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

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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, 435.1009, 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

Infectious and Parasitic Diseases (137-139) 138 Late effects of acute poliomyelitis Neoplasm of the Brain (140-239) 191 Malignant neoplasm of the brain 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.7 Neurofibromatosis (von Recklinghausen s Disease) Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders (240-279) 243 Congenital hypothyroidism 244 Acquired hypothyroidism 244.9 Unspecified hypothyroidism 252.0 Hyperparathyroidism 270.8 Lowe (-Terrey-MacLachlan) syndrome (oculocerebrorenal dystrophy) 272.7 Lipidoses 275.49 Other disorders of calcium metabolism (pseudohypoparathyroidism) 277.2 Other disorders of purine and pyrimidine metabolism (Lesch-Nyhan syndrome) 277.5 Mucopolysaccharidosis (Hunter s syndrome, Hurler s syndrome, Scheie s syndrome) 277.8 Other specified disorders of metabolism 277.9 Unspecified disorder of metabolism (enzymopathy NOS) 279.11 DiGeorge s syndrome Diseases of the Blood and Blood-Forming Organs (280-289) 287.3 Primary thrombocytopenia 287.30 Primary thrombocytopenia unspecified 287.33 Congenital and hereditary thrombocytopenic purpura (congenital and hereditary thrombocytopenia; Thrombocytopenia with Absent Radi (TAR) syndrome Psychoses with Origin Specific to Childhood (299) 299.0 Autistic disorder (childhood autism; infantile psychosis; Kanner s syndrome) 299.1 Childhood disintegrative disorder 299.8 Other specified pervasive developmental disorders (Asperger s disorder, atypical childhood psychosis; borderline psychosis of childhood) 299.9 Unspecified pervasive developmental disorder (pervasive developmental disorder NOS) Gilles de la Tourettes Disorder (307.23) 307.23 Tourette s disorder (motor-verbal tic disorder) Specific Nonpsychotic Mental Disorders - Due to organic brain damage (310-311) 310.0 Frontal lobe syndrome (lobotomy syndrome; postleucotomy syndrome [state]) 310.2 Postconcussion syndrome 310.8 Other specified nonpsychotic mental disorders following organic brain damage (postencephalitic syndrome) 310.9 Unspecified non-psychotic mental disorder following organic brain damage Center for Policy and Innovation Page 2 of 9 May 1, 2009

Specific Delays in Development (315.9) 315.9 Unspecified delay in development (developmental disorder NOS) Nervous System and Sense Organs (320-389) 320.9 Meningitis due to unspecified bacterium 323 Encephalitis, myelitis, encephalomyelitis 323.9 Unspecified cause of encephalitis 330 Cerebral degenerations usually manifest in childhood 330.0 Metachromatic leukodystrophy 330.8 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) 331.11 Pick s disease 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 331.8 Other cerebral degeneration 331.81 Reye s syndrome 331.89 Cerebral ataxia 331.9 Cerebral degeneration, unspecified 332.0 Paralysis agitans (Parkinson s disease) 332.1 Secondary Parkinsonism 333.4 Huntington s chorea 333.6 Idiopathic torsion dystonia 333.7 Symptomatic torsion dystonia (athetoid cerebral palsy) 334.0 Friedreich s ataxia 334.8 Other spinocerebellar diseases (ataxia-telangiectasia [Louis-Bar syndrome]) 335.10 Spinal muscular atrophy, unspecified 335.11 Kugelberg-Welander disease 336.9 Unspecified disease of spinal cord 340 Multiple sclerosis 341.9 Demyelinating disease of central nervous system, unspecified 342.1 Spastic hemiplegia 342.9 Hemiplegia, unspecified 343.0 Diplegic (congenital diplegia) 343.9 Infantile cerebral palsy, unspecified 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia (paralysis of both lower limbs) 344.5 Unspecified monoplegia 344.9 Paralysis, unspecified 345.0 Generalized non-convulsive epilepsy 345.1 Generalized convulsive epilepsy 345.2 Petit mal status 345.3 Grand mal status 345.4 Partial epilepsy, with impairment of consciousness (psychomotor epilepsy) 345.9 Epilepsy, unspecified 348.0 Cerebral cysts (arachnoid cyst) Center for Policy and Innovation Page 3 of 9 May 1, 2009

348.1 Anoxic brain damage 348.3 Encephalopathy, not elsewhere classified 349.8 Other specified disorders of nervous system 349.9 Unspecified disorders of nervous system 350.1 Trigeminal neuralgia 358.0 Myasthenia gravis 359.0 Congenital hereditary muscular dystrophy 359.1 Hereditary progressive muscular dystrophy 359.8 Other myopathies 369.0 Profound impairment, both eyes 369.1 Moderate or severe impairment, better eye, profound impairment lesser eye 369.4 Legal blindness, as defined in U.S.A. 389.0 Conductive hearing loss 389.1 Sensorineural hearing loss 389.2 Mixed conductive and sensorineural hearing loss 389.7 Deaf mutism, not elsewhere classifiable 389.8 Other specified forms of hearing loss 389.9 Unspecified hearing loss Cerebrovascular Disease (430-438) 436 Acute, but ill-defined cerebrovascular disease 438 Late effects of cerebrovascular disease Arthropathies and Related Disorders (710-719) 710.4 Polymyositis 714.3 Juvenile chronic polyarthritis Rheumatism, Excluding the Back (725-729) 728.3 Other specific muscle disorders (arthrogryposis) Congenital Anomalies (740-759) 741.0 Spina bifida with hydrocephalus 741.9 Spina bifida without mention of hydrocephalus 742.0 Encephalocele 742.2 Reduction deformities of brain 742.3 Congenital hydrocephalus 742.8 Other specified anomalies of nervous system (familial dysautonomia; Riley-Day syndrome) 742.9 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)] 754.8 Larsen s syndrome 755 Other congenital anomalies of limbs 755.23 Longitudinal deficiency, combined, involving humerus, radius, and ulna (complete or incomplete) Center for Policy and Innovation Page 4 of 9 May 1, 2009

755.25 Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete) 755.33 Longitudinal deficiency, combined, involving femur, tibia, and fibula (complete or incomplete) 755.55 Acrocephalosyndactyly (Apert s syndrome) 756.0 Anomalies of skull and face bones (Hallerman-Streiff syndrome, craniosynostosis) 756.10 Anomalies of spine, unspecified 756.51 Osteogenesis imperfecta 756.59 Conradi syndrome 758.0 Down s syndrome 758.1 Patau s syndrome 758.3 Autosomal deletion syndromes 758.6 Gonadal dysgenesis (Turner s syndrome) 758.7 Klinefelter s syndrome 758.9 Conditions due to anomaly of unspecified chromosome 759.5 Tuberous sclerosis 759.81 Prader-Willi syndrome 759.82 Marfan syndrome 759.83 Fragile X syndrome 759.89 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 (760-779) 760.71 Fetal alcohol syndrome 767.4 Injury to spine and spinal cord 768.5 Severe birth asphyxia 771.0 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 851-854: 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

Fracture of Skull (800 804) Fracture of Vault of Skull (800) (Requires fifth digit - see chart on page 5 for codes and definitions) Includes: frontal bone and parietal bone. 800.0 Closed without mention of intracranial injury 800.1 Closed with cerebral laceration and contusion 800.2 Closed with subarachnoid, subdural, and extradural hemorrhage 800.3 Closed with other and unspecified intracranial hemorrhage 800.4 Closed with intracranial injury of other and unspecified nature 800.5 Open without mention of intracranial injury 800.6 Open with cerebral laceration and contusion 800.7 Open with subarachnoid, subdural, and extradural hemorrhage 800.8 Open with other and unspecified intracranial hemorrhage 800.9 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. 801.0 Closed without mention of intracranial injury 801.1 Closed with cerebral laceration and contusion 801.2 Closed with subarachnoid, subdural, and extradural hemorrhage 801.3 Closed with other and unspecified intracranial hemorrhage 801.4 Closed with intracranial injury of other and unspecified nature 801.5 Open without mention of intracranial injury 801.6 Open with cerebral laceration and contusion 801.7 Open with subarachnoid, subdural, and extradural hemorrhage 801.8 Open with other and unspecified intracranial hemorrhage 801.9 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. 803.0 Closed without mention of intracranial injury 803.1 Closed with cerebral laceration and contusion 803.2 Closed with subarachnoid, subdural, and extradural hemorrhage 803.3 Closed with other and unspecified intracranial hemorrhage 803.4 Closed with intracranial injury of other and unspecified nature 803.5 Open without mention of intracranial injury 803.6 Open with cerebral laceration and contusion 803.7 Open with subarachnoid, subdural, and extradural hemorrhage 803.8 Open with other and unspecified intracranial hemorrhage 803.9 Open with intracranial injury of other unspecified nature Center for Policy and Innovation Page 6 of 9 May 1, 2009

Multiple Fractures Involving Skull or Face with Other Bones (804) (Requires fifth digit see chart on page 5 for codes and definitions) 804.0 Closed without mention of intracranial injury 804.1 Closed with cerebral laceration and contusion 804.2 Closed with subarachnoid, subdural, and extradural hemorrhage 804.3 Closed with other and unspecified intracranial hemorrhage 804.4 Closed with intracranial injury of other and unspecified nature 804.5 Open without mention of intracranial injury 804.6 Open with cerebral laceration and contusion 804.7 Open with subarachnoid, subdural, and extradural hemorrhage 804.8 Open with other and unspecified intracranial hemorrhage 804.9 Open with intracranial injury of other and unspecified nature Intracranial Injury, Excluding Those with Skull Fracture (850 854) Concussion (850) Includes: commotio cerebri 850.0 With no loss of consciousness (concussion with mental confusion or disorientation, without loss of consciousness) 850.1 With brief loss of consciousness (of consciousness for less than one hour) 850.2 With moderate loss of consciousness (loss of consciousness for 1-24 hours) 850.3 With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) 850.4 With prolonged loss of consciousness, without return to pre-existing conscious level 850.5 With loss of consciousness of unspecified duration 850.9 Concussion, unspecified Cerebral Laceration and Contusion (851) (Requires fifth digit - see chart on page 5 for codes and definitions) 851.0 Cortex (cerebral) contusion without mention of open intracranial wound 851.1 Cortex (cerebral) contusion with open intracranial wound 851.2 Cortex (cerebral) laceration without mention of open intracranial wound 851.3 Cortex (cerebral) laceration with open intracranial wound 851.4 Cerebellar or brain stem contusion without mention of open intracranial wound 851.5 Cerebellar or brain stem contusion with open intracranial wound 851.6 Cerebellar or brain stem laceration without mention of open intracranial wound 851.7 Cerebellar or brain stem laceration with open intracranial wound 851.8 Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound 851.9 Other and unspecified cerebral laceration and contusion, with open intracranial wound Center for Policy and Innovation Page 7 of 9 May 1, 2009

Subarachnoid, Subdural, and Extradural Hemorrhage Following Injury (852) (Requires fifth digit see chart on page 5 for codes and definitions) 852.0 Subarachnoid hemorrhage following injury without mention of open intracranial wound (middle meningeal hemorrhage following injury) 852.1 Subarachnoid hemorrhage following injury with open intracranial wound 852.2 Subdural hemorrhage following injury without mention of open intracranial wound 852.3 Subdural hemorrhage following injury with open intracranial wound 852.4 Extradural hemorrhage following injury without mention of open intracranial wound (epidural hematoma following injury) 852.5 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) 853.0 Without mention of open intracranial wound (cerebral compression due to injury, intracranial hematoma following injury, traumatic cerebral hemorrhage) 853.1 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 854.0 Without mention of open intracranial wound 854.1 With open intracranial wound Open Wound of Head, Neck, and Trunk Open Wound of Ocular Adnex (870 879) 870.0 Laceration of skin of eyelid and periocular area 870.1 Laceration of eyelid, full-thickness, not involving lacrimal passages 870.2 Laceration of eyelid involving lacrimal passages 870.3 Penetrating wound of orbit, without mention of foreign body 870.4 Penetrating wound of orbit with foreign body in orbit 870.8 Other specified open wounds of ocular adnexa 870.9 Unspecified open wound of ocular adnexa Injury to Nerves and Spinal Cord (950-957) Injury to Optic Nerve and Pathways (950) 950.0 Optic nerve injury (second cranial nerve) 950.1 Injury to optic chiasm 950.2 Injury to optic pathways 950.3 Injury to visual cortex 950.9 Unspecified (traumatic blindness NOS) Injury to Other Cranial Nerves (951) 951.0 Injury to oculomotor nerve (third cranial nerve) 951.1 Injury to trochlear nerve (fourth cranial nerve) Center for Policy and Innovation Page 8 of 9 May 1, 2009

951.2 Injury to trigeminal nerve (fifth cranial nerve) 951.3 Injury to abducens nerve (sixth cranial nerve) 951.4 Injury to facial nerve (seventh cranial nerve) 951.5 Injury to acoustic nerve (auditory nerve, eighth cranial nerve) 951.6 Injury to accessory nerve (eleventh cranial nerve) 951.7 Injury to hypoglossal nerve (twelfth cranial nerve) 951.8 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 951.9 Injury to unspecified cranial nerve Spinal Cord Injury Without Evidence of Spinal Bone Injury (952) 952.0 Cervical 952.00 C1-C4 level with unspecified spinal cord injury (spinal cord injury, cervical region NOS) 952.01 C1-C4 level with complete lesion of spinal cord 952.02 C1-C4 level with anterior cord syndrome 952.03 C1-C4 level with central cord syndrome 952.04 C1-C4 level with other specified spinal cord injury (incomplete spinal cord lesion at C1-C4 level: NOS with posterior cord syndrome) 952.05 C5-C7 level with unspecified spinal cord injury 952.06 C5-C7 level with complete lesion of spinal cord 952.07 C5-C7 level with anterior cord syndrome 952.08 C5-C7 level with central cord syndrome 952.09 C5-C7 level with other specified spinal cord injury (incomplete spinal cord lesion at C5-C7 level: NOS with posterior cord syndrome) 952.1 Dorsal (thoracic) 952.10 T1-T6 level with unspecified spinal cord injury (spinal cord injury, thoracic region NOS) 952.11 T1-T6 level with complete lesion of spinal cord 952.12 T1-T6 level with anterior cord syndrome 952.13 T1-T6 level with central cord syndrome 952.14 T1-T6 level with other specified spinal cord injury (incomplete spinal cord lesion at T1-T6 level: NOS with posterior cord syndrome) 952.15 T7-T12 level with unspecified spinal cord injury 952.16 T7-T12 level with complete lesion of spinal cord 952.17 T7-T12 level with anterior cord syndrome 952.18 T7-T12 level with central cord syndrome 952.19 T7-T12 level with other specified spinal cord injury (incomplete spinal cord lesion at T7-T12 level: NOS with posterior cord syndrome) 952.2 Lumbar 952.3 Sacral 952.4 Cauda equina 952.8 Multiple sites of spinal cord 952.9 Unspecified site of spinal cord Center for Policy and Innovation Page 9 of 9 May 1, 2009

Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of 10/1/07) ICD-9-2006 Code Acquired hypothyroidism 244 Acrocephalosyndactyly (Apert s syndrome) 755.55 Acute, but ill-defined cerebrovascular disease 436 Angelman's Syndrome 759.89 Anomalies of cerebrovascular system (arteriovenous malformation of brain; cerebral arteriovenous aneurysm, congenital; congenital anomalies of cerebral vessels) 747.81 [EXCLUDES ruptured cerebral (arteriovenous) aneurysm (430)] Anomalies of skull and face bones (Hallerman-Streiff syndrome, craniosynostosis) 756.0 Anomalies of spine, unspecified 756.10 Anoxic brain damage 348.1 Autistic disorder (childhood autism; infantile psychosis; Kanner s syndrome) 299.0 Autosomal deletion syndromes 758.3 C1-C4 level with anterior cord syndrome 952.02 C1-C4 level with central cord syndrome 952.03 C1-C4 level with complete lesion of spinal cord 952.01 C1-C4 level with other specified spinal cord injury (incomplete spinal cord lesion at C1- C4 level: NOS with posterior cord syndrome) 952.04 C1-C4 level with unspecified spinal cord injury (spinal cord injury, cervical region NOS) 952.00 C5-C7 level with anterior cord syndrome 952.07 C5-C7 level with central cord syndrome 952.08 C5-C7 level with complete lesion of spinal cord 952.06 C5-C7 level with other specified spinal cord injury (incomplete spinal cord lesion at C5- C7 level: NOS with posterior cord syndrome) 952.09 C5-C7 level with unspecified spinal cord injury 952.05 Cauda equina 952.4 Cerebellar or brain stem contusion with open intracranial wound 851.5 Cerebellar or brain stem contusion without mention of open intracranial wound 851.4 Cerebellar or brain stem laceration with open intracranial wound 851.7 Cerebellar or brain stem laceration without mention of open intracranial wound 851.6 Cerebral ataxia 331.89 Cerebral cysts (arachnoid cyst) 348.0 Cerebral degeneration, unspecified 331.9 Cerebral degenerations usually manifest in childhood 330 Cerebrocostomandibular syndrome 759.89 Cervical 952.0 Childhood disintegrative disorder 299.1 Closed with cerebral laceration and contusion 800.1 Closed with cerebral laceration and contusion 801.1 Closed with cerebral laceration and contusion 803.1 Closed with cerebral laceration and contusion 804.1 Closed with intracranial injury of other and unspecified nature 800.4 Closed with intracranial injury of other and unspecified nature 801.4 Closed with intracranial injury of other and unspecified nature 803.4 Closed with intracranial injury of other and unspecified nature 804.4

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 800.3 Closed with other and unspecified intracranial hemorrhage 801.3 Closed with other and unspecified intracranial hemorrhage 803.3 Closed with other and unspecified intracranial hemorrhage 804.3 Closed with subarachnoid, subdural, and extradural hemorrhage 800.2 Closed with subarachnoid, subdural, and extradural hemorrhage 801.2 Closed with subarachnoid, subdural, and extradural hemorrhage 803.2 Closed with subarachnoid, subdural, and extradural hemorrhage 804.2 Closed without mention of intracranial injury 800.0 Closed without mention of intracranial injury 801.0 Closed without mention of intracranial injury 803.0 Closed without mention of intracranial injury 804.0 Communicating hydrocephalus 331.3 Concussion, unspecified 850.9 Conditions due to anomaly of unspecified chromosome 758.9 Conductive hearing loss 389.0 Congenital and hereditary thrombocytopenic purpura (congenital and hereditary thrombocytopenia; Thrombocytopenia with Absent Radi (TAR) syndrome 287.33 Congenital hereditary muscular dystrophy 359.0 Congenital hydrocephalus 742.3 Congenital hypothyroidism 243 Congenital malformation syndromes affecting multiple systems, NEC 759.89 Congenital rubella 771.0 Conradi syndrome 756.59 Cortex (cerebral) contusion with open intracranial wound 851.1 Cortex (cerebral) contusion without mention of open intracranial wound 851.0 Cortex (cerebral) laceration with open intracranial wound 851.3 Cortex (cerebral) laceration without mention of open intracranial wound 851.2 Deaf mutism, not elsewhere classifiable 389.7 Demyelinating disease of central nervous system, unspecified 341.9 DiGeorge s syndrome 279.11 Dorsal (thoracic) 952.1 Down s syndrome 758.0 Encephalitis, myelitis, encephalitis 323 Encephalocele 742.0 Encephalopathy, not elsewhere classified 348.3 Epilepsy, unspecified 345.9 Extradural hemorrhage following injury with open intracranial wound 852.5 Extradural hemorrhage following injury without mention of open intracranial wound (epidural hematoma following injury) 852.4 Fetal alcohol syndrome 760.71 Fragile X syndrome 759.83 Friedreich s ataxia 334.0 Frontal lobe syndrome (lobotomy syndrome; postleucotomy syndrome [state]) 310.0

Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of ICD-9-10/1/07) 2006 Code Generalized convulsive epilepsy 345.1 Generalized non-convulsive epilepsy 345 Gonadal dysgenesis (Turner s syndrome) 758.6 Grand mal status 345.3 Hemiplegia, unspecified 342.9 Hereditary progressive muscular dystrophy 359.1 Huntington s chorea 333.4 Hyperparathyroidism 252.0 Idiopathic torsion dystonia 333.6 Infantile cerebral palsy, unspecified 343.9 Injury to abducens nerve (sixth cranial nerve) 951.3 Injury to accessory nerve (eleventh cranial nerve) 951.6 Injury to acoustic nerve (auditory nerve, eighth cranial nerve) 951.5 Injury to facial nerve (seventh cranial nerve) 951.4 Injury to hypoglossal nerve (twelfth cranial nerve) 951.7 Injury to oculomotor nerve (third cranial nerve) 951.0 Injury to optic chiasm 950.1 Injury to optic pathways 950.2 Injury to other specified cranial nerves (glossopharyngeal [ninth cranial] nerve; olfactory [first cranial] nerve; pneumogastric [tenth cranial] nerve; traumatic anosmia NOS; vagus 951.8 [tenth cranial] nerve Injury to spine and spinal cord 767.4 Injury to trigeminal nerve (fifth cranial nerve) 951.2 Injury to trochlear nerve (fourth cranial nerve) 951.1 Injury to unspecified cranial nerve 951.9 Injury to visual cortex 950.3 Juvenile chronic polyarthritis 714.3 Klinefelter s syndrome 758.7 Kugelberg-Welander disease 335.11 Laceration of eyelid involving lacrimal passages 870.2 Laceration of eyelid, full-thickness, not involving lacrimal passages 870.1 Laceration of skin of eyelid and periocular area 870.0 Larsen s syndrome 754.8 Late effects of acute poliomyelitis 138 Late effects of cerebrovascular disease 438 Legal blindness, as defined in U.S.A. 369.4 Lipidoses 272.7 Longitudinal deficiency, combined, involving femur, tibia, and fibula (complete or incomplete) 755.33 Longitudinal deficiency, combined, involving humerus, radius, and ulna (complete or incomplete) 755.23 Longitudinal deficiency, radioulnar, complete or partial (with or without distal deficiencies, incomplete) 755.25 Lowe (-Terrey-MacLachlan) syndrome (oculocerebrorenal dystrophy) 270.8 Lumbar 952.2

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 759.82 Meningitis due to unspecified bacterium 320.9 Metachromatic leukodystrophy 330.0 Mixed conductive and sensorineural hearing loss 389.2 Moderate or severe impairment, better eye, profound impairment lesser eye 369.1 Mucopolysaccharidosis (Hunter s syndrome, Hurler s syndrome, Scheie s syndrome) 277.5 Multiple sclerosis 340 Multiple sites of spinal cord 952.8 Myasthenia gravis 358.0 Neoplasm of uncertain behavior of endocrine glands and nervous system 237 Neurofibromatosis (von Recklinghausen s Disease) 237.7 Obstructive hydrocephalus 331.4 Open with cerebral laceration and contusion 800.6 Open with cerebral laceration and contusion 801.6 Open with cerebral laceration and contusion 803.6 Open with cerebral laceration and contusion 804.6 Open with intracranial injury of other and unspecified nature 800.9 Open with intracranial injury of other and unspecified nature 801.9 Open with intracranial injury of other and unspecified nature 804.9 Open with intracranial injury of other unspecified nature 803.9 Open with other and unspecified intracranial hemorrhage 800.8 Open with other and unspecified intracranial hemorrhage 801.8 Open with other and unspecified intracranial hemorrhage 803.8 Open with other and unspecified intracranial hemorrhage 804.8 Open with subarachnoid, subdural, and extradural hemorrhage 800.7 Open with subarachnoid, subdural, and extradural hemorrhage 801.7 Open with subarachnoid, subdural, and extradural hemorrhage 803.7 Open with subarachnoid, subdural, and extradural hemorrhage 804.7 Open without mention of intracranial injury 800.5 Open without mention of intracranial injury 801.5 Open without mention of intracranial injury 803.5 Open without mention of intracranial injury 804.5 Optic nerve injury (second cranial nerve) 950.0 Osteogenesis imperfecta 756.51 Other and ill-defined conditions originating in the perinatal period 779 Other and unspecified cerebral laceration and contusion, with open intracranial wound 851.9 Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound 851.8 Other cerebral degeneration 331.8 Other congenital anomalies of limbs 755 Other disorders of calcium metabolism (pseudohypoparathyroidism) 275.49 Other disorders of purine and pyrimidine metabolism (Lesch-Nyhan syndrome) 277.2 Other myopathies 359.8

ICD-9-2006 Code Alphabetical List of Approved Diagnostic Codes for Persons with Related Conditions (as of 10/1/07) Other specific muscle disorders (arthrogryposis) 728.3 Other specified anomalies (Cornelia de Lange s syndrome, Seckel syndrome) 759.89 Other specified anormalies of nervous system (familial dysautonomia; Riley-Day syndrome) 742.8 Other specified cerebral degenerations in childhood (Alper's disease or gray-matter degeneration; infantile necrotizing encephalomyelopathy; Leigh's disease; subacute 330.8 necrotizing encephalopathy or encephalomyelopathy, Rett's syndrome Other specified disorders of metabolism 277.8 Other specified disorders of nervous system 349.8 Other specified forms of hearing loss 389.8 Other specified nonpsychotic mental disorders following organic brain damage (postencephalitic syndrome) 310.8 Other specified open wounds of ocular adnexa 870.8 Other specified pervasive developmental disorders (Asperger s disorder, atypical childhood psychosis; borderline psychosis of childhood) 299.8 Other spinocerebellar diseases (ataxia-telangiectasia [Louis-Bar syndrome]) 334.8 Paralysis agitans (Parkinson s disease) 332.0 Paralysis, unspecified 344.9 Paraplegia (paralysis of both lower limbs) 344.1 Partial epilepsy, with impairment of consciousness (psychomotor epilepsy) 345.4 Patau s syndrome 758.1 Penetrating wound of orbit with foreign body in orbit 870.4 Penetrating wound of orbit, without mention of foreign body 870.3 Petit mal status 345.2 Pick s disease 331.11 Polymyositis 710.4 Postconcussion syndrome 310.2 Prader-Willi syndrome 759.81 Primary thrombocytopenia 287.3 Primary thrombocytopenia unspecified 287.30 Profound impairment, both eyes 369.0 Quadriplegia and quadriparesis 344.0 Reduction deformities of brain 742.2 Reye s syndrome 331.81 Sacral 952.3 Secondary Parkinsonism 332.1 Sensorineural hearing loss 389.1 Severe birth asphyxia 768.5 Spastic hemiplegia 342.1 Spina bifida with hydrocephalus 741.0 Spina bifida without mention of hydrocephalus 741.9 Spinal muscular atrophy, unspecified 335.10 Subarachnoid hemorrhage following injury with open intracranial wound 852.1 Subarachnoid hemorrhage following injury without mention of open intracranial wound (middle meningeal hemorrhage following injury) 852.0

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 852.3 Subdural hemorrhage following injury without mention of open intracranial wound 852.2 Symptomatic torsion dystonia (athetoid cerebral palsy) 333.7 T1-T6 level with anterior cord syndrome 952.12 T1-T6 level with central cord syndrome 952.13 T1-T6 level with complete lesion of spinal cord 952.11 T1-T6 level with other specified spinal cord injury (incomplete spinal cord lesion at T1-T6 level: NOS with posterior cord syndrome) 952.14 T1-T6 level with unspecified spinal cord injury (spinal cord injury, thoracic region NOS) 952.10 T7-T12 level with anterior cord syndrome 952.17 T7-T12 level with central cord syndrome 952.18 T7-T12 level with complete lesion of spinal cord 952.16 T7-T12 level with other specified spinal cord injury (incomplete spinal cord lesion at T7- T12 level: NOS with posterior cord syndrome) 952.19 T7-T12 level with unspecified spinal cord injury 952.15 Tourette s disorder (motor-verbal tic disorder) 307.23 Trigeminal neuralgia 350.1 Tuberous sclerosis 759.5 Unspecified (traumatic blindness NOS) 950.9 Unspecified anomaly of brain, spinal cord, and nervous system 742.9 Unspecified cause of encephalitis 323.9 Unspecified delay in development (developmental disorder NOS) 315.9 Unspecified disease of spinal cord 336.9 Unspecified disorder of metabolism (enzymopathy NOS) 277.9 Unspecified disorders of nervous system 349.9 Unspecified hearing loss 389.9 Unspecified hypothyroidism 244.9 Unspecified monoplegia 344.5 Unspecified non-psychotic mental disorder following organic brain damage 310.9 Unspecified open wound of ocular adnexa 870.9 Unspecified pervasive developmental disorder (pervasive developmental disorder NOS) 299.9 Unspecified site of spinal cord 952.9 With brief loss of consciousness (of consciousness for less than one hour) 850.1 With loss of consciousness of unspecified duration 850.5 With moderate loss of consciousness (loss of consciousness for 1-24 hours) 850.2 With no loss of consciousness (concussion with mental confusion or disorientation, without loss of consciousness) 850.0 With open intracranial wound 853.1 With open intracranial wound 854.1 With prolonged loss of consciousness and return to pre-existing conscious level (loss of consciousness for more than 24 hours with complete recovery) 850.3 With prolonged loss of consciousness, without return to pre-existing conscious level 850.4 Without mention of open intracranial wound 854.0 Without mention of open intracranial wound (cerebral compression due to injury, intracranial hematoma following injury, traumatic cerebral hemorrhage) 853.0

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 2000-03 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:! 758.20 Edward's Syndrome (Trisomy: 18)! 758.60 Bonnevie-Ullrich Syndrome If you have any questions, please contact Don Mann, CLASS Unit Manager, at 512/438-3642 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 149030 Austin, TX 78714-9030 (512) 438-3011 Call your local DHS office for assistance.

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. 99004 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: 330.8 747.81 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 149030 Austin, TX 78714-9030 (512) 438-3011 Call your local DHS office for assistance.

CLASS Policy Clarification No. 99004 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 149030 Austin, Texas 78714-9030! 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) 438-3642. Sincerely, [Signature on File] Becky Beechinor Assistant Deputy Commissioner Long Term Care Programs BB:aa

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