ICD-9-CM MENTAL DISORDERS DIAGNOSIS CODES AND DESCRIPTIONS

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. 295.00 09/16/02 Unspecified 295.01 09/16/02 Subchronic 295.02 09/16/02 Chronic 295.03 09/16/02 Subchronic with acute exacerbation 295.04 09/16/02 Chronic with acute exacerbation 295.05 09/16/02 In remission 295.10 09/16/02 Disorganized type unspecified 295.11 09/16/02 Disorganized type subchronic 295.12 09/16/02 Disorganized type chronic 295.13 09/16/02 Disorganized type subchronic with acute exacerbation 295.14 09/16/02 Disorganized type chronic with acute exacerbation 295.15 09/16/02 Disorganized type in remission 295.20 09/16/02 Catatonic type unspecified 295.21 09/16/02 Catatonic type subchronic 295.22 09/16/02 Catatonic type chronic 295.23 09/16/02 Catatonic type subchronic with acute exacerbation 295.24 09/16/02 Catatonic type chronic with acute exacerbation 295.25 09/16/02 Catatonic type in remission 295.30 09/16/02 Paranoid type unspecified 295.31 09/16/02 Paranoid type subchronic 295.32 09/16/02 Paranoid type chronic 295.33 09/16/02 Paranoid type subchronic with acute exacerbation 295.34 09/16/02 Paranoid type chronic with acute exacerbation 295.35 09/16/02 Paranoid type in remission 295.40 09/16/02 Schizophreniform disorder, unspecified 295.41 09/16/02 Schizophreniform disorder, subchronic 295.42 09/16/02 Schizophreniform disorder, chronic 295.43 09/16/02 Schizophreniform disorder, subchronic with acute exacerbation 1

ATTACHMENT A 295.44 09/16/02 Schizophreniform disorder, chronic with acute exacerbation 295.45 09/16/02 Schizophreniform disorder, in remission 295.50 09/16/02 Latent schizophrenia unspecified 295.51 09/16/02 Latent schizophrenia subchronic 295.52 09/16/02 Latent schizophrenia chronic 295.53 09/16/02 Latent schizophrenia subchronic with acute exacerbation 295.54 09/16/02 Latent schizophrenia chronic with acute exacerbation 295.55 09/16/02 Latent schizophrenia in remission 295.60 09/16/02 Schizophrenic disorders, residual type, unspecified 295.61 09/16/02 Schizophrenic disorders, residual type, subchronic 295.62 09/16/02 Schizophrenic disorders, residual type, chronic 295.63 09/16/02 Schizophrenic disorders, residual type, subchronic with acute exacerbation 295.64 09/16/02 Schizophrenic disorders, residual type, chronic with acute exacerbation 295.65 09/16/02 Schizophrenic disorders, residual type, in remission 295.70 09/16/02 Schizoaffective disorder,unspecified 295.71 09/16/02 Schizoaffective disorder, subchronic 295.72 09/16/02 Schizoaffective disorder, chronic 295.73 09/16/02 Schizoaffective disorder, subchronic with acute exacerbation 295.74 09/16/02 Schizoaffective disorder, chronic with acute exacerbation 295.75 09/16/02 Schizoaffective disorder, in remission 295.80 09/16/02 Other specified types of schizophrenia unspecified 295.81 09/16/02 Other specified types of schizophrenia subchronic 295.82 09/16/02 Other specified types of schizophrenia chronic 295.83 09/16/02 Other specified types of schizophrenia subchronic with acute exacerbation 295.84 09/16/02 Other specified types of schizophrenia chronic with acute exacerbation 295.85 09/16/02 Other specified types of schizophrenia in remission 295.90 09/16/02 Unspecified 295.91 09/16/02 Subchronic 295.92 09/16/02 Chronic 295.93 09/16/02 Subchronic with acute exacerbation 295.94 09/16/02 Chronic with acute exacerbation 295.95 09/16/02 In remission 296.00 09/16/02 Bipolar I disorder, single manic episode, unspecified 296.01 09/16/02 Bipolar I disorder, single manic episode, mild 296.02 09/16/02 Bipolar I disorder, single manic episode, moderate 296.03 09/16/02 Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior 2

ATTACHMENT A 296.04 09/16/02 Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior 296.05 09/16/02 Bipolar I disorder, single manic episode, in partial or unspecified remission 296.06 09/16/02 Bipolar I disorder, single manic episode, in full remission 296.10 09/16/02 Manic disorder, recurrent episode unspecified 296.11 09/16/02 Manic disorder, recurrent episode mild 296.12 09/16/02 Manic disorder, recurrent episode moderate 296.13 09/16/02 Manic disorder, recurrent episode severe, without mention of psychotic behavior 296.14 09/16/02 Manic disorder, recurrent episode severe, specified as with psychotic behavior 296.15 09/16/02 Manic disorder, recurrent episode in partial or unspecified remission 296.16 09/16/02 Manic disorder, recurrent episode in full remission 296.20 09/16/02 Major depressive disorder, single episode unspecified 296.21 09/16/02 Major depressive disorder, single episode mild 296.22 09/16/02 Major depressive disorder, single episode moderate 296.23 09/16/02 Major depressive disorder, single episode severe, without mention of psychotic behavior 296.24 09/16/02 Major depressive disorder, single episode severe, specified as with psychotic behavior 296.25 09/16/02 Major depressive disorder, single episode in partial or unspecified remission 296.26 09/16/02 Major depressive disorder, single episode in full remission 296.30 09/16/02 Major depressive disorder, recurrent episode unspecified 296.31 09/16/02 Major depressive disorder, recurrent episode mild 296.32 09/16/02 Major depressive disorder, recurrent episode moderate 296.33 09/16/02 Major depressive disorder, recurrent episode severe, without mention of psychotic behavior 296.34 09/16/02 Major depressive disorder, recurrent episode severe, specified as with psychotic behavior 296.35 09/16/02 Major depressive disorder, recurrent episode in partial or unspecified remission 296.36 09/16/02 Major depressive disorder, recurrent episode in full remission 296.40 09/16/02 Bipolar I disorder, most recent episode (or current) manic, unspecified 296.41 09/16/02 Bipolar I disorder, most recent episode (or current) manic, mild 296.42 09/16/02 Bipolar I disorder, most recent episode (or current) manic, moderate 296.43 09/16/02 Bipolar I disorder, most recent episode (or current) manic, 3

ATTACHMENT A severe, without mention of psychotic behavior 296.44 09/16/02 Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior 296.45 09/16/02 Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified remission 296.46 09/16/02 Bipolar I disorder, most recent episode (or current) manic, in full remission 296.50 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, unspecified 296.51 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, mild 296.52 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, moderate 296.53 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior 296.54 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior 296.55 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified remission 296.56 09/16/02 Bipolar I disorder, most recent episode (or current) depressed, in full remission 296.60 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, unspecified 296.61 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, mild 296.62 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, moderate 296.63 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of psychotic behavior 296.64 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior 296.65 09/16/02 Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified remission 296.66 09/16/02 Bipolar I disorder, most recent episode (or current), mixed, in full remission 296.7 09/16/02 Bipolar I disorder, most recent episode (or current), unspecified 296.80 09/16/02 Bipolar disorder, unspecified 296.81 09/16/02 Atypical manic disorder 296.82 09/16/02 Atypical depressive disorder 296.89 09/16/02 Other and unspecified bipolar disorders, other 296.90 09/16/02 Unspecified episode mood disorder 296.99 09/16/02 Other specified episodic mood disorder 4

ATTACHMENT A 297.0 09/16/02 Paranoid state, simple 297.1 09/16/02 Delusional disorder 297.2 09/16/02 Paraphrenia 297.3 09/16/02 Shared psychotic disorder 297.8 09/16/02 Other specified paranoid states 297.9 09/16/02 Unspecified paranoid state 298.0 09/16/02 Depressive type psychoses 298.1 09/16/02 Excitative type psychoses 298.2 09/16/02 Reactive confusion 298.3 09/16/02 Acute paranoid reaction 298.4 09/16/02 Psychogenic paranoid psychosis 298.8 09/16/02 Other and unspecified reactive psychosis 298.9 09/16/02 Unspecified psychosis 299.00 09/16/02 Autistic disorder, current or active state 299.01 09/16/02 Autistic disorder, residual state 299.10 09/16/02 Childhood disintegrative disorder, current or active state 299.11 09/16/02 Childhood disintegrative disorder, residual state 299.80 09/16/02 Other specified pervasive developmental disorders, current or active state 299.81 09/16/02 Other specified pervasive developmental disorders, residual state 299.90 09/16/02 Unspecified pervasive developmental disorders, current or active state 299.91 09/16/02 Unspecified pervasive developmental disorders, residual state 300.00 09/16/02 Anxiety state, unspecified 300.01 09/16/02 Panic disorder without agoraphobia 300.02 09/16/02 Generalized anxiety disorder 300.09 09/16/02 Neurotic disorders other 300.10 09/16/02 Hysteria, unspecified 300.11 09/16/02 Conversion disorder 300.12 09/16/02 Dissociative amnesia 300.13 09/16/02 Dissociative fugue 300.14 09/16/02 Dissociative identity disorder 300.15 09/16/02 Dissociative disorder or reaction, unspecified 300.16 09/16/02 Factitious disorder with predominantly psychological signs and symptoms 300.19 09/16/02 Other and unspecified factitious illness 300.20 09/16/02 Phobia, unspecified 300.21 09/16/02 Agoraphobia with panic disorder 300.22 09/16/02 Agoraphobia without mention of panic attacks 300.23 09/16/02 Social phobia 300.29 09/16/02 Other isolated or specific phobias 5

ATTACHMENT A 300.3 09/16/02 Obsessive-compulsive disorders 300.4 09/16/02 Dysthymic disorder 300.5 09/16/02 Neurasthenia 300.6 09/16/02 Depersonalization disorder 300.7 09/16/02 Hypochondriasis 300.81 09/16/02 Somatization disorder 300.82 09/16/02 Undifferentiated somatoform disorder 300.89 09/16/02 Other somatoform disorders 300.9 09/16/02 Unspecified nonpsychotic mental disorder 301.0 09/16/02 Paranoid personality disorder 301.10 09/16/02 Affective personality disorder, unspecified 301.11 09/16/02 Chronic hypomanic personality disorder 301.12 09/16/02 Chronic depressive personality disorder 301.13 09/16/02 Cyclothymic disorder 301.20 09/16/02 Schizoid personality disorder, unspecified 301.21 09/16/02 Introverted personality 301.22 09/16/02 Schizotypal personality disorder 301.3 09/16/02 Explosive personality disorder 301.4 09/16/02 Obsessive-compulsive personality disorder 301.50 09/16/02 Histrionic personality disorder, unspecified 301.51 09/16/02 Chronic factitious illness with physical symptoms 301.59 09/16/02 Other histrionic personality disorder 301.6 09/16/02 Dependent personality disorder 301.7 09/16/02 Antisocial personality disorder 301.81 09/16/02 Narcissistic personality disorder 301.82 09/16/02 Avoidant personality disorder 301.83 09/16/02 Borderline personality disorder 301.84 09/16/02 Passive-aggressive personality 301.89 09/16/02 Other personality disorder 301.9 09/16/02 Unspecified personality disorder 302.0 09/16/02 Ego-dystonic sexual orientation 302.1 09/16/02 Zoophilia 302.2 09/16/02 Pedophilia 302.3 09/16/02 Transvestic fetishism 302.4 09/16/02 Exhibitionism 302.50 09/16/02 Trans-sexualism with unspecified sexual history 302.51 09/16/02 Trans-sexualism with asexual history 302.52 09/16/02 Trans-sexualism with homosexual history 302.53 09/16/02 Trans-sexualism with heterosexual history 302.6 09/16/02 Gender identity disorder in children 302.70 09/16/02 Psychosexual dysfunction, unspecified 6

ATTACHMENT A 302.71 09/16/02 Hypoactive sexual desire disorder 302.72 09/16/02 Psychosexual dysfunction with inhibited sexual excitement 302.73 09/16/02 Female orgasmic disorder 302.74 09/16/02 Male orgasmic disorder 302.75 09/16/02 Premature ejaculation 302.76 09/16/02 Dyspareunia, psychogenic 302.79 09/16/02 Psychosexual dysfunction with other specified psychosexual dysfunctions 302.81 09/16/02 Fetishism 302.82 09/16/02 Voyeurism 302.83 09/16/02 Sexual masochism 302.84 09/16/02 Sexual sadism 302.85 09/16/02 Gender identity disorder in adolescent or adults 302.89 09/16/02 Other specified psychosexual disorder 302.9 09/16/02 Unspecified psychosexual disorder 307.0 09/16/02 Stuttering 307.20 09/16/02 Tic disorder, unspecified 307.21 09/16/02 Transient tic disorder 307.22 09/16/02 Chronic motor or vocal tic disorder 307.23 09/16/02 Tourette s disorder 307.3 09/16/02 Stereotyped movement disorder 307.40 09/16/02 Nonorganic sleep disorder, unspecified 307.41 09/16/02 Transient disorder of initiating or maintaining sleep 307.42 09/16/02 Persistent disorder of initiating or maintaining sleep 307.43 09/16/02 Transient disorder of initiating or maintaining wakefulness 307.44 09/16/02 Persistent disorder of initiating or maintaining wakefulness 307.45 09/16/02 Circadian rhythm sleep disorder 307.46 09/16/02 Sleep arousal disorder 307.47 09/16/02 Other dysfunctions of sleep stages or arousal from sleep 307.49 09/16/02 Other 307.50 09/16/02 Eating disorder, unspecified 307.6 09/16/02 Enuresis 307.7 09/16/02 Encopresis 307.80 09/16/02 Psychogenic pain, site unspecified 307.9 09/16/02 Psychalgia Other and unspecified special symptoms or syndromes, not elsewhere classified 308.0 09/16/02 Predominant disturbance of emotions 308.1 09/16/02 Predominant disturbance of consciousness 308.2 09/16/02 Predominant psychomotor disturbance 308.3 09/16/02 Other acute reactions to stress 308.4 09/16/02 Mixed disorders as reaction to stress 7

ATTACHMENT A 308.9 09/16/02 Unspecified acute reaction to stress 309.0 09/16/02 Adjustment disorder with depressed mood 309.1 09/16/02 Prolonged depressive reaction 309.21 09/16/02 Separation anxiety disorder 309.22 09/16/02 Emancipation disorder of adolescence and early adult life 309.23 09/16/02 Specific academic or work inhibition 309.24 09/16/02 Adjustment disorder with anxiety 309.28 09/16/02 Adjustment disorder with mixed anxiety and depressed mood 309.29 09/16/02 Other predominant disturbance of other emotions 309.3 09/16/02 Adjustment disorder with disturbance of conduct 309.4 09/16/02 Adjustment disorder with disturbance of emotions and conduct 309.81 09/16/02 Posttraumatic stress disorder 309.82 09/16/02 Adjustment reaction with physical symptoms 309.83 09/16/02 Adjustment reaction with withdrawal 309.89 09/16/02 Other specified adjustment reaction 309.9 09/16/02 Unspecified adjustment reaction 310.0 09/16/02 Frontal lobe syndrome 311 09/16/02 Depressive disorder, not elsewhere classified 312.00 09/16/02 Undersocialized conduct disorder, aggressive type, unspecified 312.01 09/16/02 Undersocialized conduct disorder, aggressive type, mild 312.02 09/16/02 Undersocialized conduct disorder, aggressive type, moderate 312.03 09/16/02 Undersocialized conduct disorder, aggressive type, severe 312.10 09/16/02 Undersocialized conduct disorder, unaggressive type, unspecified 312.11 09/16/02 Undersocialized conduct disorder, unaggressive type, mild 312.12 09/16/02 Undersocialized conduct disorder, unaggressive type, moderate 312.13 09/16/02 Undersocialized conduct disorder, unaggressive type, severe 312.20 09/16/02 Socialized conduct disorder, unspecified 312.21 09/16/02 Socialized conduct disorder, mild 312.22 09/16/02 Socialized conduct disorder, moderate 312.23 09/16/02 Socialized conduct disorder, severe 312.30 09/16/02 Impulse control disorder, unspecified 312.31 09/16/02 Pathological gambling 312.32 09/16/02 Kleptomania 312.33 09/16/02 Pyromania 312.34 09/16/02 Intermittent explosive disorder 312.35 09/16/02 Isolated explosive disorder 312.39 09/16/02 Other 312.4 09/16/02 Mixed disturbance of conduct and emotions 312.81 09/16/02 Conduct disorder, childhood onset type 312.82 09/16/02 Conduct disorder, adolescent onset type 8

ATTACHMENT A 312.89 09/16/02 Other conduct disorder 312.9 09/16/02 Unspecified disturbance of conduct 313.0 09/16/02 Overanxious disorder 313.1 09/16/02 Misery and unhappiness disorder 313.21 09/16/02 Shyness disorder of childhood 313.22 09/16/02 Introverted disorder of childhood 313.23 09/16/02 Selective mutism 313.3 09/16/02 Relationship problems 313.81 09/16/02 Oppositional defiant disorder 313.82 09/16/02 Identity disorder 313.83 09/16/02 Academic underachievement disorder 313.89 09/16/02 Other 313.9 09/16/02 Unspecified emotional disturbance of childhood or adolescence 314.00 09/16/02 Attention deficit disorder Without mention of hyperactivity 314.01 09/16/02 Attention deficit disorder With hyperactivity 314.1 09/16/02 Hyperkinesis with developmental delay 314.2 09/16/02 Hyperkinetic conduct disorder 314.8 09/16/02 Other specified manifestations of hyperkinetic syndrome 314.9 09/16/02 Unspecified hyperkinetic syndrome 315.00 09/16/02 Reading disorder, unspecified 315.01 09/16/02 Alexia 315.02 09/16/02 Developmental dyslexia 315.09 09/16/02 Other 315.1 09/16/02 Mathematics disorder 315.2 09/16/02 Other specific learning difficulties 315.31 09/16/02 Expressive language disorder 315.32 09/16/02 Mixed receptive-expressive language disorder 315.34 10/01/07 Speech and language developmental delay due to hearing loss 315.39 09/16/02 Other 315.4 09/16/02 Developmental coordination disorder 315.5 09/16/02 Mixed development disorder 315.8 09/16/02 Other specified delays in development 315.9 09/16/02 Unspecified delay in development 317 09/16/02 Mild mental retardation 318.0 09/16/02 Moderate mental retardation 318.1 09/16/02 Severe mental retardation 318.2 09/16/02 Profound mental retardation 319 09/16/02 Unspecified mental retardation 9

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. 290.0 09/16/02 Senile dementia, uncomplicated 290.10 09/16/02 Presenile dementia, uncomplicated 290.11 09/16/02 Presenile dementia with delirium 290.12 09/16/02 Presenile dementia with delusional features 290.13 09/16/02 Presenile dementia with depressive features 290.20 09/16/02 Senile dementia with delusional features 290.21 09/16/02 Senile dementia with depressive features 290.3 09/16/02 Senile dementia with delirium 290.40 09/16/02 Vascular dementia, uncomplicated 290.41 09/16/02 Vascular dementia, with delirium 290.42 09/16/02 Vascular dementia, with delusions 290.43 09/16/02 Vascular dementia, with depressed mood 290.8 09/16/02 Other specified senile psychotic conditions 290.9 09/16/02 Unspecified senile psychotic condition 291.0 09/16/02 Alcohol withdrawal delirium 291.1 09/16/02 Alcohol-induced persisting amnestic disorder 291.2 09/16/02 Alcohol-induced persisting dementia 291.3 09/16/02 Alcohol-induced psychotic disorder with hallucinations 291.4 09/16/02 Idiosyncratic alcohol intoxication 291.5 09/16/02 Alcohol-induced psychotic disorder with delusions 291.81 09/16/02 Alcohol withdrawal 291.82 09/16/02 Alcohol-induced sleep disorder 291.89 09/16/02 Other specified alcohol-induced mental disorders 291.9 09/16/02 Unspecified alcohol-induced mental disorders 292.0 09/16/02 Drug withdrawal 292.11 09/16/02 Drug-induced psychotic disorder with delusions 292.12 09/16/02 Drug-induced psychotic disorder with hallucinations 292.2 09/16/02 Pathological drug intoxication 292.81 09/16/02 Drug-induced delirium 292.82 09/16/02 Drug-induced persisting dementia 1

ATTACHMENT B 292.83 09/16/02 Drug-induced persisting amnestic disorder 292.84 09/16/02 Drug-induced mood disorder 292.85 12/01/05 Drug-induced sleep disorder 292.89 09/16/02 Other 292.9 09/16/02 Unspecified drug-induced mental disorder 293.0 09/16/02-12/31/04 Delirium due to conditions classified elsewhere 11/01/08-current 293.1 09/16/02 Subacute delirium 306.0 09/16/02 Physiological malfunction arising from mental factors Musculoskeletal 306.1 09/16/02 Physiological malfunction arising from mental factors Respiratory 306.2 09/16/02 Physiological malfunction arising from mental factors Cardiovascular 306.3 09/16/02 Physiological malfunction arising from mental factors Skin 306.4 09/16/02 Physiological malfunction arising from mental factors Gastrointestinal 306.50 09/16/02 Psychogenic genitourinary malfunction, unspecified 306.51 09/16/02 Psychogenic vaginismus 306.52 09/16/02 Psychogenic dysmenorrhea 306.53 09/16/02 Psychogenic dysuria 306.59 09/16/02 Other 306.6 09/16/02 Endocrine 306.7 09/16/02 Organs of special sense 306.8 09/16/02 Other specified psychophysiological malfunction 306.9 09/16/02 Unspecified psychophysiological malfunction 307.1 09/16/02 Anorexia nervosa 307.48 09/16/02 Repetitive intrusions of sleep 307.51 09/16/02 Bulimia nervosa 307.52 09/16/02 Pica 307.53 09/16/02 Rumination disorder 307.54 09/16/02 Psychogenic vomiting 307.59 09/16/02 Other 307.81 09/16/02 Tension headache 307.89 09/16/02 Other, pain disorder related to psychological factors 310.2 09/16/02 Postconcussion syndrome 310.8 09/16/02 Other specified nonpsychotic mental disorders following organic brain damage 310.9 09/16/02 Unspecified nonpsychotic mental disorder following organic brain damage 316 09/16/02 Psychic factors associated with diseases classified elsewhere 2

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. 038.0 09/16/02-02/28/07 038.10 09/16/02-02/28/07 038.11 09/16/02-02/28/07 Streptococcal septicemia 1 Staphylococcal septicemia, unspecified Methicillin susceptible Staphylococcus aureus septicemia (revised) MSSA septicemia Staphylococcus aureus septicemia NOS Other staphylococcal septicemia 038.19 09/16/02-02/28/07 038.2 06/01/08 Pneumococcal septicemia 038.3 06/01/08 Septicemia due to anaerobes 038.40 09/16/02-02/28/07 Septicemia due to Gram-negative organism, unspecified 038.41 06/01/08 Septicemia due to hemophilus influenzae (H.influenzae) 038.42 09/16/02 Septicemia due to Escherichia coli (E. Coli) 038.43 09/16/02-02/28/07 Septicemia due to Pseudomonas 038.44 06/01/08 Septicemia due to Serratia 038.49 09/16/02 Septicemia due to other gram-negative organisms 038.8 09/16/02 Other specified septicemias 038.9 09/16/02 Unspecified septicemia 250.00 09/16/02 Diabetes mellitus without (w/o) mention of complication, type II or unspecified type, not stated as uncontrolled 250.01 09/16/02 Diabetes mellitus w/o mention of complication type I [juvenile type], not stated as uncontrolled 250.02 09/16/02 Diabetes mellitus w/o mention of complication, type II or unspecified type, uncontrolled 250.03 09/16/02 Diabetes mellitus w/o mention of complication, type I [Juvenile type], uncontrolled 250.10 03/01/07 Diabetes with ketoacidiosis, type II, not stated as uncontrolled 250.11 03/01/07 Diabetes with ketoacidiosis, type I, not stated as uncontrolled 250.12 11/01/08 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled 250.13 03/01/07 Diabetes with ketoacidiosis, type I, uncontrolled 250.20 11/01/08 Diabetes with hyperosmolarity, type II or unspecified type, not

ATTACHMENT C stated as uncontrolled 250.21 11/01/08 Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled 250.22 11/01/08 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled 250.23 11/01/08 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled 250.80 09/16/02 Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled 250.81 01/01/05 Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled 250.82 09/16/02 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled 250.83 09/16/02 Diabetes with other specified manifestations type I [juvenile type], uncontrolled 276.1 06/01/08 Hyposmolality and/or hyponatremia 276.50 10/01/05 Volume Depletion, Unspecified 276.51 10/01/05 Dehydration 276.52 10/01/05 Hypovolemia 276.7 06/01/08 Hyperpotassemia 276.8 06/01/08 Hypopotassemia 280.0 09/16/02 Iron Deficiency anemia Secondary to blood loss (chronic) 280.9 09/16/02 Iron Deficiency anemia, unspecified 401.0 09/16/02 Essential hypertension, malignant 401.9 09/16/02 Essential hypertension, unspecified 403.91 09/16/02 Hypertensive Chronic Kidney disease, Unspecified, with Chronic Kidney Disease Stage V or End Stage Renal Disease 410.00 03/01/07 Acute Myocardial Infarction of Anterolateral wall; Episode of Care Unspecified 410.01 03/01/07 Acute Myocardial Infarction of Anterolateral wall; Initial Episode of Care 410.02 03/01/07 Acute Myocardial Infarction of Anterolateral wall; Subsequent 410.10 03/01/07 Acute Myocardial Infarction of Other Anterior wall; Episode of Care Unspecified 410.11 03/01/07 Acute Myocardial Infarction of Other Anterior wall; Initial 410.12 03/01/07 Acute Myocardial Infarction of Other Anterior wall; Subsequent 410.20 03/01/07 Acute Myocardial Infarction of Inferolateral wall; Unspecified 410.21 03/01/07 Acute Myocardial Infarction of Inferolateral wall; Initial Episode of Care 2

ATTACHMENT C 410.22 03/01/07 Acute Myocardial Infarction of Inferolateral wall; Subsequent 410.30 03/01/07 Acute Myocardial Infarction of Inferoposterior wall; Episode of Care Unspecified 410.31 03/01/07 Acute Myocardial Infarction of Inferoposterior wall; Initial 410.32 03/01/07 Acute Myocardial Infarction of Inferoposterior wall; Subsequent 410.40 03/01/07 Acute Myocardial Infarction of Other Inferior wall; Episode of Care Unspecified 410.41 03/01/07 Acute Myocardial Infarction of Other Inferior wall; Initial Episode of Care 410.42 03/01/07 Acute Myocardial Infarction of Other Inferior wall; Subsequent 410.50 03/01/07 Acute Myocardial Infarction of Other Lateral wall; Episode of Care Unspecified 410.51 03/01/07 Acute Myocardial Infarction of Other Lateral wall; Initial Episode of Care 410.52 03/01/07 Acute Myocardial Infarction of Other Lateral wall; Subsequent episode of Care 410.60 03/01/07 Acute Myocardial Infarction of True Posterior wall; Episode of Care Unspecified 410.61 03/01/07 Acute Myocardial Infarction of True Posterior wall; Initial Episode of Care 410.62 03/01/07 Acute Myocardial Infarction of True Posterior wall; Subsequent 410.70 03/01/07 Acute Myocardial Infarction - Subendocardial Infarction; Episode of Care Unspecified 410.71 03/01/07 Acute Myocardial Infarction - Subendocardial Infarction; Initial 410.72 03/01/07 Acute Myocardial Infarction - Subendocardial Infarction; Subsequent 410.80 03/01/07 Acute Myocardial Infarction of Other Specified Sites; Episode of Care Unspecified 410.81 03/01/07 Acute Myocardial Infarction of Other Specified Sites; Initial 410.82 03/01/07 Acute Myocardial Infarction of Other Specified Sites; Subsequent 410.90 03/01/07 Acute Myocardial Infarction of Unspecified Site; Unspecified 410.91 03/01/07 Acute Myocardial Infarction of Unspecified Site; Initial Episode of Care 410.92 03/01/07 Acute Myocardial Infarction of Unspecified Site; Subsequent 3

ATTACHMENT C 411.0 03/01/07 Post Myocardial Infarction Syndrome 411.1 03/01/07 Intermediate Coronary Syndrome 411.81 03/01/07 Acute Coronary Occlusion without Myocardial Infarction 411.89 03/01/07 Other Ischemic Heart Disease 428.0 03/01/07 Unspecified Congestive Heart Failure 428.1 03/01/07 Left Heart Failure 428.20 03/01/07 Unspecified Systolic Heart Failure 428.21 03/01/07 Acute Systolic Heart Failure 428.22 03/01/07 Chronic Systolic Heart Failure 428.23 03/01/07 Acute on Chronic Systolic Heart Failure 428.30 03/01/07 Unspecified Diastolic Heart Failure 428.31 03/01/07 Acute Diastolic Heart Failure 428.32 03/01/07 Chronic Diastolic Heart Failure 428.33 03/01/07 Acute on Chronic Diastolic Heart Failure 428.40 03/01/07 Unspecified Combined Systolic and Diastolic Heart Failure 428.41 03/01/07 Acute Combined Systolic and Diastolic Heart Failure 428.42 03/01/07 Chronic Combined Systolic and Diastolic Heart Failure 428.43 03/01/07 Acute on Chronic Combined Systolic and Diastolic Heart Failure 428.9 03/01/07 Unspecified Heart Failure 453.40 01/01/05 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity 453.41 01/01/05 Acute venous embolism and thrombosis of proximal lower extremity 453.42 01/01/05 Acute venous embolism and thrombosis of deep vessels of distal lower extremity 453.50 01/01/10 Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity 453.51 01/01/10 Chronic venous embolism and thrombosis of deep vessels of lower of proximal lower extremity 453.52 01/01/10 Chronic venous embolism and thrombosis of deep vessels of lower of distal lower extremity 453.6 01/01/10 Venous embolism and thrombosis of superficial vessels of lower extremity 453.71 01/01/10 Chronic venous embolism and thrombosis of superficial veins of upper extremity 453.72 01/01/10 Chronic venous embolism and thrombosis of deep veins of upper extremity 453.73 01/01/10 Chronic venous embolism and thrombosis of upper extremity, unspecified 453.74 01/01/10 Chronic venous embolism and thrombosis of axillary veins 453.75 01/01/10 Chronic venous embolism and thrombosis of subclavian veins 453.76 01/01/10 Chronic venous embolism and thrombosis of internal jugular veins 4

ATTACHMENT C 453.77 01/01/10 Chronic venous embolism and thrombosis of other thoracic veins 453.79 01/01/10 Chronic venous embolism and thrombosis of other specified veins 453.81 10/01/09 Acute venous embolism and thrombosis of superficial veins of upper extremity 453.82 10/01/09 Acute venous embolism and thrombosis of deep veins of upper extremity 453.83 10/01/09 Acute venous embolism and thrombosis of upper extremity, unspecified 453.84 10/01/09 Acute venous embolism and thrombosis of axillary veins 453.85 10/01/09 Acute venous embolism and thrombosis of subclavian veins 453.86 10/01/09 Acute venous embolism and thrombosis of internal jugular veins 453.87 10/01/09 Acute venous embolism and thrombosis of other thoracic veins 453.89 10/01/09 Acute venous embolism and thrombosis of specified veins 486 09/16/02 Pneumonia, organism unspecified 490 09/16/02 Bronchitis, not specified as acute or chronic 491.20 09/16/02-02/28/07 Obstructive Chronic bronchitis without exacerbation 491.21 09/16/02 Obstructive Chronic bronchitis with acute exacerbation 491.22 01/01/05 Obstructive Chronic bronchitis with acute bronchitis 493.00 03/01/07 Unspecified Extrinsic Asthma 493.01 03/01/07 Extrinsic Asthma with Status Asthmaticus 493.02 03/01/07 Extrinsic Asthma with (acute) Exacerbation 493.10 03/01/07 Unspecified Intrinsic Asthma 493.11 03/01/07 Intrinsic Asthma with Status Asthmaticus 493.12 03/01/07 Intrinsic Asthma with (acute) Exacerbation 493.20 03/01/07 Unspecified Chronic Obstructive Asthma 493.21 03/01/07 Chronic Obstructive Asthma with Status Asthmaticus 493.22 03/01/07 Chronic Obstructive Asthma with (acute) Exacerbation 493.81 03/01/07 Exercise Induced Bronchospasm 493.82 03/01/07 Cough Variant Asthma 493.90 03/01/07 Unspecified Asthma 493.91 03/01/07 Unspecified Asthma with Status Asthmaticus 493.92 03/01/07 Unspecified Asthma with (acute) Exacerbation 496 03/01/07 Chronic Airway Obstruction, not elsewhere classified 530.81 09/16/02 Esophageal reflux 535.00 09/16/02 Acute gastritis without mention of hemorrhage 535.40 09/16/02 Other specified gastritis without mention of hemorrhage 535.50 09/16/02 Unspecified gastritis and gastroduodenitis without mention of hemorrhage 535.70 11/01/08 Eosinophilic gastritis without mention of hemorrhage 535.71 11/01/08 Eosinophilic gastritis with hemorrhage 558.9 09/16/02 Other and unspecified noninfectious gastroenteritis and colitis 571.2 09/16/02 Alcoholic cirrhosis of liver 5

ATTACHMENT C 585.1 10/01/05 Chronic Kidney Disease, Stage I (1) 585.2 10/01/05 Chronic Kidney Disease, Stage II (2) (Mild) 585.3 10/01/05 Chronic Kidney Disease, Stage III (3) (Moderate) 585.4 10/01/05 Chronic Kidney Disease, Stage IV (4) (Severe) 585.5 10/01/05 Chronic Kidney Disease, Stage V (5) 585.6 10/01/05 End Stage Renal Disease 585.9 10/01/05 Chronic Kidney Disease, Unspecified 599.0 09/16/02 Urinary tract infection, site not specified 707.00 01/01/05 Pressure ulcer, unspecified site 707.01 01/01/05 Pressure ulcer, elbow 707.02 01/01/05 Pressure ulcer, upper back 707.03 01/01/05 Pressure ulcer, lower back 707.04 01/01/05 Pressure ulcer, hip 707.05 01/01/05 Pressure ulcer, buttock 707.06 01/01/05 Pressure ulcer, ankle 707.07 01/01/05 Pressure ulcer, heel 707.09 01/01/05 Pressure ulcer, other site 707.10 09/16/02 Ulcer of lower limb, except pressure ulcer, unspecified 707.11 09/16/02-02/28/07 Ulcer of thigh, except pressure ulcer 707.12 09/16/02-02/28/07 Ulcer of calf, except pressure ulcer 707.13 09/16/02 Ulcer of ankle, except pressure ulcer 707.14 09/16/02-02/28/07 Ulcer of heel and midfoot, except pressure ulcer 707.15 09/16/02 Ulcer of other part of foot, except pressure ulcer 707.19 09/16/02 Ulcer of other part of lower limb, except pressure ulcer 707.8 06/01/08 Chronic skin ulcer of other specified sites 707.20 11/01/08 Pressure ulcer, unspecified stage Healing pressure ulcer NOS Healing pressure ulcer, unspecified stage 707.21 11/01/08 Pressure ulcer, stage I Healing pressure ulcer, stage I Pressure pre-ulcer skin changes limited to persistent focal erythema 707.22 11/01/08 Pressure ulcer, stage II Healing pressure ulcer, stage II Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis 707.23 11/01/08 Pressure ulcer, stage III Healing pressure ulcer, stage III Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue 6

ATTACHMENT C 707.24 11/01/08 Pressure ulcer, stage IV Healing pressure ulcer, stage IV Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon or bone 707.25 11/01/08 Pressure ulcer, unstageable 724.2 09/16/02 Lumbago 780.2 09/16/02 Syncope and collapse 780.39 09/16/02 Other convulsions 780.4 09/16/02 Dizziness and giddiness 783.0 09/16/02 Anorexia 786.09 09/16/02 Symptoms involving respiratory system and other chest symptoms, other 786.50 09/16/02 Chest pain unspecified 786.59 09/16/02 Chest pain other 789.00 09/16/02 Abdominal pain unspecified site 789.03 09/16/02 Abdominal pain right lower quadrant 789.04 09/16/02 Abdominal pain left lower quadrant 789.51 06/01/08 Malignant Ascites 789.59 06/01/08 Other Ascites 7

ATTACHMENT D DRG Codes Subject to Prepayment Review DRG Beginning Review 025 09/16/02 Seizure & Headache, Age > 17 years, Without Complications and Comorbidities 134 09/16/02 Hypertension 143 09/16/02 Chest Pain 182 09/16/02 Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age > 17 years, With Complications and Comorbidities 183 09/16/02 Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders, Age > 17 years 184 09/16/02 Esophagitis, Gastroenteritis, & Miscellaneous Digestive Disorders, Age 0-17 years 243 09/16/02 Medical Back Problems 369 09/16/02 Menstrual and Other Female Reproductive System Disorders 381 09/16/02 Abortion with Dilation and Curettage, Aspiration Curettage or Hysterotomy 386 08/01/04 Extreme Immaturity or Respiratory Distress Syndrome 435 09/16/02 Alcohol/Drug Abuse or Dependence, Detoxification or Other Symptomatic Treatment, Without Complications and Comorbidities 468 09/16/02 Extensive OR Procedure Unrelated to Principal Diagnosis 477 09/16/02 Non-Extensive OR Procedure Unrelated to Principal Diagnosis 986 08/01/04 Extreme Immaturity or Respiratory Distress Syndrome 1