Last Review Date: June 27, 2017 Number: MG.MM.ME.18fv2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, ( EmblemHealth ) has adopted the herein policy in providing management, administrative and other services to HIP Health Plan of New York, HIP Insurance Company of New York, Group Health Incorporated and GHI HMO Select, related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definition Neuropsychological testing (NPT) is a specialty area of psychological testing consisting primarily of individually administered tests that comprehensively sample ability domains that are known to be sensitive to the functional integrity of the brain (eg, abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, and constructional praxis). These procedures are objective and quantitative in nature and require that patients directly demonstrate a level of competence in a particular cognitive domain. Cognitive deficits may have nonorganic, transient roots and be associated with anxiety disorders, depressive conditions, and severe psychological trauma. 1 Guideline Members are eligible for NPT coverage when there has been a significant behavioral change, mental status change, memory loss, or organic brain injury under any of the conditions listed in tables 1 and 2. Psychological evaluations that can be accomplished through the clinical interview would not require NPT and shall not be covered. 1 Brief screening measures such as the Folstein Mini-Mental Status Exam or use of other mental status exams in isolation should not be reported separately as psychological or neuropsychological testing, as they are typically part of a more general clinical exam or interview.
Page 2 of 34 Table 1 Medical Issues Brain tumor Cerebral anoxic or hypoxic episode Cerebrovascular disease (eg, vascular dementias, i.e., single- or multi-infarct dementia) Central nervous system (CNS) infection (eg, herpes encephalitis, HIV) Demyelinating disease (eg, multiple sclerosis) Epilepsy (for patients under consideration for temporal lobectomy, to assess the cognitive integrity of the remaining hemisphere and lateralized representation of specific cognitive capacities) Extrapyramidal disease (eg, Parkinson s or Huntington s diseases) Head injury (open or closed) Metabolic encephalopathy (associated with hepatic or renal disease) Neurodegenerative disorders (eg, AIDS, Alzheimer s disease and other mixed-type dementias) (See also footnote 3) Neurocognitive monitoring of recovery from or progression of CNS disorders Table 2 Mental Health Issues Note: EmblemHealth s Behavioral Management Program is administered by the following delegates: Montefiore Care Management (CMO) in partnership with University Behavioral Associates (UBA) for members managed by the CMO Medical Group with plans underwritten by HIP Beacon Health Options for plans underwritten by GHI, HIP and HIPIC and administered by VHMS. Chronic exposure to agents known to be associated with cerebral dysfunction (eg, solvents, heavy metal such as lead or illicit drugs) 2 Assessment of mental functioning for individuals with suspected or known mental disorders, for purposes of differential diagnosis and treatment Assessment of patient s strengths and disabilities, for use in treatment planning or management, when signs or symptoms of a mental disorder are present Assessment of patient s capacity for decision making when impairment that would affect patient care or management is suspected Differential diagnosis between psychogenic and neurogenic syndromes (eg, depression versus dementia) 3 2 The workers compensation carrier may provide coverage, particularly in the occupational or environmental medicine realm. 3 When a psychiatric condition or the presence of dementia is previously diagnosed, there is value to the testing only if the information derived would be expected to significantly influence management. Examples include a significant change in the patient s condition, the need to evaluate a patient s capacity to function in a given situation or environment, and the need to specifically tailor therapeutic or compensatory techniques to particular aspects of the patient s pattern of strengths and disabilities.
Page 3 of 34 Documentation The medical record should include all of the following information: 1. Diagnosis (or suspected diagnosis that was the basis for the testing if no mental illness was found) 2. Identity of person performing service 3. Present evaluation 4. Reason for referral 5. Recommendations for interventions, if necessary 6. Tests administered, scoring and interpretation and time involved Administration of NPT Only a psychologist, psychiatrist or other qualified (non-physician) provider (practitioner) may perform NPT. 4 The Plan covers up to 8 hours of NPT; any combination of CPT codes 96118, 96119 and 96120 (inclusive of administration, scoring and interpretation) initially. If a provider wants additional hours for testing, they must submit an additional request. All psychological / neuropsychological testing is subject to medical necessity review. (See Revision History for clarifications specific to lines of business) NPT for routine re-evaluation of chronically disabled patients will be covered only if it is required for a diagnosis or continued treatment. Limitations/Exclusions Each test administered must be medically necessary. Standardized batteries of tests are only acceptable if each component test is medically necessary. A. When neuropsychological testing for a diagnosis of Autism Spectrum Disorder (ASD) is provided by a licensed physician or psychologist it is the responsibility of Beacon. If the testing is provided by a developmental pediatrician or pediatric neurologist it is covered by the medical plan. B. NPT is not covered under any of the following circumstances: No suspicion of mental illness or disability This is screening, which is not medically necessary. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing. Solely for educational or vocational purposes Circumstances that may interfere with the accuracy or interpretation of test results, such as: Positive history of substance abuse when any of the following apply: a. Continued use precludes accurate NPT result b. The patient is 10 days post-detoxification 4 NPT may be conducted by the following provider types. Individuals who are not licensed or otherwise authorized by state law to provide psychological services may not provide psychological services. Pediatrics (developmental-behavioral and neurodevelopmental specialists) Psychiatrist (MD or DO) Clinical Psychologist (CP) Clinical Social Worker (CSW) Psychiatric Nurse Practitioners (NPs) Clinical Nurse Specialists (CNS) Physician Assistants (PAs) Relevant NYS Education Department information for education, law and licensure is available at: http://www.op.nysed.gov/prof/
Page 4 of 34 The effects of certain daily medications (eg, mood-altering drugs or beta blockers) have not been ruled out Similar testing has been performed in the last 12 months C. NPT is not covered for the purposes of diagnosing any of the following conditions, as it is not considered medically necessary: ADD/ADHD NPT is rarely required for uncomplicated ADD with or without hyperactivity; however, a referral to an outpatient mental health or chemical dependency clinic may be medically necessary and covered for the evaluation and comprehensive bio-psychosocial treatment for these disorders. NPT may be medically necessary and covered for neurologically complicated cases of ADD/ADHD (eg, post head trauma, seizures) Developmental disability (except Medicaid members; see Note on page 1) Learning disability Mental retardation Tourette s syndrome D. Specific to Medicare members: Revision History 6/27/2017 5/12/2017 Testing of every patient upon entry to a nursing home would be considered a routine service and would therefore not be covered Adjustment reactions or dysphoria associated with moving to a nursing home does not automatically constitute medical necessity for testing. Some individuals, however, enter a nursing home at a time of physical and cognitive decline; in such cases, psychological testing may be warranted to arrive at a diagnosis and care plan Decisions to provide psychological testing to individuals who have recently entered a nursing home should be made judiciously on a case-by-case basis Clarifications specific to lines of business: The CMS standards basic package of neuropsychological testing is 8 Units For HMO members, preauthorization is required for both the initial 8 hours of testing as well as any additional hours For PPO members, clinicians may seek preauthorization for units greater than 8, or may request claims reconsideration for any denied hours billed if supported by medical documentation. The value of 10 units of testing has been changed from 10 to 8 in accordance with medical unlikely edits (MUE) Clarified that preauthorization is required for both the initial 8 hours of testing as well as any additional hours Provided information for when pre-service requests for ASDs are to be directed to EmblemHealth versus its delegate Beacon 10/25/2015 Clarified use of CPT coding regarding 96118, 96119 and 96120 Applicable Procedure Codes 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report 96118 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin
Page 5 of 34 Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report 96119 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face 96120 Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Applicable ICD-10 Diagnosis Codes Codes Pertaining to Medical Issues C70.0 Malignant neoplasm of cerebral meninges C70.9 Malignant neoplasm of meninges, unspecified C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of occipital lobe C71.5 Malignant neoplasm of cerebral ventricle C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem C71.8 Malignant neoplasm of overlapping sites of brain C71.9 Malignant neoplasm of brain, unspecified C72.20 Malignant neoplasm of unspecified olfactory nerve C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve C72.30 Malignant neoplasm of unspecified optic nerve C72.31 Malignant neoplasm of right optic nerve C72.32 Malignant neoplasm of left optic nerve C72.40 Malignant neoplasm of unspecified acoustic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.50 Malignant neoplasm of unspecified cranial nerve C72.59 Malignant neoplasm of other cranial nerves C79.31 Secondary malignant neoplasm of brain D32.0 Benign neoplasm of cerebral meninges D32.9 Benign neoplasm of meninges, unspecified D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.2 Benign neoplasm of brain, unspecified D33.7 Benign neoplasm of other specified parts of central nervous system D43.0 Neoplasm of uncertain behavior of brain, supratentorial D43.1 Neoplasm of uncertain behavior of brain, infratentorial D43.2 Neoplasm of uncertain behavior of brain, unspecified D43.4 Neoplasm of uncertain behavior of spinal cord D49.6 Neoplasm of unspecified behavior of brain E75.00 GM2 gangliosidosis, unspecified
Page 6 of 34 Codes Pertaining to Medical Issues E75.01 Sandhoff disease E75.02 Tay-Sachs disease E75.09 Other GM2 gangliosidosis E75.10 Unspecified gangliosidosis E75.11 Mucolipidosis IV E75.19 Other gangliosidosis E75.23 Krabbe disease E75.25 Metachromatic leukodystrophy E75.29 Other sphingolipidosis E75.4 Neuronal ceroid lipofuscinosis F01.50 Vascular dementia without behavioral disturbance F01.51 Vascular dementia with behavioral disturbance F01.51 Vascular dementia with behavioral disturbance F01.51 Vascular dementia with behavioral disturbance F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance F07.0 Personality change due to known physiological condition F07.89 Other personality and behavioral disorders due to known physiological condition F84.2 Rett's syndrome G05.3 Encephalitis and encephalomyelitis in diseases classified elsewhere G10 G20 Huntington's disease Parkinson's disease G21.11 Neuroleptic induced parkinsonism G21.19 Other drug induced secondary parkinsonism G21.2 Secondary parkinsonism due to other external agents G21.3 Postencephalitic parkinsonism G21.4 Vascular parkinsonism G21.8 Other secondary parkinsonism G21.9 Secondary parkinsonism, unspecified G25.9 Extrapyramidal and movement disorder, unspecified G31.81 Alpers disease G31.82 Leigh's disease G31.83 Dementia with Lewy bodies G31.9 Degenerative disease of nervous system, unspecified G35 Multiple sclerosis G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst] G36.8 Other specified acute disseminated demyelination G36.9 Acute disseminated demyelination, unspecified G37.1 Central demyelination of corpus callosum G37.2 Central pontine myelinolysis G37.4 Subacute necrotizing myelitis of central nervous system G37.8 Other specified demyelinating diseases of central nervous system G37.9 Demyelinating disease of central nervous system, unspecified G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not
Page 7 of 34 Codes Pertaining to Medical Issues intractable, without status epilepticus G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus G40.801 Other epilepsy, not intractable, with status epilepticus G40.802 Other epilepsy, not intractable, without status epilepticus G40.803 Other epilepsy, intractable, with status epilepticus G40.804 Other epilepsy, intractable, without status epilepticus G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus G40.89 Other seizures G40.89 Other seizures G40.901 Epilepsy, unspecified, not intractable, with status epilepticus G40.909 Epilepsy, unspecified, not intractable, without status epilepticus G40.911 Epilepsy, unspecified, intractable, with status epilepticus G40.919 Epilepsy, unspecified, intractable, without status epilepticus G40.A01 G40.A09 G40.A11 G40.A19 Absence epileptic syndrome, not intractable, with status epilepticus Absence epileptic syndrome, not intractable, without status epilepticus Absence epileptic syndrome, intractable, with status epilepticus Absence epileptic syndrome, intractable, without status epilepticus
Page 8 of 34 Codes Pertaining to Medical Issues G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus G92 Toxic encephalopathy G93.1 Anoxic brain damage, not elsewhere classified G93.41 Metabolic encephalopathy G93.89 Other specified disorders of brain G93.9 Disorder of brain, unspecified G93.9 Disorder of brain, unspecified G96.9 Disorder of central nervous system, unspecified G97.2 Intracranial hypotension following ventricular shunting G97.82 Other postprocedural complications and disorders of nervous system G98.8 Other disorders of nervous system I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries I63.319 Cerebral infarction due to thrombosis of unspecified middle cerebral artery I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery I63.323 Cerebral infarction due to thrombosis of bilateral anterior cerebral arteries (Revision eff. 10/1/2017) I63.329 Cerebral infarction due to thrombosis of unspecified anterior cerebral artery I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery I63.333 Cerebral infarction to thrombosis of bilateral posterior cerebral arteries (Revision eff. 10/1/2017) I63.339 Cerebral infarction due to thrombosis of unspecified posterior cerebral artery I63.341 Cerebral infarction due to thrombosis of right cerebellar artery I63.342 Cerebral infarction due to thrombosis of left cerebellar artery I63.343 Cerebral infarction to thrombosis of bilateral cerebellar arteries I63.349 Cerebral infarction due to thrombosis of unspecified cerebellar artery I63.39 Cerebral infarction due to thrombosis of other cerebral artery I63.40 Cerebral infarction due to embolism of unspecified cerebral artery I63.411 Cerebral infarction due to embolism of right middle cerebral artery I63.412 Cerebral infarction due to embolism of left middle cerebral artery I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery I63.421 Cerebral infarction due to embolism of right anterior cerebral artery I63.422 Cerebral infarction due to embolism of left anterior cerebral artery I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery I63.431 Cerebral infarction due to embolism of right posterior cerebral artery I63.432 Cerebral infarction due to embolism of left posterior cerebral artery I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery
Page 9 of 34 Codes Pertaining to Medical Issues I63.441 Cerebral infarction due to embolism of right cerebellar artery I63.442 Cerebral infarction due to embolism of left cerebellar artery I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other cerebral artery I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries (Revision eff. 10/1/2017) I63.519 Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries (Revision eff. 10/1/2017) I63.529 Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries (Revision eff. 10/1/2017) I63.539 Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries I63.549 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage) I69.019 Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage I69.111 Memory deficit following nontraumatic intracerebral hemorrhage I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I69.119 Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage) I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage I69.211 Memory deficit following other nontraumatic intracranial hemorrhage
Page 10 of 34 Codes Pertaining to Medical Issues I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I69.219 Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I69.310 Attention and concentration deficit following cerebral infarction I69.311 Memory deficit following cerebral infarction I69.312 Visuospatial deficit and spatial neglect following cerebral infarction I69.313 Psychomotor deficit following cerebral infarction I69.314 Frontal lobe and executive function deficit following cerebral infarction I69.315 Cognitive social or emotional deficit following cerebral infarction I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction I69.319 Unspecified symptoms and signs involving cognitive functions following cerebral infarction I69.810 Attention and concentration deficit following other cerebrovascular disease I69.811 Memory deficit following other cerebrovascular disease I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease I69.813 Psychomotor deficit following other cerebrovascular disease I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease I69.815 Cognitive social or emotional deficit following other cerebrovascular disease I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease I69.819 Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease I69.910 Attention and concentration deficit following unspecified cerebrovascular disease I69.911 Memory deficit following unspecified cerebrovascular disease I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease I69.913 Psychomotor deficit following unspecified cerebrovascular disease I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease I69.919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified S01.90xS Unspecified open wound of unspecified part of head, sequela S02.0xxS Fracture of vault of skull, sequela S02.101S Fracture of base of skull, right side, sequela S02.102S Fracture of base of skull, left side, sequela S02.109S Fracture of base of skull, unspecified side, sequela S02.110S Type I occipital condyle fracture, unspecified side, sequela S02.111S Type II occipital condyle fracture, unspecified side, sequela S02.112S Type III occipital condyle fracture, unspecified side, sequela S02.113S Unspecified occipital condyle fracture, sequela S02.118S Other fracture of occiput, unspecified side, sequel
Page 11 of 34 Codes Pertaining to Medical Issues S02.119S S02.11AS S02.11BS S02.11CS S02.11DS S02.11ES S02.11FS S02.11GS S02.11HS S02.19xS S02.2xxS S02.30XS S02.31XS S02.32XS S02.400S S02.401S S02.402S S02.40AS S02.40BS S02.40CS S02.40DS S02.40ES S02.40FS S02.411S S02.412S S02.413S S02.42xS S02.5xxS S02.600S S02.601S S02.602S S02.609S S02.610S S02.611S S02.612S S02.620S S02.621S S02.622S S02.630S S02.631S S02.632S S02.640S S02.641S S02.642S S02.650S Unspecified fracture of occiput, sequela Type I occipital condyle fracture, right side, sequela Type I occipital condyle fracture, left side, sequela Type II occipital condyle fracture, right side, sequela Type II occipital condyle fracture, left side, sequela Type III occipital condyle fracture, right side, sequela Type III occipital condyle fracture, left side, sequela Other fracture of occiput, right side, sequela Other fracture of occiput, left side, sequela Other fracture of base of skull, sequela Fracture of nasal bones, sequela Fracture of orbital floor, unspecified side, sequela Fracture of orbital floor, right side, sequela Fracture of orbital floor, left side, sequela Malar fracture, unspecified side, sequela Maxillary fracture, unspecified side, sequela Zygomatic fracture, unspecified side, sequela Malar fracture, right side, sequela Malar fracture, left side, sequela Maxillary fracture, right side, sequela Maxillary fracture, left side, sequela Zygomatic fracture, right side, sequela Zygomatic fracture, left side, sequela LeFort I fracture, sequela LeFort II fracture, sequela LeFort III fracture, sequela Fracture of alveolus of maxilla, sequela Fracture of tooth (traumatic), sequela Fracture of unspecified part of body of mandible, unspecified side, sequela Fracture of unspecified part of body of right mandible, sequela Fracture of unspecified part of body of left mandible, sequela Fracture of mandible, unspecified, sequela Fracture of condylar process of mandible, unspecified side, sequela Fracture of condylar process of right mandible, sequela Fracture of condylar process of left mandible, sequela Fracture of subcondylar process of mandible, unspecified side, sequela Fracture of subcondylar process of right mandible, sequela Fracture of subcondylar process of left mandible, sequela Fracture of coronoid process of mandible, unspecified side, sequela Fracture of coronoid process of right mandible, sequela Fracture of coronoid process of left mandible, sequela Fracture of ramus of mandible, unspecified side, sequela Fracture of ramus of right mandible, sequela Fracture of ramus of left mandible, sequela Fracture of angle of mandible, unspecified side, sequela
Page 12 of 34 Codes Pertaining to Medical Issues S02.651S S02.652S S02.66xS S02.670S S02.671S S02.672S S02.69xS S02.80XS S02.81XS S02.82XS S02.91xS S02.92xS S06.0X0S S06.0X1S S06.0X9S S06.1X0S S06.1X1S S06.1X2S S06.1X3S S06.1X4S S06.1X5S S06.1X7S S06.1X8S S06.1X9S S06.2X0S S06.2X1S S06.2X2S S06.2X3S S06.2X4S S06.2X5S S06.2X7S S06.2X8S S06.2X9S S06.300S S06.301S S06.302S S06.303S S06.304S S06.305S S06.307S S06.308S Fracture of angle of right mandible, sequela Fracture of angle of left mandible, sequela Fracture of symphysis of mandible, sequela Fracture of alveolus of mandible, unspecified side, sequela Fracture of alveolus of right mandible, sequela Fracture of alveolus of left mandible, sequela Fracture of mandible of other specified site, sequela Fracture of other specified skull and facial bones, unspecified side, sequela Fracture of other specified skull and facial bones, right side, sequela Fracture of other specified skull and facial bones, left side, sequela Unspecified fracture of skull, sequela Unspecified fracture of facial bones, sequela Concussion without loss of consciousness, sequela Concussion with loss of consciousness of 30 minutes or less, sequela Concussion with loss of consciousness of unspecified duration, sequela Traumatic cerebral edema without loss of consciousness, sequela Traumatic cerebral edema with loss of consciousness of 30 minutes or less, sequela Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Traumatic cerebral edema with loss of consciousness of unspecified duration, sequela Diffuse traumatic brain injury without loss of consciousness, sequela Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, sequela Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, sequela Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels, sequela Diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Diffuse traumatic brain injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela Unspecified focal traumatic brain injury without loss of consciousness, sequela Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, sequela Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, sequela Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, sequela Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Unspecified focal traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Unspecified focal traumatic brain injury with loss of consciousness of any duration with death due to other cause prior
Page 13 of 34 Codes Pertaining to Medical Issues S06.309S S06.310S S06.311S S06.312S S06.313S S06.314S S06.315S S06.317S S06.318S S06.319S S06.320S S06.321S S06.322S S06.323S S06.324S S06.325S S06.327S S06.328S S06.329S S06.330S S06.331S S06.332S S06.333S S06.334S S06.335S S06.337S S06.338S S06.339S S06.340S S06.341S S06.342S S06.343S S06.344S S06.345S S06.347S S06.348S S06.349S S06.350S to regaining consciousness, sequela Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela Contusion and laceration of right cerebrum without loss of consciousness, sequela Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, sequela Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, sequela Contusion and laceration of left cerebrum without loss of consciousness, sequela Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, sequela Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, sequela Contusion and laceration of cerebrum, unspecified, without loss of consciousness, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela Traumatic hemorrhage of right cerebrum without loss of consciousness, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, sequela Traumatic hemorrhage of left cerebrum without loss of consciousness, sequela
Page 14 of 34 Codes Pertaining to Medical Issues S06.351S S06.352S S06.353S S06.354S S06.355S S06.357S S06.358S S06.359S S06.360S S06.361S S06.362S S06.363S S06.364S S06.365S S06.367S S06.368S S06.369S S06.370S S06.371S S06.372S S06.373S S06.374S S06.375S S06.377S S06.378S S06.379S S06.380S S06.381S S06.382S S06.383S S06.384S S06.385S S06.387S S06.388S S06.389S S06.4X0S S06.4X1S S06.4X2S Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, sequela Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to preexisting conscious level, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, sequela Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, sequela Epidural hemorrhage without loss of consciousness, sequela Epidural hemorrhage with loss of consciousness of 30 minutes or less, sequela Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela
Page 15 of 34 Codes Pertaining to Medical Issues S06.4X3S S06.4X4S S06.4X5S S06.4X7S S06.4X8S S06.4X9S S06.5X0S S06.5X1S S06.5X2S S06.5X3S S06.5X4S S06.5X5S S06.5X7S S06.5X8S S06.5X9S S06.6X0S S06.6X1S S06.6X2S S06.6X3S S06.6X4S S06.6X5S S06.6X7S S06.6X8S S06.6X9S Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Epidural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Epidural hemorrhage with loss of consciousness of any duration with death due to other causes prior to regaining consciousness, sequela Epidural hemorrhage with loss of consciousness of unspecified duration, sequela Traumatic subdural hemorrhage without loss of consciousness, sequela Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, sequela Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, sequela Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness, sequela Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela Traumatic subarachnoid hemorrhage without loss of consciousness, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, sequela S06.810S Injury of right internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, sequela S06.811S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, sequela S06.812S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 31 minutes to 59 minutes, sequela S06.813S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.814S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 6 hours to 24 hours, sequela S06.815S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.817S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, sequela S06.818S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, sequela S06.819S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of S06.820S unspecified duration, sequela Injury of left internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, sequela S06.821S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, sequela