ICD-9-CM MENTAL DISORDERS DIAGNOSIS CODES AND DESCRIPTIONS

Transcription

1 ATTACHMENT A ICD-9-CM MENTAL DISORDERS DIAGNOSIS CODES AND DESCRIPTIONS Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code This list contains principal diagnosis codes for psychiatric services Category of Service 21. If a code from this list is used as the principal diagnosis code, general care hospitals that are not enrolled for COS 21 may only bill for a maximum of three days of emergency psychiatric care using COS 20. The Department s current peer review organization began utilization review of inpatient claims effective 09/16/02. Codes that were part of the initial review lists have a beginning review date of 09/16/02. Codes added later for review will have other beginning review dates /16/02 Unspecified /16/02 Subchronic /16/02 Chronic /16/02 Subchronic with acute exacerbation /16/02 Chronic with acute exacerbation /16/02 In remission /16/02 Disorganized type unspecified /16/02 Disorganized type subchronic /16/02 Disorganized type chronic /16/02 Disorganized type subchronic with acute exacerbation /16/02 Disorganized type chronic with acute exacerbation /16/02 Disorganized type in remission /16/02 Catatonic type unspecified /16/02 Catatonic type subchronic /16/02 Catatonic type chronic /16/02 Catatonic type subchronic with acute exacerbation /16/02 Catatonic type chronic with acute exacerbation /16/02 Catatonic type in remission /16/02 Paranoid type unspecified /16/02 Paranoid type subchronic /16/02 Paranoid type chronic /16/02 Paranoid type subchronic with acute exacerbation /16/02 Paranoid type chronic with acute exacerbation /16/02 Paranoid type in remission /16/02 Schizophreniform disorder, unspecified /16/02 Schizophreniform disorder, subchronic /16/02 Schizophreniform disorder, chronic /16/02 Schizophreniform disorder, subchronic with acute exacerbation 1

2 ATTACHMENT A /16/02 Schizophreniform disorder, chronic with acute exacerbation /16/02 Schizophreniform disorder, in remission /16/02 Latent schizophrenia unspecified /16/02 Latent schizophrenia subchronic /16/02 Latent schizophrenia chronic /16/02 Latent schizophrenia subchronic with acute exacerbation /16/02 Latent schizophrenia chronic with acute exacerbation /16/02 Latent schizophrenia in remission /16/02 Schizophrenic disorders, residual type, unspecified /16/02 Schizophrenic disorders, residual type, subchronic /16/02 Schizophrenic disorders, residual type, chronic /16/02 Schizophrenic disorders, residual type, subchronic with acute exacerbation /16/02 Schizophrenic disorders, residual type, chronic with acute exacerbation /16/02 Schizophrenic disorders, residual type, in remission /16/02 Schizoaffective disorder,unspecified /16/02 Schizoaffective disorder, subchronic /16/02 Schizoaffective disorder, chronic /16/02 Schizoaffective disorder, subchronic with acute exacerbation /16/02 Schizoaffective disorder, chronic with acute exacerbation /16/02 Schizoaffective disorder, in remission /16/02 Other specified types of schizophrenia unspecified /16/02 Other specified types of schizophrenia subchronic /16/02 Other specified types of schizophrenia chronic /16/02 Other specified types of schizophrenia subchronic with acute exacerbation /16/02 Other specified types of schizophrenia chronic with acute exacerbation /16/02 Other specified types of schizophrenia in remission /16/02 Unspecified /16/02 Subchronic /16/02 Chronic /16/02 Subchronic with acute exacerbation /16/02 Chronic with acute exacerbation /16/02 In remission /16/02 Bipolar I disorder, single manic episode, unspecified /16/02 Bipolar I disorder, single manic episode, mild /16/02 Bipolar I disorder, single manic episode, moderate /16/02 Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior 2

3 ATTACHMENT A /16/02 Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior /16/02 Bipolar I disorder, single manic episode, in partial or unspecified remission /16/02 Bipolar I disorder, single manic episode, in full remission /16/02 Manic disorder, recurrent episode unspecified /16/02 Manic disorder, recurrent episode mild /16/02 Manic disorder, recurrent episode moderate /16/02 Manic disorder, recurrent episode severe, without mention of psychotic behavior /16/02 Manic disorder, recurrent episode severe, specified as with psychotic behavior /16/02 Manic disorder, recurrent episode in partial or unspecified remission /16/02 Manic disorder, recurrent episode in full remission /16/02 Major depressive disorder, single episode unspecified /16/02 Major depressive disorder, single episode mild /16/02 Major depressive disorder, single episode moderate /16/02 Major depressive disorder, single episode severe, without mention of psychotic behavior /16/02 Major depressive disorder, single episode severe, specified as with psychotic behavior /16/02 Major depressive disorder, single episode in partial or unspecified remission /16/02 Major depressive disorder, single episode in full remission /16/02 Major depressive disorder, recurrent episode unspecified /16/02 Major depressive disorder, recurrent episode mild /16/02 Major depressive disorder, recurrent episode moderate /16/02 Major depressive disorder, recurrent episode severe, without mention of psychotic behavior /16/02 Major depressive disorder, recurrent episode severe, specified as with psychotic behavior /16/02 Major depressive disorder, recurrent episode in partial or unspecified remission /16/02 Major depressive disorder, recurrent episode in full remission /16/02 Bipolar I disorder, most recent episode (or current) manic, unspecified /16/02 Bipolar I disorder, most recent episode (or current) manic, mild /16/02 Bipolar I disorder, most recent episode (or current) manic, moderate /16/02 Bipolar I disorder, most recent episode (or current) manic, 3

4 ATTACHMENT A severe, without mention of psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified remission /16/02 Bipolar I disorder, most recent episode (or current) manic, in full remission /16/02 Bipolar I disorder, most recent episode (or current) depressed, unspecified /16/02 Bipolar I disorder, most recent episode (or current) depressed, mild /16/02 Bipolar I disorder, most recent episode (or current) depressed, moderate /16/02 Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified remission /16/02 Bipolar I disorder, most recent episode (or current) depressed, in full remission /16/02 Bipolar I disorder, most recent episode (or current) mixed, unspecified /16/02 Bipolar I disorder, most recent episode (or current) mixed, mild /16/02 Bipolar I disorder, most recent episode (or current) mixed, moderate /16/02 Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior /16/02 Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified remission /16/02 Bipolar I disorder, most recent episode (or current), mixed, in full remission /16/02 Bipolar I disorder, most recent episode (or current), unspecified /16/02 Bipolar disorder, unspecified /16/02 Atypical manic disorder /16/02 Atypical depressive disorder /16/02 Other and unspecified bipolar disorders, other /16/02 Unspecified episode mood disorder /16/02 Other specified episodic mood disorder 4

5 ATTACHMENT A /16/02 Paranoid state, simple /16/02 Delusional disorder /16/02 Paraphrenia /16/02 Shared psychotic disorder /16/02 Other specified paranoid states /16/02 Unspecified paranoid state /16/02 Depressive type psychoses /16/02 Excitative type psychoses /16/02 Reactive confusion /16/02 Acute paranoid reaction /16/02 Psychogenic paranoid psychosis /16/02 Other and unspecified reactive psychosis /16/02 Unspecified psychosis /16/02 Autistic disorder, current or active state /16/02 Autistic disorder, residual state /16/02 Childhood disintegrative disorder, current or active state /16/02 Childhood disintegrative disorder, residual state /16/02 Other specified pervasive developmental disorders, current or active state /16/02 Other specified pervasive developmental disorders, residual state /16/02 Unspecified pervasive developmental disorders, current or active state /16/02 Unspecified pervasive developmental disorders, residual state /16/02 Anxiety state, unspecified /16/02 Panic disorder without agoraphobia /16/02 Generalized anxiety disorder /16/02 Neurotic disorders other /16/02 Hysteria, unspecified /16/02 Conversion disorder /16/02 Dissociative amnesia /16/02 Dissociative fugue /16/02 Dissociative identity disorder /16/02 Dissociative disorder or reaction, unspecified /16/02 Factitious disorder with predominantly psychological signs and symptoms /16/02 Other and unspecified factitious illness /16/02 Phobia, unspecified /16/02 Agoraphobia with panic disorder /16/02 Agoraphobia without mention of panic attacks /16/02 Social phobia /16/02 Other isolated or specific phobias 5

6 ATTACHMENT A /16/02 Obsessive-compulsive disorders /16/02 Dysthymic disorder /16/02 Neurasthenia /16/02 Depersonalization disorder /16/02 Hypochondriasis /16/02 Somatization disorder /16/02 Undifferentiated somatoform disorder /16/02 Other somatoform disorders /16/02 Unspecified nonpsychotic mental disorder /16/02 Paranoid personality disorder /16/02 Affective personality disorder, unspecified /16/02 Chronic hypomanic personality disorder /16/02 Chronic depressive personality disorder /16/02 Cyclothymic disorder /16/02 Schizoid personality disorder, unspecified /16/02 Introverted personality /16/02 Schizotypal personality disorder /16/02 Explosive personality disorder /16/02 Obsessive-compulsive personality disorder /16/02 Histrionic personality disorder, unspecified /16/02 Chronic factitious illness with physical symptoms /16/02 Other histrionic personality disorder /16/02 Dependent personality disorder /16/02 Antisocial personality disorder /16/02 Narcissistic personality disorder /16/02 Avoidant personality disorder /16/02 Borderline personality disorder /16/02 Passive-aggressive personality /16/02 Other personality disorder /16/02 Unspecified personality disorder /16/02 Ego-dystonic sexual orientation /16/02 Zoophilia /16/02 Pedophilia /16/02 Transvestic fetishism /16/02 Exhibitionism /16/02 Trans-sexualism with unspecified sexual history /16/02 Trans-sexualism with asexual history /16/02 Trans-sexualism with homosexual history /16/02 Trans-sexualism with heterosexual history /16/02 Gender identity disorder in children /16/02 Psychosexual dysfunction, unspecified 6

7 ATTACHMENT A /16/02 Hypoactive sexual desire disorder /16/02 Psychosexual dysfunction with inhibited sexual excitement /16/02 Female orgasmic disorder /16/02 Male orgasmic disorder /16/02 Premature ejaculation /16/02 Dyspareunia, psychogenic /16/02 Psychosexual dysfunction with other specified psychosexual dysfunctions /16/02 Fetishism /16/02 Voyeurism /16/02 Sexual masochism /16/02 Sexual sadism /16/02 Gender identity disorder in adolescent or adults /16/02 Other specified psychosexual disorder /16/02 Unspecified psychosexual disorder /16/02 Stuttering /16/02 Tic disorder, unspecified /16/02 Transient tic disorder /16/02 Chronic motor or vocal tic disorder /16/02 Tourette s disorder /16/02 Stereotyped movement disorder /16/02 Nonorganic sleep disorder, unspecified /16/02 Transient disorder of initiating or maintaining sleep /16/02 Persistent disorder of initiating or maintaining sleep /16/02 Transient disorder of initiating or maintaining wakefulness /16/02 Persistent disorder of initiating or maintaining wakefulness /16/02 Circadian rhythm sleep disorder /16/02 Sleep arousal disorder /16/02 Other dysfunctions of sleep stages or arousal from sleep /16/02 Other /16/02 Eating disorder, unspecified /16/02 Enuresis /16/02 Encopresis /16/02 Psychogenic pain, site unspecified /16/02 Psychalgia Other and unspecified special symptoms or syndromes, not elsewhere classified /16/02 Predominant disturbance of emotions /16/02 Predominant disturbance of consciousness /16/02 Predominant psychomotor disturbance /16/02 Other acute reactions to stress /16/02 Mixed disorders as reaction to stress 7

8 ATTACHMENT A /16/02 Unspecified acute reaction to stress /16/02 Adjustment disorder with depressed mood /16/02 Prolonged depressive reaction /16/02 Separation anxiety disorder /16/02 Emancipation disorder of adolescence and early adult life /16/02 Specific academic or work inhibition /16/02 Adjustment disorder with anxiety /16/02 Adjustment disorder with mixed anxiety and depressed mood /16/02 Other predominant disturbance of other emotions /16/02 Adjustment disorder with disturbance of conduct /16/02 Adjustment disorder with disturbance of emotions and conduct /16/02 Posttraumatic stress disorder /16/02 Adjustment reaction with physical symptoms /16/02 Adjustment reaction with withdrawal /16/02 Other specified adjustment reaction /16/02 Unspecified adjustment reaction /16/02 Frontal lobe syndrome /16/02 Depressive disorder, not elsewhere classified /16/02 Undersocialized conduct disorder, aggressive type, unspecified /16/02 Undersocialized conduct disorder, aggressive type, mild /16/02 Undersocialized conduct disorder, aggressive type, moderate /16/02 Undersocialized conduct disorder, aggressive type, severe /16/02 Undersocialized conduct disorder, unaggressive type, unspecified /16/02 Undersocialized conduct disorder, unaggressive type, mild /16/02 Undersocialized conduct disorder, unaggressive type, moderate /16/02 Undersocialized conduct disorder, unaggressive type, severe /16/02 Socialized conduct disorder, unspecified /16/02 Socialized conduct disorder, mild /16/02 Socialized conduct disorder, moderate /16/02 Socialized conduct disorder, severe /16/02 Impulse control disorder, unspecified /16/02 Pathological gambling /16/02 Kleptomania /16/02 Pyromania /16/02 Intermittent explosive disorder /16/02 Isolated explosive disorder /16/02 Other /16/02 Mixed disturbance of conduct and emotions /16/02 Conduct disorder, childhood onset type /16/02 Conduct disorder, adolescent onset type 8

9 ATTACHMENT A /16/02 Other conduct disorder /16/02 Unspecified disturbance of conduct /16/02 Overanxious disorder /16/02 Misery and unhappiness disorder /16/02 Shyness disorder of childhood /16/02 Introverted disorder of childhood /16/02 Selective mutism /16/02 Relationship problems /16/02 Oppositional defiant disorder /16/02 Identity disorder /16/02 Academic underachievement disorder /16/02 Other /16/02 Unspecified emotional disturbance of childhood or adolescence /16/02 Attention deficit disorder Without mention of hyperactivity /16/02 Attention deficit disorder With hyperactivity /16/02 Hyperkinesis with developmental delay /16/02 Hyperkinetic conduct disorder /16/02 Other specified manifestations of hyperkinetic syndrome /16/02 Unspecified hyperkinetic syndrome /16/02 Reading disorder, unspecified /16/02 Alexia /16/02 Developmental dyslexia /16/02 Other /16/02 Mathematics disorder /16/02 Other specific learning difficulties /16/02 Expressive language disorder /16/02 Mixed receptive-expressive language disorder /01/07 Speech and language developmental delay due to hearing loss /16/02 Other /16/02 Developmental coordination disorder /16/02 Mixed development disorder /16/02 Other specified delays in development /16/02 Unspecified delay in development /16/02 Mild mental retardation /16/02 Moderate mental retardation /16/02 Severe mental retardation /16/02 Profound mental retardation /16/02 Unspecified mental retardation 9

10 ATTACHMENT B ICD-9-CM MENTAL DISORDERS DIAGNOSIS CODES AND DESCRIPTIONS Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code This list contains principal diagnosis codes for medical services Category of Service 20 or psychiatric services Category of Service 21. If a code from this list is used as the principal diagnosis code, general care hospitals that are not enrolled for COS 21 may only bill for a maximum of three days of emergency psychiatric care using COS 20. The Department s current peer review organization began utilization review of inpatient claims effective 09/16/02. Codes that were part of the initial review lists have a beginning review date of 09/16/02. Codes added later for review will have other beginning review dates /16/02 Senile dementia, uncomplicated /16/02 Presenile dementia, uncomplicated /16/02 Presenile dementia with delirium /16/02 Presenile dementia with delusional features /16/02 Presenile dementia with depressive features /16/02 Senile dementia with delusional features /16/02 Senile dementia with depressive features /16/02 Senile dementia with delirium /16/02 Vascular dementia, uncomplicated /16/02 Vascular dementia, with delirium /16/02 Vascular dementia, with delusions /16/02 Vascular dementia, with depressed mood /16/02 Other specified senile psychotic conditions /16/02 Unspecified senile psychotic condition /16/02 Alcohol withdrawal delirium /16/02 Alcohol-induced persisting amnestic disorder /16/02 Alcohol-induced persisting dementia /16/02 Alcohol-induced psychotic disorder with hallucinations /16/02 Idiosyncratic alcohol intoxication /16/02 Alcohol-induced psychotic disorder with delusions /16/02 Alcohol withdrawal /16/02 Alcohol-induced sleep disorder /16/02 Other specified alcohol-induced mental disorders /16/02 Unspecified alcohol-induced mental disorders /16/02 Drug withdrawal /16/02 Drug-induced psychotic disorder with delusions /16/02 Drug-induced psychotic disorder with hallucinations /16/02 Pathological drug intoxication /16/02 Drug-induced delirium /16/02 Drug-induced persisting dementia 1

11 ATTACHMENT B /16/02 Drug-induced persisting amnestic disorder /16/02 Drug-induced mood disorder /01/05 Drug-induced sleep disorder /16/02 Other /16/02 Unspecified drug-induced mental disorder /16/02-12/31/04 Delirium due to conditions classified elsewhere 11/01/08-current /16/02 Subacute delirium /16/02 Physiological malfunction arising from mental factors Musculoskeletal /16/02 Physiological malfunction arising from mental factors Respiratory /16/02 Physiological malfunction arising from mental factors Cardiovascular /16/02 Physiological malfunction arising from mental factors Skin /16/02 Physiological malfunction arising from mental factors Gastrointestinal /16/02 Psychogenic genitourinary malfunction, unspecified /16/02 Psychogenic vaginismus /16/02 Psychogenic dysmenorrhea /16/02 Psychogenic dysuria /16/02 Other /16/02 Endocrine /16/02 Organs of special sense /16/02 Other specified psychophysiological malfunction /16/02 Unspecified psychophysiological malfunction /16/02 Anorexia nervosa /16/02 Repetitive intrusions of sleep /16/02 Bulimia nervosa /16/02 Pica /16/02 Rumination disorder /16/02 Psychogenic vomiting /16/02 Other /16/02 Tension headache /16/02 Other, pain disorder related to psychological factors /16/02 Postconcussion syndrome /16/02 Other specified nonpsychotic mental disorders following organic brain damage /16/02 Unspecified nonpsychotic mental disorder following organic brain damage /16/02 Psychic factors associated with diseases classified elsewhere 2

12 ATTACHMENT C ICD-9-CM DIAGNOSIS CODES Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code The Department s current peer review organization began utilization review of inpatient claims effective 09/16/02. Codes that were part of the initial review lists have a beginning review date of 09/16/02. Codes added later for review will have other beginning review dates /16/02-02/28/ /16/02-02/28/ /16/02-02/28/07 Streptococcal septicemia 1 Staphylococcal septicemia, unspecified Methicillin susceptible Staphylococcus aureus septicemia (revised) MSSA septicemia Staphylococcus aureus septicemia NOS Other staphylococcal septicemia /16/02-02/28/ /01/08 Pneumococcal septicemia /01/08 Septicemia due to anaerobes /16/02-02/28/07 Septicemia due to Gram-negative organism, unspecified /01/08 Septicemia due to hemophilus influenzae (H.influenzae) /16/02 Septicemia due to Escherichia coli (E. Coli) /16/02-02/28/07 Septicemia due to Pseudomonas /01/08 Septicemia due to Serratia /16/02 Septicemia due to other gram-negative organisms /16/02 Other specified septicemias /16/02 Unspecified septicemia /16/02 Diabetes mellitus without (w/o) mention of complication, type II or unspecified type, not stated as uncontrolled /16/02 Diabetes mellitus w/o mention of complication type I [juvenile type], not stated as uncontrolled /16/02 Diabetes mellitus w/o mention of complication, type II or unspecified type, uncontrolled /16/02 Diabetes mellitus w/o mention of complication, type I [Juvenile type], uncontrolled /01/07 Diabetes with ketoacidiosis, type II, not stated as uncontrolled /01/07 Diabetes with ketoacidiosis, type I, not stated as uncontrolled /01/08 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled /01/07 Diabetes with ketoacidiosis, type I, uncontrolled /01/08 Diabetes with hyperosmolarity, type II or unspecified type, not

13 ATTACHMENT C stated as uncontrolled /01/08 Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled /01/08 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled /01/08 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled /16/02 Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled /01/05 Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled /16/02 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled /16/02 Diabetes with other specified manifestations type I [juvenile type], uncontrolled /01/08 Hyposmolality and/or hyponatremia /01/05 Volume Depletion, Unspecified /01/05 Dehydration /01/05 Hypovolemia /01/08 Hyperpotassemia /01/08 Hypopotassemia /16/02 Iron Deficiency anemia Secondary to blood loss (chronic) /16/02 Iron Deficiency anemia, unspecified /16/02 Essential hypertension, malignant /16/02 Essential hypertension, unspecified /16/02 Hypertensive Chronic Kidney disease, Unspecified, with Chronic Kidney Disease Stage V or End Stage Renal Disease /01/07 Acute Myocardial Infarction of Anterolateral wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Anterolateral wall; Initial Episode of Care /01/07 Acute Myocardial Infarction of Anterolateral wall; Subsequent /01/07 Acute Myocardial Infarction of Other Anterior wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Other Anterior wall; Initial /01/07 Acute Myocardial Infarction of Other Anterior wall; Subsequent /01/07 Acute Myocardial Infarction of Inferolateral wall; Unspecified /01/07 Acute Myocardial Infarction of Inferolateral wall; Initial Episode of Care 2

14 ATTACHMENT C /01/07 Acute Myocardial Infarction of Inferolateral wall; Subsequent /01/07 Acute Myocardial Infarction of Inferoposterior wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Inferoposterior wall; Initial /01/07 Acute Myocardial Infarction of Inferoposterior wall; Subsequent /01/07 Acute Myocardial Infarction of Other Inferior wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Other Inferior wall; Initial Episode of Care /01/07 Acute Myocardial Infarction of Other Inferior wall; Subsequent /01/07 Acute Myocardial Infarction of Other Lateral wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Other Lateral wall; Initial Episode of Care /01/07 Acute Myocardial Infarction of Other Lateral wall; Subsequent episode of Care /01/07 Acute Myocardial Infarction of True Posterior wall; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of True Posterior wall; Initial Episode of Care /01/07 Acute Myocardial Infarction of True Posterior wall; Subsequent /01/07 Acute Myocardial Infarction - Subendocardial Infarction; Episode of Care Unspecified /01/07 Acute Myocardial Infarction - Subendocardial Infarction; Initial /01/07 Acute Myocardial Infarction - Subendocardial Infarction; Subsequent /01/07 Acute Myocardial Infarction of Other Specified Sites; Episode of Care Unspecified /01/07 Acute Myocardial Infarction of Other Specified Sites; Initial /01/07 Acute Myocardial Infarction of Other Specified Sites; Subsequent /01/07 Acute Myocardial Infarction of Unspecified Site; Unspecified /01/07 Acute Myocardial Infarction of Unspecified Site; Initial Episode of Care /01/07 Acute Myocardial Infarction of Unspecified Site; Subsequent 3

15 ATTACHMENT C /01/07 Post Myocardial Infarction Syndrome /01/07 Intermediate Coronary Syndrome /01/07 Acute Coronary Occlusion without Myocardial Infarction /01/07 Other Ischemic Heart Disease /01/07 Unspecified Congestive Heart Failure /01/07 Left Heart Failure /01/07 Unspecified Systolic Heart Failure /01/07 Acute Systolic Heart Failure /01/07 Chronic Systolic Heart Failure /01/07 Acute on Chronic Systolic Heart Failure /01/07 Unspecified Diastolic Heart Failure /01/07 Acute Diastolic Heart Failure /01/07 Chronic Diastolic Heart Failure /01/07 Acute on Chronic Diastolic Heart Failure /01/07 Unspecified Combined Systolic and Diastolic Heart Failure /01/07 Acute Combined Systolic and Diastolic Heart Failure /01/07 Chronic Combined Systolic and Diastolic Heart Failure /01/07 Acute on Chronic Combined Systolic and Diastolic Heart Failure /01/07 Unspecified Heart Failure /01/05 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity /01/05 Acute venous embolism and thrombosis of proximal lower extremity /01/05 Acute venous embolism and thrombosis of deep vessels of distal lower extremity /01/10 Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity /01/10 Chronic venous embolism and thrombosis of deep vessels of lower of proximal lower extremity /01/10 Chronic venous embolism and thrombosis of deep vessels of lower of distal lower extremity /01/10 Venous embolism and thrombosis of superficial vessels of lower extremity /01/10 Chronic venous embolism and thrombosis of superficial veins of upper extremity /01/10 Chronic venous embolism and thrombosis of deep veins of upper extremity /01/10 Chronic venous embolism and thrombosis of upper extremity, unspecified /01/10 Chronic venous embolism and thrombosis of axillary veins /01/10 Chronic venous embolism and thrombosis of subclavian veins /01/10 Chronic venous embolism and thrombosis of internal jugular veins 4

16 ATTACHMENT C /01/10 Chronic venous embolism and thrombosis of other thoracic veins /01/10 Chronic venous embolism and thrombosis of other specified veins /01/09 Acute venous embolism and thrombosis of superficial veins of upper extremity /01/09 Acute venous embolism and thrombosis of deep veins of upper extremity /01/09 Acute venous embolism and thrombosis of upper extremity, unspecified /01/09 Acute venous embolism and thrombosis of axillary veins /01/09 Acute venous embolism and thrombosis of subclavian veins /01/09 Acute venous embolism and thrombosis of internal jugular veins /01/09 Acute venous embolism and thrombosis of other thoracic veins /01/09 Acute venous embolism and thrombosis of specified veins /16/02 Pneumonia, organism unspecified /16/02 Bronchitis, not specified as acute or chronic /16/02-02/28/07 Obstructive Chronic bronchitis without exacerbation /16/02 Obstructive Chronic bronchitis with acute exacerbation /01/05 Obstructive Chronic bronchitis with acute bronchitis /01/07 Unspecified Extrinsic Asthma /01/07 Extrinsic Asthma with Status Asthmaticus /01/07 Extrinsic Asthma with (acute) Exacerbation /01/07 Unspecified Intrinsic Asthma /01/07 Intrinsic Asthma with Status Asthmaticus /01/07 Intrinsic Asthma with (acute) Exacerbation /01/07 Unspecified Chronic Obstructive Asthma /01/07 Chronic Obstructive Asthma with Status Asthmaticus /01/07 Chronic Obstructive Asthma with (acute) Exacerbation /01/07 Exercise Induced Bronchospasm /01/07 Cough Variant Asthma /01/07 Unspecified Asthma /01/07 Unspecified Asthma with Status Asthmaticus /01/07 Unspecified Asthma with (acute) Exacerbation /01/07 Chronic Airway Obstruction, not elsewhere classified /16/02 Esophageal reflux /16/02 Acute gastritis without mention of hemorrhage /16/02 Other specified gastritis without mention of hemorrhage /16/02 Unspecified gastritis and gastroduodenitis without mention of hemorrhage /01/08 Eosinophilic gastritis without mention of hemorrhage /01/08 Eosinophilic gastritis with hemorrhage /16/02 Other and unspecified noninfectious gastroenteritis and colitis /16/02 Alcoholic cirrhosis of liver 5

17 ATTACHMENT C /01/05 Chronic Kidney Disease, Stage I (1) /01/05 Chronic Kidney Disease, Stage II (2) (Mild) /01/05 Chronic Kidney Disease, Stage III (3) (Moderate) /01/05 Chronic Kidney Disease, Stage IV (4) (Severe) /01/05 Chronic Kidney Disease, Stage V (5) /01/05 End Stage Renal Disease /01/05 Chronic Kidney Disease, Unspecified /16/02 Urinary tract infection, site not specified /01/05 Pressure ulcer, unspecified site /01/05 Pressure ulcer, elbow /01/05 Pressure ulcer, upper back /01/05 Pressure ulcer, lower back /01/05 Pressure ulcer, hip /01/05 Pressure ulcer, buttock /01/05 Pressure ulcer, ankle /01/05 Pressure ulcer, heel /01/05 Pressure ulcer, other site /16/02 Ulcer of lower limb, except pressure ulcer, unspecified /16/02-02/28/07 Ulcer of thigh, except pressure ulcer /16/02-02/28/07 Ulcer of calf, except pressure ulcer /16/02 Ulcer of ankle, except pressure ulcer /16/02-02/28/07 Ulcer of heel and midfoot, except pressure ulcer /16/02 Ulcer of other part of foot, except pressure ulcer /16/02 Ulcer of other part of lower limb, except pressure ulcer /01/08 Chronic skin ulcer of other specified sites /01/08 Pressure ulcer, unspecified stage Healing pressure ulcer NOS Healing pressure ulcer, unspecified stage /01/08 Pressure ulcer, stage I Healing pressure ulcer, stage I Pressure pre-ulcer skin changes limited to persistent focal erythema /01/08 Pressure ulcer, stage II Healing pressure ulcer, stage II Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis /01/08 Pressure ulcer, stage III Healing pressure ulcer, stage III Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue 6

18 ATTACHMENT C /01/08 Pressure ulcer, stage IV Healing pressure ulcer, stage IV Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon or bone /01/08 Pressure ulcer, unstageable /16/02 Lumbago /16/02 Syncope and collapse /16/02 Other convulsions /16/02 Dizziness and giddiness /16/02 Anorexia /16/02 Symptoms involving respiratory system and other chest symptoms, other /16/02 Chest pain unspecified /16/02 Chest pain other /16/02 Abdominal pain unspecified site /16/02 Abdominal pain right lower quadrant /16/02 Abdominal pain left lower quadrant /01/08 Malignant Ascites /01/08 Other Ascites 7

19 ATTACHMENT D DRG Codes Subject to Prepayment Review DRG Beginning Review /16/02 Seizure & Headache, Age > 17 years, Without Complications and Comorbidities /16/02 Hypertension /16/02 Chest Pain /16/02 Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age > 17 years, With Complications and Comorbidities /16/02 Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders, Age > 17 years /16/02 Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age 0-17 years /16/02 Medical Back Problems /16/02 Menstrual and Other Female Reproductive System Disorders /16/02 Abortion with Dilation and Curettage, Aspiration Curettage or Hysterotomy /01/04 Extreme Immaturity or Respiratory Distress Syndrome /16/02 Alcohol/Drug Abuse or Dependence, Detoxification or Other Symptomatic Treatment, Without Complications and Comorbidities /16/02 Extensive OR Procedure Unrelated to Principal Diagnosis /16/02 Non-Extensive OR Procedure Unrelated to Principal Diagnosis /01/04 Extreme Immaturity or Respiratory Distress Syndrome 1