11/26/08 ELIGIBLE POPULATION for DMHDD funded MH Services. Must have both I and II:

Transcription

1 11/26/08 ELIGIBLE POPULATION for DMHDD funded MH Services AGE: Birth and older Must have both I and II: I. Diagnostic Criteria: "Mental illness" as used herein refers to "a mental or emotional disorder verified by a diagnosis contained in the DSM-IV or ICD-9-CM which substantially impairs the person's cognitive, emotional and /or behavioral functioning, excluding" the conditions listed in the column to the right. The Client must have one of the diagnoses on the attached listing of DSM-IV diagnostic and ICD-9-CM Codes. Excluded Diagnoses: EOther Conditions That May Be a Focus of Clinical Attention (V-codes) EOrganic disorders such as dementia and those associated with know or unknown physical conditions such as hallucinosis, amnestic disorder and delirium EPsychoactive substance induced organic mental disorders EMental retardation or pervasive developmental disorders associated with mental retardation. EPsychoactive substance use disorders For purposes of eligibility, this does not exclude individuals with a dual diagnosis of mental retardation or psychoactive substance abuse disorders as long as it co-occurs with an eligible diagnosable disorder to the left which is the principal diagnosis. II. Impairment Has significant impairment in an important area of life functioning as a result of the mental disorder identified in diagnostic criteria above and as indicated on the Global Level of Functioning (GAF) or Children's Global Assessment Scale (CGAS).

2 DSMIV CODES ICD-9-CM DMHDD ELIGIBLE POPULATION -- 11/26/08 LISTING OF DSM IV DIAGNOSES AND ICD-9 CODES Schizophrenic Disorder, Simple type Schizophrenia, Simple Type, Subchronic Schizophrenia, Simple Type, Chronic Schizophrenia, Simple Type, Subchronic with Acute Exacerbation Schizophrenia, Simple Type, Chronic with Acute Exacerbation Schizophrenia, Simple Type, In Remission Schizophrenia, Disorganized Type Schizophrenia, Disorganized Type, Subchronic Schizophrenia, Disorganized Type, Chronic Schizophrenia, Disorganized Type, Subchronic with Acute Exacerbation Schizophrenia, Disorganized Type, Chronic with Acute Exacerbation Schizophrenia, Disorganized Type, In Remission Schizophrenia, Catatonic Type Schizophrenia, Catatonic Type, Subchronic Schizophrenia, Catatonic Type, Chronic Schizophrenia, Catatonic Type, Subchronic with Acute Exacerbation Schizophrenia, Catatonic Type, Chronic with Acute Exacerbation Schizophrenia, Catatonic Type, In Remission Schizophrenia, Paranoid Type Schizophrenia, Paranoid Type, Subchronic Schizophrenia, Paranoid Type, Chronic Schizophrenia, Paranoid Type, Subchronic with Acute Exacerbation Schizophrenia, Paranoid Type, Chronic with Acute Exacerbation Schizophrenia, Paranoid Type, In Remission Schizophreniform Disorder/Acute Schizophrenic Episode

3 Acute Schizophrenic Episode, Subchronic Acute Schizophrenic Episode, Chronic Acute Schizophrenic Episode, Subchronic With Acute Exacerbation Acute Schizophrenic Episode, Chronic With Acute Exacerbation Acute Schizophrenic Episode, In Remission Schizophrenia, Residual Type Schizophrenia, Residual Type. Subchronic Schizophrenia, Residual Type. Chronic Schizophrenia, Residual Type, Subchronic with Acute Exacerbation Schizophrenia, Residual Type, Chronic with Acute Exacerbation Schizophrenia, Residual Type, In Remission Schizoaffective Disorder Schizoaffective Disorder, Subchronic Schizoaffective Disorder, Chronic Schizoaffective Disorder, Subchronic With Acute Exacerbation Schizoaffective Disorder, Chronic With Acute Exacerbation Schizoaffective Disorder, In Remission Schizophrenia, Undifferentiated Type Schizophrenia, Undifferentiated Type, Subchronic Schizophrenia, Undifferentiated Type, Chronic Schizophrenia, Undifferentiated Type, Subchronic with Acute Exacerbation Schizophrenia, Undifferentiated Type, Chronic with Acute Exacerbation Schizophrenia, Undifferentiated Type, In Remission Bipolar I Disorder, Single Manic Episode, Unspecified Bipolar I Disorder, Single Manic Episode, Mild Bipolar I Disorder, Single Manic Episode, Moderate Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features Bipolar I Disorder, Single Manic Episode, Severe With Psychotic Features Bipolar I Disorder, Single Manic Episode, In Partial Remission

4 Bipolar I Disorder, Single Manic Episode, In Full Remission Manic Disorder, Recurrent Episode, Unspecified Manic Disorder, Recurrent Episode, Mild Manic Disorder, Recurrent Episode, Moderate Manic Disorder, Recurrent Episode, Severe, Without Psychotic Features Manic Disorder, Recurrent Episode, With Psychotic Features Manic Disorder, Recurrent Episode, In Partial Remission Manic Disorder, Recurrent Episode, In Full Remission Major Depressive Disorder, Single Episode, Unspecified Major Depressive Disorder, Single Episode, Mild Major Depressive Disorder, Single Episode, Moderate Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Major Depressive Disorder, Single Episode, Severe With Psychotic Features Major Depressive Disorder, Single Episode, In Partial Remission Major Depressive Disorder, Single Episode, In Full Remission Major Depressive Disorder, Recurrent, Unspecified Major Depressive Disorder, Recurrent, Mild Major Depressive Disorder, Recurrent, Moderate Major Depressive Disorder, Recurrent, Severe Without Psychotic Features Major Depressive Disorder, Recurrent, Severe With Psychotic Features Major Depressive Disorder, Recurrent, In Partial Remission Major Depressive Disorder, Recurrent, In Full Remission Bipolar I Disorder, Most Recent Episode Manic, Unspecified Bipolar I Disorder, Most Recent Episode Hypomanic Bipolar I Disorder, Most Recent Episode Manic, Mild Bipolar I Disorder, Most Recent Episode Manic, Moderate Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission Bipolar I Disorder, Most Recent Episode Manic, In Full Remission

5 Bipolar I Disorder, Most Recent Episode Depressed, Unspecified Bipolar I Disorder, Most Recent Episode Depressed, Mild Bipolar I Disorder, Most Recent Episode Depressed, Moderate Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission Bipolar I Disorder, Most Recent Episode Mixed, Unspecified Bipolar I Disorder, Most Recent Episode Mixed, Mild Bipolar I Disorder, Most Recent Episode Mixed, Moderate Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission Bipolar I Disorder, Most Recent Episode Unspecified Bipolar Disorder NOS Atypical Manic Disorder Atypical Depressive Disorder Bipolar II Disorder Mood Disorder NOS/Unspecified Affective Psychosis Other Specified Affective Psychoses Paranoid State, Simple Delusional Disorder/Paranoia Paraphrenia Shared Psychotic Disorder/Shared Paranoid Disorder Other Specified Paranoid States Unspecified Paranoid State Depressive Type Psychosis Excitative Type Psychosis Reactive Confusion

6 298.3 Acute Paranoid Reaction Psychogenic Paranoid Psychosis Brief Psychotic Disorder/ Other and Unspecified Reactive Psychosis Psychotic Disorder NOS Anxiety Disorder NOS Panic Disorder Without Agoraphobia Generalized Anxiety Disorder Anxiety States, Other Hysteria, Unspecified Conversion Disorder Dissociative Amnesia/Psychogenic Amnesia Dissociative Fugue/Psychogenic Fugue Dissociative Identity Disorder/Multiple Personality Dissociative Disorder NOS Factitious Disorder With Predominantly Psychological Signs and Symptoms Factitious Disorder NOS/Other and Unspecified Factitious Illness Factitious Disorder With Combined Psychological and Physical Signs and Symptoms/Other and Unspecified Factitious Illness Factitious Disorder With Predominantly Physical Signs and Symptoms/Other and Unspecified Factitious Illness Phobia, Unspecified Panic Disorders with Agoraphobia Agoraphobia Without History of Panic Disorder Social Phobia Specific Phobia/Other Isolated or Simple Phobias Obsessive-Compulsive Disorder Dysthymic Disorder/Neurotic Depression Neurasthenia Depersonalization Disorder Body Dysmorphic Disorder/Hypochondriasis Somatization Disorder Somatoform Disorder NOS, Undifferentiated Somatoform Disorder

7 Unspecified Mental Disorder (non-psychotic)/unspecified Neurotic Disorder Paranoid Personality Disorder Affective Personality Disorder, Unspecified Chronic Hypomanic Personality Disorder Chronic Depressive Personality Disorder Cyclothymic Disorder Schizoid Personality Disorder Introverted Personality Schizotypal Personality Disorder Explosive Personality Disorder Obsessive-Complusive Personality Disorder Histrionic Personality Disorder Chronic Factitious Illness With Physical Symptoms Other Histrionic Personality Disorder Dependent Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Borderline Personality Disorder Passive-aggressive Personality Personality Disorder, Other Personality Disorder NOS Zoophilia Pedophilia Transvestic Fetishism Exhibitionism Trans-sexualism, With Unspecified Sexual History Trans-sexualism, With Asexual History Trans-sexualism, With Homosexual History

8 Trans-sexualism, With Heterosexual History Gender Identity Disorder NOS/Disorders of Psychosexual Identity Gender Identity Disorder in Children/Disorders of Psychosexual Identity Sexual Dysfunction NOS Hypoactive Sexual Desire Disorder/Psychosexual Dysfunction With Inhibited Sexual Desire Female Sexual Arousal Disorder/Psychosexual Dysfunction With Inhibited Sexual Excitement Male Erectile Disorder/Psychosexual Dysfunction With Inhibited Sexual Excitement Female Orgasmic Disorder/Psychosexual Dysfunction With Inhibited Female Orgasm Male Orgasmic Disorder/Psychosexual Dysfunction With Inhibited Male Orgasm Premature Ejaculation/Psychosexual Dysfunction with Premature Ejaculation Dyspareunia [Not Due to a General Medical Condition]/Psychosexual Disorder With Functional Dysparenunia Sexual Aversion Disorder/Psychosexual Dysfunction With Other Specified Psychosexual Dysfunctions Fetishism Voyeurism Sexual Masochism Sexual Sadism Gender Identity Disorder in Adolescents or Adults Frotteurism/Other Specified Psychosexual Disorder Sexual Disorder NOS/Unspecified Psychosexual Disorder Paraphilia NOS/Unspecified Psychosexual Disorder Vaginismus [Not Due to a General Medical Condition]/Psychogenic Vaginismus Anorexia Nervosa Tic Disorder NOS Transient Tic Disorder/Transiant Tic Disorder of Childhood Chronic Motor or Vocal Tic Disorder Tourette's Disorder Stereotypic Movement Disorder/Stereotyped Repetitive Movements Dyssomnia NOS/Parasomnia NOS Insomnia Related To..[Indicate the Axis I or II Disorder]/Persistent Disorder of Initiating or Maintaining Sleep Primary Insomnia/Persistent Disorder of Initiating or Maintaining Sleep Primary Hypersomnia/Persistent Disorder of Initiating or Maintaining Wakefulness

9 Hypersomnia Related to..[indicate the Axis I or II Disorder]/Persistent Disorder of Initiating or Maintaining Wakefulness Sleep Terror Disorder/Somnambulism or Night Terrors Sleepwalking Disorder/Somnambulism or Night Terrors Dyssomnia NOS/Other Dysfunctions of Sleep Stages or Arousal from Sleep Nightmare Disorder/Other Dysfunctions of Sleep Stages or Arousal from Sleep Parasomnia NOS/Other Dysfunctions of Sleep Stages or Arousal from Sleep Eating Disorder NOS Bulimia Nervosa Pica Rumination Disorder/Psychogenic Rumination Psychogenic Vomiting Feeding Disorder of Infancy or Early Childhood Enuresis (Not Due to General Medical Condition) Encopresis, Without Constipation and Overflow Incontinence Acute Reaction to Stress, Predominant Disturbance of Emotions Acute Reaction to Stress, Predominant Disturbance of Consciousness Acute Reaction to Stress, Predominant Psychomotor Dysfunction Acute Stress Disorder/Other Acute Reactions to Stress Mixed Disorders as Reaction to Stress Acute Reaction to Stress, Unspecified Adjustment Disorder With Depressed Mood/Brief Depressive Reaction Prolonged Depressive Reaction Separation Anxiety Disorder Adjustment Disorder With Anxiety/Adjustment Reaction with Anxious Mood Adjustment Disorder With Mixed Anxiety and Depressed Mood Adjustment Reaction With Predominant Disturbance of Other Emotions, Other Adjustment Disorder with Disturbance of Conduct Adjustment Disorder with Mixed Disturbance of Emotions and Conduct Posttraumatic Stress Disorder Adjustment Disorder Unspecified

10 Personality Change Due to..(indicate the General Medical Condition)/Organic Personality Syndrome Depressive Disorder NOS Undersocialized Conduct Disorder, Aggressive Type Undersocialized Conduct Disorder, Aggressive Type, Mild Undersocialized Conduct Disorder, Aggressive Type, Moderate Undersocialized Conduct Disorder, Aggressive Type, Severe Undersocialized Conduct Disorder, Unaggressive Type Undersocialized Conduct Disorder, Unaggressive Type, Mild Undersocialized Conduct Disorder, Unaggressive Type, Moderate Undersocialized Conduct Disorder, Unaggressive Type, Severe Socialized Conduct Disorder Socialized Conduct Disorder, Mild Socialized Conduct Disorder, Moderate Socialized Conduct Disorder, Severe Impulse-Control Disorder NOS Pathological Gambling Kleptomania Pyromania Intermittent Explosive Disorder Isolated Explosive Disorder Trichotillomania/Disorder of Impulse Control, Other Mixed Disturbance of Conduct and Emotions Conduct Disorder, Childhood-Onset Type Conduct Disorder, Adolescent-Onset Type Conduct Disorder, Unspecified Onset Disruptive Behavior Disorder NOS/Unspecified Disturbance of Conduct Overanxious Disorder Shyness Disorder of Childhood Introverted Disorder of Childhood

11 Selective Mutism/Elective Mutism Oppositional Defiant Disorder Identity Problem/Identity Disorder Reactive Attachment Disorder of Infancy or Early Childhood/Other or Mixed Emotional Disturbances of Childhood or Adolescence, Other Disorder of Infancy, Childhood or Adolescence NOS/Unspecified Emotional Disturbance of Childhood or Adolescence Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type Attention-Deficit/Hyperactivity Disorder, Combined Type Hyperkinesis With Developmental Delay Hyperkinetic Conduct Disorder Other Specified Manifestations of Hyperkinetic Syndrome Attention-Deficit/Hyperactivity Disorder NOS/Unspecified Hyperkinetic Syndrome [Specified Psychological Factor] Affecting..[Ind. the Gen. Med. Cond.]/Psychic Factors Associated with Disease Classified Elsewhere V71.09 Observation of suspected mental illness, other NOTE: In a diagnosis where the DSMIV and ICD-9 Code is listed and different, the DSMIV diagnosis is listed prior to the "/".

12 SMI TARGET POPULATION: Serious Mental Illness (SMI) for DMHDD funded MH services AGE: Must be 18 years of age or older Individuals with serious mental illness are adults whose emotional or behavioral functioning is so impaired as to interfere with their capacity to remain in the community without supportive treatment. The mental impairment is severe and persistent and may result in a limitation of their capacities for primary activities of daily living, interpersonal relationships, homemaking, self-care, employment or recreation. The mental impairment may limit their ability to seek or receive local, state or federal assistance such as housing, medical and dental care, rehabilitation services, income assistance and food stamps, or protective services. Must meet I + (II or III): I. Diagnostic Criteria: The client must have one of the following diagnoses that meets DSM-IV criteria and which is the focus of the treatment being provided: ESchizophrenia (295.xx) ESchizophreniform Disorder (295.4) ESchizo-affective Disorder (295.7) EDelusional Disorder (297.1) EShared Psychotic Disorder (297.3) EBrief Psychotic Disorder (298.8) EPsychotic Disorder NOS (298.9) EBipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, , , ) ECyclothymic Disorder (301.13) EMajor Depression (296.2x, 296.3x) EObsessive-Compulsive Disorder (300.30) EAnorexia Nervosa (307.1) EBulimiaNervosa(307.51)

13 SMI 4/15/97 II. Treatment History (Treatment history covers the client s lifetime treatment and is restricted to treatment for the DSM IV diagnosis specified in Section I.) To qualify under this section, the client must meet at least ONE of the criteria below: A. Continuous treatment of 6 months or more, including treatment during adolescence, in one, or a combination of, the following modalities: inpatient treatment, day treatment or partial hospitalization. B. Six months continuous residence in residential programming (e.g., long-term care facility or assisted, supported or supervised residential programs) C. Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential programming within a 12-month period. D. A history of using the following outpatient services over a 1 year period, either continuously or intermittently: psychotropic medication management, case management, outreach and engagement services. E. Previous treatment in an outpatient modality, and a history of at least one mental health psychiatric hospitalization. III. Functional Criteria (Functional criteria has been purposely narrowed to descriptors of the most serious levels of functional impairment and are not intended to reflect the full range of possible impairment.) To qualify under this section, the client must meet at least TWO of the criteria, A1 through A7, or B1 as a result of the DSM- IV diagnosis specified in Section I. The client: A. 1) Has a serious impairment in social, occupational or school functioning. 2) Is unemployed or working only part-time due to mental illness and not for reasons of physical disability or some other role responsibility (e.g., student or primary caregiver for dependent family member); is employed in a sheltered setting or supportive work situation, or has markedly limited work skills. 3) Requires help to seek public financial assistance for out-of-hospital maintenance (e.g., Medicaid, SSI, SSDI, other indicators). 4) Does not seek appropriate supportive community services, e.g. recreational, educational or vocational support services, without assistance. 5) Lacks supportive social systems in the community (e.g., no intimate or confiding relationship with anyone in their personal life, no close friends or group affiliations, is highly transient or has inability to co-exist within family setting). 6) Requires assistance in basic life and survival skills (must be reminded to take medication, must have transportation to mental health clinic and other supportive services, needs assistance in self-care, household management, food preparation or money management, etc., is homeless or at risk of becoming homeless). 7) Exhibits inappropriate or dangerous social behavior which results in demand for intervention by the mental health and/or judicial/legal system. B. The client does not currently meet the functional criteria listed above, however, the client: 1) is currently receiving treatment, has a history within the past 5 years of functional impairment meeting TWO of the functional criteria listed above which persisted for at least 1 months, and there is documentation supporting the professional judgement that regression in functional impairment would occur without continuing treatment.

14 4/15/97 SED TARGET POPULATION: Serious Emotional Disturbance (SED) for DMHDD funded MH services AGE: Birth through 17 years of age A. Diagnoses: Must meet I + (II or III): One of the following DSM-IV diagnoses which is the focus of the treatment being provided: EAttention Deficit/Hyperactivity Disorders (314.00, , 314.9) ESchizophrenia (295.xx) ESchizophreniform Disorder (295.4) ESchizo-Affective Disorder (295.7) EDelusional Disorder (297.1) EShared Psychotic Disorder (297.3) EBrief Psychotic Disorder (298.8) EPsychotic Disorder NOS (298.9) EBipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, , , ) ECyclothymic Disorder (301.13) EMajor Depression (296.2x, 296.3x) EPanic Disorder with or without Agoraphobia (300.01, ) EObsessive-Compulsive Disorder (300.30) EAnorexia Nervosa (307.1) EBulimia Nervosa (307.51) EPost Traumatic Stress Disorder (309.81) EIntermittent Explosive Disorder (312.34) ETourette's Disorder (307.23)

15 SED 4/15/97 II. Treatment History (Treatment history cover s the client s lifetime treatment and is restricted to treatment for a DSM IV diagnosis specified in Section I.) The youth must meet at least ONE of the criteria below: A. Continuous treatment of 6 months or more in one, or a combination of, the following: inpatient treatment; day treatment; or partial hospitalization. B. Six months continuous residence in a residential treatment center. C. Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential treatment programming within a 12 month period. D. A history of using the following outpatient services over a 1 year period, either continuously or intermittently: psychotropic medication management, case management or SASS/intensive community based services. E. Previous treatment in an outpatient modality and a history of at least one mental health psychiatric hospitalization. III. Functional Criteria (Functional criteria has been purposely narrowed to descriptors of the most serious levels of functional impairment and are not intended to reflect the full range of possible impairments.) The youth must meet criteria for functional impairment in TWO of the following areas. The functional impairment must: 1) be the result of the mental health problems for which the child is or will be receiving care and 2) expected to persist in the absence of treatment. A. B. C. Functioning in self care - Impairment in age-appropriate self care skills is manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs. Functioning in community - Impairment in community functioning is manifested by a consistent lack of age appropriate behavioral controls, decision-making, judgment and value systems which results in potential involvement or involvement the juvenile justice system. Functioning in social relationships - Impairment of social relationships is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults. D. Functioning in the family - Impairment in family functioning is manifested by a pattern of 1) disregard for safety and welfare of self or others, e.g., fire setting, serious and chronic destructiveness, 2) significantly disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents, or 3) inability to conform to reasonable limitations and expectations. The degree of impairment requires intensive (i.e. beyond age appropriate) supervision by parent/caregiver and may result in removal from the family or its equivalent. E. Functioning at school - Impairment in functioning at school is manifested by the inability to pursue educational goals in a normal time frame - e.g. consistently failing grades, repeated truancy, expulsion, property damage or violence towards others --that cannot be remediated by a classroom setting (whether traditional or specialized).