins r residual debilitatin