RESIDENTIAL TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS

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1 CLINICAL POLICY RESIDENTIAL TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS Policy Number: BEHAVIORAL T2 Effective Date: March 1, 2013 Table of Contents CONDITIONS OF COVERAGE... COVERAGE RATIONALE BACKGROUND... APPLICABLE CODES... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Policy History Revision Information The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Page Related Policies: Early Intervention Program / Birth to Three Applicable Lines of Business/Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership General benefits package No No 1 - Outpatient Yes - Inpatient Yes Residential Center/Facility 1 Precertification is not required for mental health or substance abuse treatment services performed in an outpatient Residential Treatment Center setting. Note: Residential treatment, except for professional services, is excluded from coverage for New York Individual Plans and Healthy New York Plans , Oxford Health Plans, LLC 1

2 COVERAGE RATIONALE The following grids provide benefit coverage considerations, including state/federal requirements as applicable, for treatment of mental health and substance use disorders Coverage Guidelines Connecticut Large and Small Group Plans Oxford will provide coverage for mental health or substance abuse residential treatment as indicated below: Services must be provided by providers who are certified by the appropriate state agency to provide such services and whose programs for such services have been approved by Oxford. Covered services upon confinement in a residential treatment facility 1 must be based on an individual treatment plan 2 prescribed by the attending physician and approved by Oxford. For the purpose of this benefit, Members must meet all of the following criteria: 1. The Member has a serious mental illness which substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs behavior as manifested by recent disturbed behavior; and 2. Upon an assessment by a physician, psychiatrist, psychologist or clinical social worker, the member cannot be effectively treated in an acute care, partial hospitalization, intensive outpatient or outpatient setting. 1 "Residential Treatment Facility" means a residential treatment center that provides a program of effective Mental Health/Substance Abuse treatment and meets all of the following requirements: It is established and operated in accordance with any applicable state law. It has or maintains a written, specific and detailed regimen requiring full-time residence and full-time participation by the patient. It provides at least the following basic services: Room and board. Evaluation and diagnosis. Counseling. Referral and orientation to specialized community resources. Parity Guidelines 2 "Individual Treatment Plan" means a treatment plan prescribed by a physician with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program. Coverage and cost share structure is equal to that of standard medical/surgical benefits, except for the following diagnoses and applicable ICD-9 codes which are excluded from Connecticut parity legislation: Family rehabilitation for substance abuse Mental retardation ( ) Learning disorders ( , 315.9) , Oxford Health Plans, LLC 2

3 Parity Guidelines (continued) Motor skills disorder (315.4) Communication disorders (315.4, , , , 307.9, 307.0) Caffeine-related disorders (305.9, , 292.9) Relational problems (V61.9, V61.20, V61.10, V61.8, V62.81) Additional conditions that may be a focus of clinical attention and are not defined as mental disorders in the DSMIV. (V15.81, V65.2, V71.01, V71.02, V62.89, 780.9, V62.82, V62.3, V62.2x, , V62.89, V62.4) Refer to the Member's certificate of coverage and/or health benefits plan documentation for confirmation of applicable benefits and exclusions. Exclusions The following are excluded from coverage: Non-medical services and long-term rehabilitation for physical therapy including non-medical and rehabilitation services in a specialized inpatient or residential facility. Services for the evaluation or treatment (including remedial education) of: learning disabilities or minimal brain dysfunction; mental retardation; developmental and learning disorders or behavioral problems (except as noted under policy: Early Intervention Program / Birth to Three. Behavioral training or cognitive rehabilitation. Court ordered services or services that have been ordered as a condition of probation or parole. However, these services may be covered if Oxford agrees that the services are medically necessary, are otherwise covered, the Member has not exhausted their applicable benefit, and the treatment is provided in accordance with our policies and procedures. Coverage Guidelines New York Plans Oxford will provide coverage for mental health or substance abuse residential treatment as indicated below: The residential facility must have been established and operated in accordance with the standards pursuant to regulations of the New York Commissioner of Mental Health as defined by subdivision 10 of section 1.03 of the Mental Hygiene Law. It provides a program of treatment under the active participation and direction of a Physician and approved by the Mental Health/Substance Use Disorder Designee. It has or maintains written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient. It provides at least the following basic services in a 24-hour per day, structured milieu: o Room and board. o Evaluation and diagnosis. o Counseling o Referral and orientation to specialized community resources o A Residential Treatment Facility that qualifies as a hospital is considered a Hospital. Services provided in a rehabilitation facility are provided as an alternative to a mental health inpatient day. Member must have a biologically based or non-biologically based mental illness as defined by the State of New York - Chapter 748 of the Laws of 2006 ("Timothy's Law") , Oxford Health Plans, LLC 3

4 Parity Guidelines Biologically Based Illnesses and Children with Serious Emotional Disturbances: Coverage parity is required for Biologically Based Mental Illnesses and for Children with Serious Emotional Disorders. These illnesses are defined as the following: Biologically based (for all ages): Anorexia nervosa Bipolar disorder Bulimia nervosa Delusional disorders Major depression Obsessive compulsive disorder Panic disorder Schizophrenia/psychotic disorders Children with Serious Emotional Disturbances: Note: Members under the age of eighteen (18) years must have one or more of the following diagnoses and meet the criteria which follow. Attention deficit disorders Disruptive behavior disorders Pervasive developmental disorders In addition to the diagnoses listed above, the Member must display one or more of the following symptoms and/or behavioral issues: Serious suicidal symptoms or other life-threatening self-destructive behaviors Significant psychotic symptoms (hallucinations, delusions, bizarre behaviors) Behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage Behavior caused by emotional disturbances that placed the child at substantial risk or removal from the household. Day Limits: The total amount of days available for either inpatient treatment or residential treatment (or a combination of the two): Must be equal to or greater than the amount of days available for medical inpatient admissions when treatment is for a biologically based diagnosis. Can be less than the amount of days available for medical inpatient admissions when treatment is for a Non-Biologically Based Diagnosis. NY Large Group Plans Cost Share: The parity law requires parity with the cost sharing (i.e., deductible, copayments, coinsurance, maximum-out-of-pocket) as well as with day limits. Therefore, regardless of group size and diagnosis (biologically based vs. non biologically based), the cost sharing must always match the medical cost sharing. This applies to both large groups and small groups. NY Large groups automatically have coverage for both biologically based and nonbiologically based services as described in the parity section above , Oxford Health Plans, LLC 4

5 NY Small Group Plans NY Small groups will automatically receive coverage that will treat all mental illness (both biologically based and non-biologically based) and services for Children with Serious Emotional Disturbances. These services will be limited to the number of days and/or visits shown in the Summary of Benefits. Small Groups do have the option to purchase a rider that will cover Biologically Based Mental Illness and Services for Children with Serious Emotional Disturbances on a parity basis (like NY large groups). Therefore, small group policies/certificates should always be checked to determine if biologically based parity coverage has been purchased. IMPORTANT NOTE: Small groups are generally exempt from the requirements of federal mental health parity but there are some exceptions. The small group policies/certificates should always be checked to determine application of the federal mental health parity requirements. Exclusions The following are excluded from coverage: Residential treatment provided in connection with services for individuals who are: o o Receiving treatment provided in connection with services for individuals who are presently incarcerated, confined or committed to a local correctional facility or prison, or a custodial facility for youth operated by the office of children and family services, unless authorized by us. Seeking mental health care services solely because such services are ordered by a court. (They are covered if the services would otherwise be covered under the certificate.) Residential treatment provided in a transitional living facility that does not meet the definition provided under the law cited above. Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Custodial care, domiciliary care, long-term care, maintenance care, adult day care, or rest cures. Services or supplies deemed cosmetic in nature. This also applies to services or supplies deemed cosmetic even if changing or improving an individual's appearance is justified by the individual's mental health needs. Any services for which the day or visit limit identified in the Summary of Benefits has been met. This exclusion does not apply to Biologically Based Mental Illness or Children with Serious Emotional Disturbances. Room and board, nursing care or personal care which is rendered to assist a Member who, in Oxford's opinion, has reached the maximum level of physical or mental function possible and will not make further significant clinical improvement. Care for conditions that by federal, state or local law must be treated in a public facility including, but not limited to, commitments for mental illness. Additionally, to the extent allowed by law, Oxford does not cover care or treatment provided in a non-network Hospital that is owned or operated by any federal, state or other governmental entity. Except for medical emergencies and urgent care, and in-network exceptions, no coverage is available outside our Network of Providers, unless the group has purchased this coverage (only available to large groups) , Oxford Health Plans, LLC 5

6 Exclusions (continued) We may consult with professional clinical consultants, peer review committees or other appropriate sources for recommendations and information regarding whether a service or supply meets any of these criteria. Coverage Guidelines New Jersey Large Group Plans Oxford will provide coverage for Intermediate Care 1 (includes residential care) for the treatment of Mental Illness: those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded under the Certificate. Mental Illness includes Biologically Based Mental Illness as defined by New Jersey State Law. Autism Spectrum Disorder: the pervasive developmental disorders set forth in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, including but not limited to Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified. Substance Use Disorders: Covered Services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Service. 1 Note: Intermediate Care is defined as Mental Health or Substance Use Disorder treatment that encompasses care: o At a Residential Treatment Facility 2. o At a Partial Hospitalization/Day Treatment program. o Through an Intensive Outpatient Treatment program. 2 A Residential Treatment facility is a facility which provides a program of effective Mental Health Services treatment and which meets all of the following requirements: o It is established and operated in accordance with subdivision ten of section 1.03 of the mental hygiene law. o It provides a program of treatment under the active participation and direction of a Physician and approved by Oxford. o It has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient. o It provides at least the following basic services in a 24-hour per day, structured milieu: Room and board Evaluation and diagnosis Counseling Referral and orientation to specialized community resources. A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital , Oxford Health Plans, LLC 6

7 Parity Guidelines Coverage and cost share structure is equal to that of standard medical/surgical benefits. Coverage Guidelines NJ Small Group Plans Oxford provides coverage for the following conditions when treatment is prescribed by a Licensed Practitioner: Mental Illness: A behavioral, psychological or biological dysfunction. Mental illness includes a biologically-based mental illness as well as a mental illness that is not biologically-based. Note: Mental illness includes biologically based mental illness, which is defined as a condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism. The current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association may be consulted to identify conditions that are considered mental illness. Substance Abuse Parity Guidelines Inpatient or day treatment may be furnished by any licensed, certified or State approved facility, including but not limited to a: o Hospital o Detoxification Facility licensed under New Jersey P.L. 1975, Chapter 305; or o Licensed, certified or state approved residential treatment Facility under a program which meets the minimum standards of care of the Joint Commission; o Mental Health Center: A facility which mainly provides treatment for people with Mental Illness. Oxford will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either: o Accredited for its stated purpose by the Joint Commission; Approved for its stated purpose by Medicare; or Accredited or licensed by the state of New Jersey to provide mental health services. Substance Abuse Center: Facilities that mainly provide treatment for people with substance abuse problems. Oxford will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either: Accredited for its stated purpose by the Joint Commission; or Approved for its stated purpose by Medicare. Coverage and cost share structure is equal to that of standard medical/surgical benefits , Oxford Health Plans, LLC 7

8 Exclusions Oxford does not pay for Custodial Care, education or training. Coverage Guidelines New Jersey Individual Plans (Except NJ Basic & Essential Plans) Oxford provides coverage for the following conditions when treatment is prescribed by a Licensed Practitioner: Alcohol Abuse Biologically Based Mental Illnesses Non-Biologically-based Mental Illnesses Substance Abuse Alcohol Abuse Treatment may be furnished by: 1. Hospital 2. Detoxification Facility licensed under New Jersey P.L. 1975, Chapter 305; or 3. Licensed, certified or state approved residential treatment facility under a program which meets the minimum standards of care of the Joint Commission. The following definitions apply: Biologically-based Mental Illness means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism. Non-Biologically-based Mental Illness means an Illness which manifests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based. In determining whether or not a particular condition is a Non-Biologicallybased Mental Illness, we may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association. Substance Abuse Centers are Facilities that mainly provide treatment for people with substance abuse problems. We will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either: Parity Guidelines a. Accredited for its stated purpose by the Joint Commission; or b. Approved for its stated purpose by Medicare. Treatment for biologically based mental illness are covered through a Member's general benefits package and are not subject to annual limitations or maximums except as otherwise provided in the Member's certificate of coverage. Refer to the Applicable Codes section for a list of biologically based diagnosis , Oxford Health Plans, LLC 8

9 Parity Guidelines (continued) codes as well as the Coverage Guidelines above for additional information. All conditions not classified as biologically based (in the Coverage Guidelines above) are considered non-biologically based, and as such, may be subject to coverage and cost share structures individually defined by the Member's certificate of coverage. Parity guidelines do not apply. Refer to the Coverage Guidelines section above for additional information on the coverage for non-biologically based conditions. Exclusions Oxford does not pay for Custodial Care, education, or training. Coverage Guidelines New Jersey Individual Basic & Essential Plans Oxford provides coverage for the following conditions when treatment is prescribed by a Licensed Practitioner: Alcohol Abuse and Substance Abuse Biologically Based Mental Illnesses Coverage is provided on an inpatient or outpatient basis, as outlined in the Member s Certificate of Coverage. The following definitions apply: Alcohol Abuse: Abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to drugs. Please see the definition of Substance Abuse. Biologically-based Mental Illness: means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism. Hospital: A Facility which mainly provides Inpatient care for Ill or Injured people. We will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either: o Accredited as a Hospital by the Joint Commission; or o Approved as a Hospital by Medicare. Among other things, a Hospital is not a convalescent, rest or nursing home or Facility, or a Facility, or part of it, which mainly provides Custodial Care, educational care or rehabilitative care. A Facility for the aged or for Substance Abusers is not a Hospital. A specialty Facility is also not a Hospital. Non-Biologically-based Mental Illness means an Illness which manifests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based. In determining whether or not a particular condition is a Non-Biologicallybased Mental Illness, we may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric , Oxford Health Plans, LLC 9

10 Coverage Guidelines (continued) Association. Substance Abuse: Abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse. Parity Guidelines Substance Abuse Centers: are Facilities that mainly provide treatment for people with substance abuse problems. We will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either: o Accredited for its stated purpose by the Joint Commission; or o Approved for its stated purpose by Medicare. State and Federal mental health parity guidelines do not apply to the Basic & Essential Plans. Covered benefits are subject to the cost shares and limitations outlined in the Member s Certificate of Coverage. Refer to the Applicable Codes section for a list of biologically based diagnosis codes as well as the Coverage Guidelines above for additional information. All conditions not classified as biologically based (in the Coverage Guidelines above) are considered non-biologically based, and as such, are not covered. Exclusions Oxford does not pay for: Custodial Care, education, or training. Treatment of a Non-Biologically-based Mental Illness BACKGROUND Oxford administers benefit coverage for residential rehabilitation, detoxification, and/or mental health treatment in coordination with OptumHealth Behavioral Solutions. United Behavioral Health (UBH) has developed level of care (LOC) guidelines which are used for purposes of clinical guidance, utilization management and medical necessity determinations, where applicable. The LOC guidelines ensure that services are essential and appropriate, and reflect empirically validated approaches. United Behavioral Health: Level of Care Guidelines: Introduction United Behavioral Health: Level of Care Guidelines: Index For those Members with coverage for residential rehabilitation, detoxification, and/or mental health treatment, as outlined above, requests for precertification are reviewed by licensed professionals. Definitions: Legislative "Parity" Mandate: "Equality" in the administration of medical and behavioral health benefits. Affected inpatient and outpatient behavioral health benefits for conditions determined to be organic or biologic in origin need to be equivalent to the medical benefits in the following three ways: The copayment or coinsurance is equal to medical coverage; and Benefit limits (day and visit) are equal to medical/surgical coverage; and Precertification requirements are structured in a manner equivalent to medical coverage (based on site of service, level of care, and certificate of coverage/health benefits plan documentation) , Oxford Health Plans, LLC 10

11 Residential mental health treatment services are provided in a facility or a freestanding residential treatment center that provides overnight mental health services for Members who do not require acute inpatient care but who do require 24-hour structure. Residential detoxification is comprised of services that are provided in a residential setting other than an acute care hospital for the purpose of completing a medically safe withdrawal from substances. Residential Detoxification is typically indicated when withdrawal is severe enough to warrant 24-hour care, but on-site access to medical personnel is not essential. Residential rehabilitation is comprised of acute overnight services that are typically provided in a freestanding residential treatment center for the care of a substance use disorder. A residential rehabilitation program is typically intended for when a Member lacks the motivation or social support system to remain abstinent, but does not require the structure and intensity of services provided in a hospital. Additionally, these facilities may provide treatment for mental illness, both biologically based and non biologically based. APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. Applicable ICD-9 Diagnosis Codes - NY Parity Biologically Based Mental Illness ICD-9 Code 295.0x Schizophrenic disorders, simple type 295.1x Schizophrenic disorders, disorganized type 295.2x Schizophrenic disorders, catatonic type 295.3x Schizophrenic disorders, paranoid type 295.4x Schizophrenic disorders, schizophreniform disorder 295.5x Schizophrenic disorders, latent schizophrenia 295.6x Schizophrenic disorders, residual type 295.7x Schizophrenic disorders, schizoaffective disorder 295.8x Schizophrenic disorders, other specified types 295.9x Schizophrenic disorders, unspecified 296.0x Episodic mood disorders, bipolar I disorder, single manic episode 296.1x Episodic mood disorders, manic disorder, recurrent episode 296.2x Episodic mood disorders, major depressive disorder, single episode 296.3x Episodic mood disorders, major depressive disorder, recurrent episode 296.4x Episodic mood disorders, bipolar I disorder, most recent episode (or current) manic 296.5x Episodic mood disorders, bipolar I disorder, most recent episode (or current) depressed 296.6x Episodic mood disorders, bipolar I disorder, most recent episode (or current) mixed Episodic mood disorders, bipolar I disorder, most recent episode (or current) unspecified 296.8x Episodic mood disorders, other and unspecified bipolar disorders 296.9x Episodic mood disorders, other and unspecified episodic mood disorder Delusional disorders, delusional disorder Delusional disorders, shared psychotic disorder Other nonorganic psychoses, other and unspecified reactive psychosis Other nonorganic psychoses, unspecified psychosis Anxiety, dissociative and somatoform disorders, panic disorder without , Oxford Health Plans, LLC 11

12 ICD-9 Code agoraphobia Phobic disorders, agoraphobia with panic disorder Obsessive-compulsive disorders Anorexia nervosa Bulimia nervosa Applicable ICD-9 Diagnosis Codes - NY Parity Children with Serious Emotional Disturbances ICD-9 Code Pervasive developmental disorders, autistic disorder, current or active state Pervasive developmental disorders, childhood disintegrative disorder, current or active state Pervasive developmental disorders, other specified, current or active state 312.0x Disturbance of conduct, undersocialized conduct disorder, aggressive type 312.1x Disturbance of conduct, undersocialized conduct disorder, unaggressive type 312.2x Disturbance of conduct, socialized conduct disorder 312.3x Disturbance of conduct, disorders of impulse control 312.4x Disturbance of conduct, mixed disturbance of conduct and emotions 312.8x Disturbance of conduct, other specified Disturbance of conduct, unspecified Oppositional defiant disorder 314.0x Hyperkinetic syndrome of childhood, attention deficit disorder Hyperkinetic syndrome of childhood, hyperkinesis with developmental delay Hyperkinetic syndrome of childhood, hyperkinetic conduct disorder Hyperkinetic syndrome of childhood, other specified manifestations Hyperkinetic syndrome of childhood, unspecified Applicable ICD-9 Diagnosis Codes - NJ Parity Biologically Based Mental Illness ICD-9 Code 290.2x Senile dementia with delusional or depressive features 291.xx Alcohol-induced mental disorders 295.xx Schizophrenic disorders 296.xx Episodic mood disorders 297.xx Delusional disorders 299.xx Pervasive developmental disorders Anxiety state, unspecified Panic disorder without agoraphobia Generalized anxiety disorder Other anxiety states Agoraphobia with panic disorder Obsessive-compulsive disorders 303.xx Alcohol dependence syndrome 305.0x Nondependent alcohol abuse Applicable ICD-9 Code s for Mental Health and Substance Abuse ICD-9 Code Organic psychotic conditions , Oxford Health Plans, LLC 12

13 ICD-9 Code Other psychoses Neurotic disorders, personality disorders, and other nonpsychotic mental disorders ICD-10 Codes (Preview Draft) In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2014 *, a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change. Applicable ICD-10 Codes - CT Parity Exclusions ICD-10 Diagnosis Code F Opioid abuse with opioid-induced psychotic disorder, unspecified F Opioid abuse with opioid-induced sexual dysfunction F Opioid abuse with other opioid-induced disorder F11.19 Opioid abuse with unspecified opioid-induced disorder F Opioid dependence with intoxication with perceptual disturbance F Opioid dependence with opioid-induced psychotic disorder, unspecified F Opioid dependence with opioid-induced sexual dysfunction F Opioid dependence with other opioid-induced disorder F11.29 Opioid dependence with unspecified opioid-induced disorder F Opioid use, unspecified with intoxication with perceptual disturbance F Opioid use, unspecified with opioid-induced psychotic disorder, unspecified F Opioid use, unspecified with opioid-induced sexual dysfunction F Opioid use, unspecified with other opioid-induced disorder F11.99 Opioid use, unspecified with unspecified opioid-induced disorder F Cannabis abuse with intoxication with perceptual disturbance F Cannabis abuse with psychotic disorder, unspecified F Cannabis abuse with cannabis-induced anxiety disorder F Cannabis abuse with other cannabis-induced disorder F12.19 Cannabis abuse with unspecified cannabis-induced disorder F Cannabis dependence with intoxication with perceptual disturbance F Cannabis dependence with psychotic disorder, unspecified F Cannabis dependence with cannabis-induced anxiety disorder F Cannabis dependence with other cannabis-induced disorder F12.29 Cannabis dependence with unspecified cannabis-induced disorder F Cannabis use, unspecified with intoxication with perceptual disturbance F Cannabis use, unspecified with psychotic disorder, unspecified F Cannabis use, unspecified with anxiety disorder F Cannabis use, unspecified with other cannabis-induced disorder F12.99 Cannabis use, unspecified with unspecified cannabis-induced disorder F Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced psychotic disorder, unspecified F Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced anxiety disorder , Oxford Health Plans, LLC 13

14 ICD-10 Diagnosis Code F Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced sexual dysfunction F Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolyticinduced disorder F13.19 Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced disorder F Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolyticinduced psychotic disorder, unspecified F Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolyticinduced anxiety disorder F Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolyticinduced sexual dysfunction F Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder F13.29 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder F Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified F Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety disorder F Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sexual dysfunction F Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder F13.99 Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic-induced disorder F Cocaine abuse with intoxication with perceptual disturbance F Cocaine abuse with cocaine-induced psychotic disorder, unspecified F Cocaine abuse with cocaine-induced anxiety disorder F Cocaine abuse with cocaine-induced sexual dysfunction F Cocaine abuse with cocaine-induced sexual dysfunction F14.19 Cocaine abuse with unspecified cocaine-induced disorder F Cocaine dependence with intoxication with perceptual disturbance F Cocaine dependence with cocaine-induced psychotic disorder, unspecified F Cocaine dependence with cocaine-induced anxiety disorder F Cocaine dependence with cocaine-induced sexual dysfunction F Cocaine dependence with other cocaine-induced disorder F14.29 Cocaine dependence with unspecified cocaine-induced disorder F Cocaine use, unspecified with intoxication with perceptual disturbance F Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified F Cocaine use, unspecified with cocaine-induced anxiety disorder F Cocaine use, unspecified with cocaine-induced sexual dysfunction F Cocaine use, unspecified with other cocaine-induced disorder F14.99 Cocaine use, unspecified with unspecified cocaine-induced disorder F15.19 Other stimulant abuse with unspecified stimulant-induced disorder F15.29 Other stimulant dependence with unspecified stimulant-induced disorder F15.99 Other stimulant use, unspecified with unspecified stimulant-induced disorder F16.19 Hallucinogen abuse with unspecified hallucinogen-induced disorder F16.29 Hallucinogen dependence with unspecified hallucinogen-induced disorder , Oxford Health Plans, LLC 14

15 ICD-10 Diagnosis Code F16.99 Hallucinogen use, unspecified with unspecified hallucinogen-induced disorder F Nicotine dependence, unspecified, with unspecified nicotine-induced disorders F Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders F Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders F Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders F18.10 Inhalant abuse, uncomplicated F Inhalant abuse with intoxication, uncomplicated F18.19 Inhalant abuse with unspecified inhalant-induced disorder F18.29 Inhalant dependence with unspecified inhalant-induced disorder F18.90 Inhalant use, unspecified, uncomplicated F18.99 Inhalant use, unspecified with unspecified inhalant-induced disorder F19.10 Other psychoactive substance abuse, uncomplicated F19.19 Other psychoactive substance abuse with unspecified psychoactive substanceinduced disorder F19.29 Other psychoactive substance dependence with unspecified psychoactive substance-induced disorder F19.99 Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced disorder F55.0 Abuse of antacids F55.1 Abuse of herbal or folk remedies F55.2 Abuse of laxatives F55.3 Abuse of steroids or hormones F55.4 Abuse of vitamins F55.8 Abuse of other non-psychoactive substances F63.3 Trichotillomania F63.89 Other impulse disorders F64.9 Gender identity disorder, unspecified F70 Mild intellectual disabilities F71 Moderate intellectual disabilities F72 Severe intellectual disabilities F73 Profound intellectual disabilities F78 Other intellectual disabilities F79 Unspecified intellectual disabilities F80.0 Phonological disorder F80.1 Expressive language disorder F80.2 Mixed receptive-expressive language disorder F80.89 Other developmental disorders of speech and language F80.9 Developmental disorder of speech and language, unspecified F81.0 Specific reading disorder F81.0 Specific reading disorder F81.2 Mathematics disorder F81.81 Disorder of written expression F81.89 Other developmental disorders of scholastic skills F81.9 Developmental disorder of scholastic skills, unspecified F82 Specific developmental disorder of motor function , Oxford Health Plans, LLC 15

16 ICD-10 Diagnosis Code F89 Unspecified disorder of psychological development F93.8 Other childhood emotional disorders F98.5 Adult onset fluency disorder H93.25 Central auditory processing disorder R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.83 Borderline intellectual functioning R41.83 Borderline intellectual functioning R41.9 Unspecified symptoms and signs involving cognitive functions and awareness R45.1 Restlessness and agitation R45.81 Low self-esteem R45.82 Worries R45.83 Excessive crying of child, adolescent or adult R45.84 Anhedonia R48.0 Dyslexia and alexia R52 Pain, unspecified R68.11 Excessive crying of infant (baby) R68.12 Fussy Infant (baby) R68.81 Early satiety R68.89 Other general symptoms and signs Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Z55.0 Illiteracy and low-level literacy Z55.1 Schooling unavailable and unattainable Z55.2 Failed school examinations Z55.3 Underachievement in school Z55.4 Educational maladjustment and discord with teachers and classmates Z55.8 Other problems related to education and literacy Z55.9 Problems related to education and literacy, unspecified Z56.1 Change of job Z56.82 Military deployment status Z56.89 Other problems related to employment Z60.0 Problems of adjustment to life-cycle transitions Z60.3 Acculturation difficulty Z60.4 Social exclusion and rejection Z60.5 Target of (perceived) adverse discrimination and persecution Z60.8 Other problems related to social environment Z60.9 Problem related to social environment, unspecified Z62.22 Institutional upbringing Z62.29 Other upbringing away from parents Z Sibling rivalry Z63.0 Problems in relationship with spouse or partner Z63.1 Problems in relationship with in-laws Z63.31 Absence of family member due to military deployment , Oxford Health Plans, LLC 16

17 ICD-10 Diagnosis Code Z63.32 Other absence of family member Z63.4 Disappearance and death of family member Z63.71 Stress on family due to return of family member from military deployment Z63.8 Other specified problems related to primary support group Z63.9 Problem related to primary support group, unspecified Z64.4 Discord with counselors Z65.4 Victim of crime and terrorism Z65.5 Exposure to disaster, war and other hostilities Z65.8 Other specified problems related to psychosocial circumstances Z71.89 Other specified counseling Z71.89 Other specified counseling Z Child and adolescent antisocial behavior Z Adult antisocial behavior Z73.3 Stress, not elsewhere classified Z73.4 Inadequate social skills, not elsewhere classified Z73.5 Social role conflict, not elsewhere classified Z73.6 Limitation of activities due to disability Z76.5 Malingerer [conscious simulation] Z91.11 Patient's noncompliance with dietary regimen Z Patient's intentional underdosing of medication regimen due to financial hardship Z Patient's intentional underdosing of medication regimen for other reason Z Patient's unintentional underdosing of medication regimen due to age-related debility Z Patient's unintentional underdosing of medication regimen for other reason Z91.14 Patient's other noncompliance with medication regimen Z91.19 Patient's noncompliance with other medical treatment and regimen Applicable ICD-10 Diagnosis Codes - NY Parity Biologically Based Mental Illness ICD-10 Code F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.5 Residual schizophrenia F20.81 Schizophreniform disorder F20.89 Other schizophrenia F20.9 Schizophrenia, unspecified F22 Delusional disorders F23 Brief psychotic disorder F24 Shared psychotic disorder F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type , Oxford Health Plans, LLC 17

18 ICD-10 Code F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified F28 Other psychotic disorder not due to a substance or known physiological condition F29 Unspecified psychosis not due to a substance or known physiological condition F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, current episode depressed, moderate F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31.77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in full remission, most recent episode mixed F31.81 Bipolar II disorder F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features , Oxford Health Plans, LLC 18

19 ICD-10 Code F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F40.01 Agoraphobia with panic disorder F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia F42 Obsessive-compulsive disorder F50.00 Anorexia nervosa, unspecified F50.01 Anorexia nervosa, restricting type F50.02 Anorexia nervosa, binge eating/purging type F50.2 Bulimia nervosa Applicable ICD-10 Diagnosis Codes - NY Parity Children with Serious Emotional Disturbances ICD-10 Code F63.0 Pathological gambling F63.1 Pyromania F63.2 Kleptomania F63.3 Trichotillomania F63.81 Intermittent explosive disorder F63.89 Other impulse disorders F63.9 Impulse disorder, unspecified F84.0 Autistic disorder F84.3 Other childhood disintegrative disorder F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type F90.2 Attention-deficit hyperactivity disorder, combined type , Oxford Health Plans, LLC 19

20 ICD-10 Code F90.8 Attention-deficit hyperactivity disorder, other type F90.9 Attention-deficit hyperactivity disorder, unspecified type F91.0 Conduct disorder confined to family context F91.1 Conduct disorder, childhood-onset type F91.2 Conduct disorder, adolescent-onset type F91.3 Oppositional defiant disorder F91.8 Other conduct disorders F91.9 Conduct disorder, unspecified Applicable ICD-10 Diagnosis Codes - NJ Parity Biologically Based Mental Illness ICD-10 Code F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F10.10 Alcohol abuse, uncomplicated F Alcohol abuse with intoxication, uncomplicated F Alcohol abuse with intoxication delirium F Alcohol abuse with intoxication, unspecified F10.14 Alcohol abuse with alcohol-induced mood disorder F Alcohol abuse with alcohol-induced psychotic disorder with delusions F Alcohol abuse with alcohol-induced psychotic disorder with hallucinations F Alcohol abuse with alcohol-induced psychotic disorder, unspecified F Alcohol abuse with alcohol-induced anxiety disorder F Alcohol abuse with alcohol-induced sexual dysfunction F Alcohol abuse with alcohol-induced sleep disorder F Alcohol abuse with other alcohol-induced disorder F10.19 Alcohol abuse with unspecified alcohol-induced disorder F10.20 Alcohol dependence, uncomplicated F10.21 Alcohol dependence, in remission F Alcohol dependence with intoxication, uncomplicated F Alcohol dependence with intoxication delirium F Alcohol dependence with intoxication, unspecified F Alcohol dependence with withdrawal, uncomplicated F Alcohol dependence with withdrawal delirium F Alcohol dependence with withdrawal with perceptual disturbance F Alcohol dependence with withdrawal, unspecified F10.24 Alcohol dependence with alcohol-induced mood disorder F Alcohol dependence with alcohol-induced psychotic disorder with delusions F Alcohol dependence with alcohol-induced psychotic disorder with hallucinations F Alcohol dependence with alcohol-induced psychotic disorder, unspecified F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder F10.27 Alcohol dependence with alcohol-induced persisting dementia F Alcohol dependence with alcohol-induced anxiety disorder F Alcohol dependence with alcohol-induced sexual dysfunction , Oxford Health Plans, LLC 20

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