RESIDENTIAL TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) CLINICAL POLICY

RESIDENTIAL TREATMENT FOR MENTAL

HEALTH AND SUBSTANCE ABUSE DISORDERS

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare

Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

CONDITIONS OF COVERAGE

Applicable Lines of Business/Products This policy applies to Oxford Commercial plan membership

Benefit Type General benefits package

Referral Required

(Does not apply to non-gatekeeper products)

No Authorization Required

(Precertification always required for inpatient admission) No

1_{- Outpatient}

Yes - Inpatient Precertification with Medical Director

Review Required

Yes Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required)

Residential Center/Facility

Special Considerations 1Precertification is not required for mental health or substance abuse treatment services

performed in an outpatient Residential Treatment Center setting.

Note: Residential treatment, except for professional services, is excluded from coverage for New York Individual Plans and Healthy New York Plans.

Policy Number: BEHAVIORAL 020.9 T2 Effective Date: March 1, 2013

Related Policies:

Early Intervention Program / Birth to Three

Table of Contents CONDITIONS OF COVERAGE... COVERAGE RATIONALE……… BACKGROUND………... APPLICABLE CODES... REFERENCES...

POLICY HISTORY/REVISION INFORMATION...

Policy History Revision Information

Page 1 2 10 11 39 40

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COVERAGE RATIONALE

The following grids provide benefit coverage considerations, including state/federal requirements as applicable, for treatment of mental health and substance use disorders

Connecticut Large and Small Group Plans Coverage

Guidelines

Oxford will provide coverage for mental health or substance abuse residential treatment as indicated below:

 Services must be provided by providers who are certified by the appropriate state agency to provide such services and whose programs for such services have been approved by Oxford.

 Covered services upon confinement in a residential treatment facility1 must be based on an individual treatment plan2_{prescribed by the attending}

physician and approved by Oxford. For the purpose of this benefit, Members must meet all of the following criteria:

1. The Member has a serious mental illness which substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs behavior as manifested by recent disturbed behavior; and

2. Upon an assessment by a physician, psychiatrist, psychologist or clinical social worker, the member cannot be effectively treated in an acute care, partial hospitalization, intensive outpatient or outpatient setting.

1_{"Residential Treatment Facility" means a residential}

treatment center that provides a program of effective Mental Health/Substance Abuse treatment and meets all of the following requirements:

 It is established and operated in accordance with any applicable state law.

 It has or maintains a written, specific and detailed regimen requiring full-time residence and full-time participation by the patient.

 It provides at least the following basic services:  Room and board.

 Evaluation and diagnosis.  Counseling.

 Referral and orientation to specialized community resources.

2_{"Individual Treatment Plan" means a treatment plan}

prescribed by a physician with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program.

Parity Guidelines

Coverage and cost share structure is equal to that of standard medical/surgical benefits, except for the following diagnoses and applicable ICD-9 codes which are excluded from Connecticut parity legislation:

 Family rehabilitation for substance abuse  Mental retardation (317-319)

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) Parity

Guidelines (continued)

 Motor skills disorder (315.4)

 Communication disorders (315.4, 315.31, 315.32, 315.39, 307.9, 307.0)  Caffeine-related disorders (305.9, 292.89, 292.9)

 Relational problems (V61.9, V61.20, V61.10, V61.8, V62.81)

 Additional conditions that may be a focus of clinical attention and are not defined as mental disorders in the DSMIV. (V15.81, V65.2, V71.01, V71.02, V62.89, 780.9, V62.82, V62.3, V62.2x, 313.82, V62.89, V62.4)

Refer to the Member's certificate of coverage and/or health benefits plan documentation for confirmation of applicable benefits and exclusions. Exclusions The following are excluded from coverage:

 Non-medical services and long-term rehabilitation for physical therapy including non-medical and rehabilitation services in a specialized inpatient or residential facility.

 Services for the evaluation or treatment (including remedial education) of: learning disabilities or minimal brain dysfunction; mental retardation; developmental and learning disorders or behavioral problems (except as noted under policy: Early Intervention Program / Birth to Three.

 Behavioral training or cognitive rehabilitation.

 Court ordered services or services that have been ordered as a condition of probation or parole. However, these services may be covered if Oxford agrees that the services are medically necessary, are otherwise covered, the Member has not exhausted their applicable benefit, and the treatment is provided in accordance with our policies and procedures.

New York Plans Coverage

Guidelines

Oxford will provide coverage for mental health or substance abuse residential treatment as indicated below:

 The residential facility must have been established and operated in accordance with the standards pursuant to regulations of the New York Commissioner of Mental Health as defined by subdivision 10 of section 1.03 of the Mental Hygiene Law.

 It provides a program of treatment under the active participation and direction of a Physician and approved by the Mental Health/Substance Use Disorder Designee.

 It has or maintains written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient.

 It provides at least the following basic services in a 24-hour per day, structured milieu:

o Room and board.

o Evaluation and diagnosis. o Counseling

o Referral and orientation to specialized community resources o A Residential Treatment Facility that qualifies as a hospital is

considered a Hospital.

 Services provided in a rehabilitation facility are provided as an alternative to a mental health inpatient day.

 Member must have a biologically based or non-biologically based mental illness as defined by the State of New York - Chapter 748 of the Laws of 2006 ("Timothy's Law").

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Biologically Based Illnesses and Children with Serious Emotional Disturbances:

Coverage parity is required for Biologically Based Mental Illnesses and for Children with Serious Emotional Disorders. These illnesses are defined as the following:

Biologically based (for all ages):  Anorexia nervosa

 Bipolar disorder  Bulimia nervosa  Delusional disorders  Major depression

 Obsessive compulsive disorder  Panic disorder

 Schizophrenia/psychotic disorders

Children with Serious Emotional Disturbances:

Note: Members under the age of eighteen (18) years must have one or more of the following diagnoses and meet the criteria which follow.

 Attention deficit disorders  Disruptive behavior disorders  Pervasive developmental disorders

In addition to the diagnoses listed above, the Member must display one or more of the following symptoms and/or behavioral issues:

 Serious suicidal symptoms or other life-threatening self-destructive behaviors

 Significant psychotic symptoms (hallucinations, delusions, bizarre behaviors)

 Behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage

 Behavior caused by emotional disturbances that placed the child at substantial risk or removal from the household.

Day Limits:

The total amount of days available for either inpatient treatment or residential treatment (or a combination of the two):

 Must be equal to or greater than the amount of days available for medical inpatient admissions when treatment is for a biologically based diagnosis.  Can be less than the amount of days available for medical inpatient

admissions when treatment is for a Non-Biologically Based Diagnosis. Cost Share:

The parity law requires parity with the cost sharing (i.e., deductible, copayments, coinsurance, maximum-out-of-pocket) as well as with day limits. Therefore, regardless of group size and diagnosis (biologically based vs. non biologically based), the cost sharing must always match the medical cost sharing. This applies to both large groups and small groups.

NY Large Group

Plans

NY Large groups automatically have coverage for both biologically based and non-biologically based services as described in the parity section above.

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) NY Small

Group Plans

NY Small groups will automatically receive coverage that will treat all mental illness (both biologically based and non-biologically based) and services for Children with Serious Emotional Disturbances. These services will be limited to the number of days and/or visits shown in the Summary of Benefits.

Small Groups do have the option to purchase a rider that will cover Biologically Based Mental Illness and Services for Children with Serious Emotional Disturbances on a parity basis (like NY large groups). Therefore, small group policies/certificates should always be checked to determine if biologically based parity coverage has been purchased.

IMPORTANT NOTE: Small groups are generally exempt from the requirements of federal mental health parity but there are some exceptions. The small group policies/certificates should always be checked to determine application of the federal mental health parity requirements.

Exclusions

The following are excluded from coverage:

 Residential treatment provided in connection with services for individuals who are:

o Receiving treatment provided in connection with services for

individuals who are presently incarcerated, confined or committed to a local correctional facility or prison, or a custodial facility for youth operated by the office of children and family services, unless authorized by us.

o Seeking mental health care services solely because such services are ordered by a court. (They are covered if the services would otherwise be covered under the certificate.)

 Residential treatment provided in a transitional living facility that does not meet the definition provided under the law cited above.

 Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

 Custodial care, domiciliary care, long-term care, maintenance care, adult day care, or rest cures.

 Services or supplies deemed cosmetic in nature. This also applies to services or supplies deemed cosmetic even if changing or improving an individual's appearance is justified by the individual's mental health needs.  Any services for which the day or visit limit identified in the Summary of

Benefits has been met. This exclusion does not apply to Biologically Based Mental Illness or Children with Serious Emotional Disturbances.

 Room and board, nursing care or personal care which is rendered to assist a Member who, in Oxford's opinion, has reached the maximum level of physical or mental function possible and will not make further significant clinical improvement.

 Care for conditions that by federal, state or local law must be treated in a public facility including, but not limited to, commitments for mental illness. Additionally, to the extent allowed by law, Oxford does not cover care or treatment provided in a non-Network Hospital that is owned or operated by any federal, state or other governmental entity.

 Except for medical emergencies and urgent care, and in-network exceptions, no coverage is available outside our Network of Providers, unless the group has purchased this coverage (only available to large groups).

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Exclusions (continued)

We may consult with professional clinical consultants, peer review committees or other appropriate sources for recommendations and information regarding whether a service or supply meets any of these criteria.

New Jersey Large Group Plans Coverage

Guidelines

Oxford will provide coverage for Intermediate Care1 _{(includes residential care) for}

the treatment of

 Mental Illness: those mental health or psychiatric diagnostic categories that are listed in the current Diagnostic and Statistical Manual of the

American Psychiatric Association, unless those services are specifically

excluded under the Certificate. Mental Illness includes Biologically Based Mental Illness as defined by New Jersey State Law.

 Autism Spectrum Disorder: the pervasive developmental disorders set forth in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, including but not limited to Autistic Disorder, Rett's Disorder, Childhood Disintegrative

Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

 Substance Use Disorders: Covered Services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric

Association, unless those services are specifically excluded. The fact that a

disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Service.

1_Note:

 Intermediate Care is defined as Mental Health or Substance Use Disorder treatment that encompasses care:

o At a Residential Treatment Facility2.

o At a Partial Hospitalization/Day Treatment program. o Through an Intensive Outpatient Treatment program.

 2_{A Residential Treatment facility is a facility which provides a program of}

effective Mental Health Services treatment and which meets all of the following requirements:

o It is established and operated in accordance with subdivision ten of section 1.03 of the mental hygiene law.

o It provides a program of treatment under the active participation and direction of a Physician and approved by Oxford.

o It has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient.

o It provides at least the following basic services in a 24-hour per day, structured milieu:

 Room and board

 Evaluation and diagnosis  Counseling

 Referral and orientation to specialized community resources.

 A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.

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Guidelines

Coverage and cost share structure is equal to that of standard medical/surgical benefits.

NJ Small Group Plans Coverage

Guidelines

Oxford provides coverage for the following conditions when treatment is prescribed by a Licensed Practitioner:

 Mental Illness: A behavioral, psychological or biological dysfunction. Mental illness includes a biologically-based mental illness as well as a mental illness that is not biologically-based.

Note: Mental illness includes biologically based mental illness, which is defined as a condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

The current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association may be consulted to identify conditions that are considered mental illness.  Substance Abuse

Inpatient or day treatment may be furnished by any licensed, certified or State approved facility, including but not limited to a:

o Hospital

o Detoxification Facility licensed under New Jersey P.L. 1975, Chapter 305; or

o Licensed, certified or state approved residential treatment Facility under a program which meets the minimum standards of care of the Joint Commission;

o Mental Health Center: A facility which mainly provides treatment for people with Mental Illness. Oxford will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:

 Accredited for its stated purpose by the Joint Commission;  Approved for its stated purpose by Medicare; or

 Accredited or licensed by the state of New Jersey to provide mental health services.

o Substance Abuse Center: Facilities that mainly provide treatment for people with substance abuse problems. Oxford will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:

 Accredited for its stated purpose by the Joint Commission; or

 Approved for its stated purpose by Medicare. Parity

Guidelines

Coverage and cost share structure is equal to that of standard medical/surgical benefits.

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Exclusions Oxford does not pay for Custodial Care, education or training.

New Jersey Individual Plans (Except NJ Basic & Essential Plans) Coverage

Guidelines

Oxford provides coverage for the following conditions when treatment is prescribed by a Licensed Practitioner:

 Alcohol Abuse

 Biologically Based Mental Illnesses  Non-Biologically-based Mental Illnesses  Substance Abuse

Alcohol Abuse

Treatment may be furnished by: 1. Hospital

2. Detoxification Facility licensed under New Jersey P.L. 1975, Chapter 305; or

3. Licensed, certified or state approved residential treatment facility under a program which meets the minimum standards of care of the Joint Commission.

The following definitions apply:

 Biologically-based Mental Illness means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.  Non-Biologically-based Mental Illness means an Illness which manifests

symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, we may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

 Substance Abuse Centers are Facilities that mainly provide treatment for people with substance abuse problems. We will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:

a. Accredited for its stated purpose by the Joint Commission; or b. Approved for its stated purpose by Medicare.

Treatment for biologically based mental illness are covered through a Member's general benefits package and are not subject to annual limitations or maximums except as otherwise provided in the Member's certificate of coverage.

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Guidelines (continued)

codes as well as the Coverage Guidelines above for additional information. All conditions not classified as biologically based (in the Coverage Guidelines above) are considered non-biologically based, and as such, may be subject to coverage and cost share structures individually defined by the Member's certificate of coverage. Parity guidelines do not apply. Refer to theCoverage Guidelines

section above for additional information on the coverage for non-biologically based conditions.

Exclusions Oxford does not pay for Custodial Care, education, or training. New Jersey Individual Basic & Essential Plans Coverage

Guidelines Oxford provides coverage for the following conditions when treatment is prescribed _{by a Licensed Practitioner:}  Alcohol Abuse and Substance Abuse

 Biologically Based Mental Illnesses

Coverage is provided on an inpatient or outpatient basis, as outlined in the Member’s Certificate of Coverage.

The following definitions apply:

 Alcohol Abuse: Abuse of or addiction to alcohol. Alcohol Abuse does not include abuse of or addiction to drugs. Please see the definition of

Substance Abuse.

 Biologically-based Mental Illness: means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.  Hospital: A Facility which mainly provides Inpatient care for Ill or Injured

people. We will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:

o Accredited as a Hospital by the Joint Commission; or o Approved as a Hospital by Medicare.

Among other things, a Hospital is not a convalescent, rest or nursing home or Facility, or a Facility, or part of it, which mainly provides Custodial Care, educational care or rehabilitative care. A Facility for the aged or for Substance Abusers is not a Hospital. A specialty Facility is also not a Hospital.

 Non-Biologically-based Mental Illness means an Illness which manifests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, we may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric

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BACKGROUND

Oxford administers benefit coverage for residential rehabilitation, detoxification, and/or mental health treatment in coordination with OptumHealth Behavioral Solutions. United Behavioral Health (UBH) has developed level of care (LOC) guidelines which are used for purposes of clinical guidance, utilization management and medical necessity determinations, where applicable. The LOC guidelines ensure that services are essential and appropriate, and reflect empirically validated approaches.

 United Behavioral Health: Level of Care Guidelines: Introduction  United Behavioral Health: Level of Care Guidelines: Index

For those Members with coverage for residential rehabilitation, detoxification, and/or mental health treatment, as outlined above, requests for precertification are reviewed by licensed professionals.

Definitions:

Legislative "Parity" Mandate: "Equality" in the administration of medical and behavioral health

benefits. Affected inpatient and outpatient behavioral health benefits for conditions determined to be organic or biologic in origin need to be equivalent to the medical benefits in the following three ways:

 The copayment or coinsurance is equal to medical coverage; and  Benefit limits (day and visit) are equal to medical/surgical coverage; and

 Precertification requirements are structured in a manner equivalent to medical coverage (based on site of service, level of care, and certificate of coverage/health benefits plan documentation).

Coverage Guidelines (continued)

Association.

 Substance Abuse: Abuse of or addiction to drugs. Substance Abuse does not include abuse of or addiction to alcohol. Please see the definition of Alcohol Abuse.

 Substance Abuse Centers: are Facilities that mainly provide treatment for people with substance abuse problems. We will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:

o Accredited for its stated purpose by the Joint Commission; or o Approved for its stated purpose by Medicare.

State and Federal mental health parity guidelines do not apply to the Basic & Essential Plans. Covered benefits are subject to the cost shares and limitations outlined in the Member’s Certificate of Coverage.

Refer to theApplicable Codessection for a list of biologically based diagnosis codes as well as theCoverage Guidelinesabove for additional information. All conditions not classified as biologically based (in the Coverage Guidelines above) are considered non-biologically based, and as such, are not covered. Exclusions Oxford does not pay for:

 Custodial Care, education, or training.

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013)

Residential mental health treatment services are provided in a facility or a freestanding

residential treatment center that provides overnight mental health services for Members who do not require acute inpatient care but who do require 24-hour structure.

Residential detoxification is comprised of services that are provided in a residential setting

other than an acute care hospital for the purpose of completing a medically safe withdrawal from substances. Residential Detoxification is typically indicated when withdrawal is severe enough to warrant 24-hour care, but on-site access to medical personnel is not essential.

Residential rehabilitation is comprised of acute overnight services that are typically provided in

a freestanding residential treatment center for the care of a substance use disorder. A residential rehabilitation program is typically intended for when a Member lacks the motivation or social support system to remain abstinent, but does not require the structure and intensity of services provided in a hospital. Additionally, these facilities may provide treatment for mental illness, both biologically based and non biologically based.

APPLICABLE CODES

The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.

Applicable ICD-9 Diagnosis Codes - NY Parity – Biologically Based Mental Illness ICD-9 Code

Range Description

295.0x Schizophrenic disorders, simple type 295.1x Schizophrenic disorders, disorganized type 295.2x Schizophrenic disorders, catatonic type 295.3x Schizophrenic disorders, paranoid type

295.4x Schizophrenic disorders, schizophreniform disorder 295.5x Schizophrenic disorders, latent schizophrenia 295.6x Schizophrenic disorders, residual type

295.7x Schizophrenic disorders, schizoaffective disorder 295.8x Schizophrenic disorders, other specified types 295.9x Schizophrenic disorders, unspecified

296.0x Episodic mood disorders, bipolar I disorder, single manic episode 296.1x Episodic mood disorders, manic disorder, recurrent episode

296.2x Episodic mood disorders, major depressive disorder, single episode 296.3x Episodic mood disorders, major depressive disorder, recurrent episode 296.4x Episodic mood disorders, bipolar I disorder, most recent episode (or current)

manic

296.5x Episodic mood disorders, bipolar I disorder, most recent episode (or current) depressed

296.6x Episodic mood disorders, bipolar I disorder, most recent episode (or current) mixed

296.7 Episodic mood disorders, bipolar I disorder, most recent episode (or current) unspecified

296.8x Episodic mood disorders, other and unspecified bipolar disorders 296.9x Episodic mood disorders, other and unspecified episodic mood disorder

297.1 Delusional disorders, delusional disorder 297.3 Delusional disorders, shared psychotic disorder

298.8 Other nonorganic psychoses, other and unspecified reactive psychosis 298.9 Other nonorganic psychoses, unspecified psychosis

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ICD-9 Code

agoraphobia

300.21 Phobic disorders, agoraphobia with panic disorder 300.3 Obsessive-compulsive disorders

307.1 Anorexia nervosa 307.51 Bulimia nervosa

Applicable ICD-9 Diagnosis Codes - NY Parity –Children with Serious Emotional Disturbances

ICD-9 Code

299.00 Pervasive developmental disorders, autistic disorder, current or active state 299.10 Pervasive developmental disorders, childhood disintegrative disorder, current or

active state

299.80 Pervasive developmental disorders, other specified, current or active state 312.0x Disturbance of conduct, undersocialized conduct disorder, aggressive type 312.1x Disturbance of conduct, undersocialized conduct disorder, unaggressive type 312.2x Disturbance of conduct, socialized conduct disorder

312.3x Disturbance of conduct, disorders of impulse control

312.4x Disturbance of conduct, mixed disturbance of conduct and emotions 312.8x Disturbance of conduct, other specified

312.9 Disturbance of conduct, unspecified 313.81 Oppositional defiant disorder

314.0x Hyperkinetic syndrome of childhood, attention deficit disorder

314.1 Hyperkinetic syndrome of childhood, hyperkinesis with developmental delay 314.2 Hyperkinetic syndrome of childhood, hyperkinetic conduct disorder

314.8 Hyperkinetic syndrome of childhood, other specified manifestations 314.9 Hyperkinetic syndrome of childhood, unspecified

Applicable ICD-9 Diagnosis Codes - NJ Parity – Biologically Based Mental Illness ICD-9 Code

290.2x Senile dementia with delusional or depressive features 291.xx Alcohol-induced mental disorders

295.xx Schizophrenic disorders 296.xx Episodic mood disorders 297.xx Delusional disorders

299.xx Pervasive developmental disorders 300.00 Anxiety state, unspecified

300.01 Panic disorder without agoraphobia 300.02 Generalized anxiety disorder 300.09 Other anxiety states

300.21 Agoraphobia with panic disorder 300.3 Obsessive-compulsive disorders 303.xx Alcohol dependence syndrome 305.0x Nondependent alcohol abuse

Applicable ICD-9 Code Ranges for Mental Health and Substance Abuse ICD-9 Code

Range

Description 290-294 Organic psychotic conditions

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) ICD-9 Code

Range

Description 295-299 Other psychoses

300-316 Neurotic disorders, personality disorders, and other nonpsychotic mental _disorders

ICD-10 Codes (Preview Draft)

In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2014* , a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change.

Applicable ICD-10 Codes - CT Parity Exclusions ICD-10 Diagnosis Code (Effective 10/01/14) Description

F11.159 Opioid abuse with opioid-induced psychotic disorder, unspecified F11.181 Opioid abuse with opioid-induced sexual dysfunction

F11.188 Opioid abuse with other opioid-induced disorder F11.19 Opioid abuse with unspecified opioid-induced disorder

F11.222 Opioid dependence with intoxication with perceptual disturbance F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified F11.281 Opioid dependence with opioid-induced sexual dysfunction

F11.288 Opioid dependence with other opioid-induced disorder F11.29 Opioid dependence with unspecified opioid-induced disorder F11.922 Opioid use, unspecified with intoxication with perceptual disturbance F11.959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified F11.981 Opioid use, unspecified with opioid-induced sexual dysfunction

F11.988 Opioid use, unspecified with other opioid-induced disorder F11.99 Opioid use, unspecified with unspecified opioid-induced disorder F12.122 Cannabis abuse with intoxication with perceptual disturbance F12.159 Cannabis abuse with psychotic disorder, unspecified

F12.180 Cannabis abuse with cannabis-induced anxiety disorder F12.188 Cannabis abuse with other cannabis-induced disorder

F12.19 Cannabis abuse with unspecified cannabis-induced disorder F12.222 Cannabis dependence with intoxication with perceptual disturbance F12.259 Cannabis dependence with psychotic disorder, unspecified

F12.280 Cannabis dependence with cannabis-induced anxiety disorder F12.288 Cannabis dependence with other cannabis-induced disorder

F12.29 Cannabis dependence with unspecified cannabis-induced disorder F12.922 Cannabis use, unspecified with intoxication with perceptual disturbance F12.959 Cannabis use, unspecified with psychotic disorder, unspecified

F12.980 Cannabis use, unspecified with anxiety disorder

F12.988 Cannabis use, unspecified with other cannabis-induced disorder F12.99 Cannabis use, unspecified with unspecified cannabis-induced disorder F13.159 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-_{induced psychotic disorder, unspecified} F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-_{induced anxiety disorder}

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ICD-10 Diagnosis Code (Effective 10/01/14) Description

F13.181 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-_{induced sexual dysfunction} F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-_{induced disorder}

F13.19 Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or _{anxiolytic-induced disorder} F13.259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-_{induced psychotic disorder, unspecified} F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-_{induced anxiety disorder} F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-_{induced sexual dysfunction} F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or _{anxiolytic-induced disorder}

F13.29 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic _{or anxiolytic-induced disorder} F13.959 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or _{anxiolytic-induced psychotic disorder, unspecified} F13.980 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or _{anxiolytic-induced anxiety disorder} F13.981 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or _{anxiolytic-induced sexual dysfunction} F13.988 Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or _{anxiolytic-induced disorder}

F13.99 Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, _{hypnotic or anxiolytic-induced disorder} F14.122 Cocaine abuse with intoxication with perceptual disturbance

F14.159 Cocaine abuse with cocaine-induced psychotic disorder, unspecified F14.180 Cocaine abuse with cocaine-induced anxiety disorder

F14.181 Cocaine abuse with cocaine-induced sexual dysfunction F14.188 Cocaine abuse with cocaine-induced sexual dysfunction

F14.19 Cocaine abuse with unspecified cocaine-induced disorder

F14.222 Cocaine dependence with intoxication with perceptual disturbance

F14.259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified F14.280 Cocaine dependence with cocaine-induced anxiety disorder

F14.281 Cocaine dependence with cocaine-induced sexual dysfunction F14.288 Cocaine dependence with other cocaine-induced disorder

F14.29 Cocaine dependence with unspecified cocaine-induced disorder F14.922 Cocaine use, unspecified with intoxication with perceptual disturbance

F14.959 Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified F14.980 Cocaine use, unspecified with cocaine-induced anxiety disorder

F14.981 Cocaine use, unspecified with cocaine-induced sexual dysfunction F14.988 Cocaine use, unspecified with other cocaine-induced disorder

F14.99 Cocaine use, unspecified with unspecified cocaine-induced disorder F15.19 Other stimulant abuse with unspecified stimulant-induced disorder F15.29 Other stimulant dependence with unspecified stimulant-induced disorder F15.99 Other stimulant use, unspecified with unspecified stimulant-induced disorder F16.19 Hallucinogen abuse with unspecified hallucinogen-induced disorder

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) ICD-10 Diagnosis Code (Effective 10/01/14) Description

F16.99 Hallucinogen use, unspecified with unspecified hallucinogen-induced disorder F17.209 Nicotine dependence, unspecified, with unspecified nicotine-induced disorders F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders F17.229 Nicotine dependence, chewing tobacco, with unspecified nicotine-induced _disorders F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine-induced _disorders

F18.10 Inhalant abuse, uncomplicated

F18.120 Inhalant abuse with intoxication, uncomplicated

F18.19 Inhalant abuse with unspecified inhalant-induced disorder F18.29 Inhalant dependence with unspecified inhalant-induced disorder F18.90 Inhalant use, unspecified, uncomplicated

F18.99 Inhalant use, unspecified with unspecified inhalant-induced disorder F19.10 Other psychoactive substance abuse, uncomplicated

F19.19 Other psychoactive substance abuse with unspecified psychoactive substance-_{induced disorder} F19.29 Other psychoactive substance dependence with unspecified psychoactive _{substance-induced disorder} F19.99 Other psychoactive substance use, unspecified with unspecified psychoactive _{substance-induced disorder}

F55.0 Abuse of antacids

F55.1 Abuse of herbal or folk remedies F55.2 Abuse of laxatives

F55.3 Abuse of steroids or hormones F55.4 Abuse of vitamins

F55.8 Abuse of other non-psychoactive substances F63.3 Trichotillomania

F63.89 Other impulse disorders

F64.9 Gender identity disorder, unspecified F70 Mild intellectual disabilities

F71 Moderate intellectual disabilities F72 Severe intellectual disabilities F73 Profound intellectual disabilities F78 Other intellectual disabilities F79 Unspecified intellectual disabilities F80.0 Phonological disorder

F80.1 Expressive language disorder

F80.2 Mixed receptive-expressive language disorder

F80.89 Other developmental disorders of speech and language F80.9 Developmental disorder of speech and language, unspecified F81.0 Specific reading disorder

F81.0 Specific reading disorder F81.2 Mathematics disorder

F81.81 Disorder of written expression

F81.89 Other developmental disorders of scholastic skills F81.9 Developmental disorder of scholastic skills, unspecified

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ICD-10 Diagnosis Code (Effective 10/01/14) Description

F89 Unspecified disorder of psychological development F93.8 Other childhood emotional disorders

F98.5 Adult onset fluency disorder

H93.25 Central auditory processing disorder R41.0 Disorientation, unspecified

R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia

R41.82 Altered mental status, unspecified R41.83 Borderline intellectual functioning R41.83 Borderline intellectual functioning

R41.9 Unspecified symptoms and signs involving cognitive functions and awareness R45.1 Restlessness and agitation

R45.81 Low self-esteem R45.82 Worries

R45.83 Excessive crying of child, adolescent or adult R45.84 Anhedonia

R48.0 Dyslexia and alexia R52 Pain, unspecified

R68.11 Excessive crying of infant (baby) R68.12 Fussy Infant (baby)

R68.81 Early satiety

R68.89 Other general symptoms and signs

Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Z55.0 Illiteracy and low-level literacy

Z55.1 Schooling unavailable and unattainable Z55.2 Failed school examinations

Z55.3 Underachievement in school

Z55.4 Educational maladjustment and discord with teachers and classmates Z55.8 Other problems related to education and literacy

Z55.9 Problems related to education and literacy, unspecified Z56.1 Change of job

Z56.82 Military deployment status

Z56.89 Other problems related to employment

Z60.0 Problems of adjustment to life-cycle transitions Z60.3 Acculturation difficulty

Z60.4 Social exclusion and rejection

Z60.5 Target of (perceived) adverse discrimination and persecution Z60.8 Other problems related to social environment

Z60.9 Problem related to social environment, unspecified Z62.22 Institutional upbringing

Z62.29 Other upbringing away from parents Z62.891 Sibling rivalry

Z63.0 Problems in relationship with spouse or partner Z63.1 Problems in relationship with in-laws

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) ICD-10 Diagnosis Code (Effective 10/01/14) Description

Z63.32 Other absence of family member

Z63.4 Disappearance and death of family member

Z63.71 Stress on family due to return of family member from military deployment Z63.8 Other specified problems related to primary support group

Z63.9 Problem related to primary support group, unspecified Z64.4 Discord with counselors

Z65.4 Victim of crime and terrorism

Z65.5 Exposure to disaster, war and other hostilities

Z65.8 Other specified problems related to psychosocial circumstances Z71.89 Other specified counseling

Z71.89 Other specified counseling

Z72.810 Child and adolescent antisocial behavior Z72.811 Adult antisocial behavior

Z73.3 Stress, not elsewhere classified

Z73.4 Inadequate social skills, not elsewhere classified Z73.5 Social role conflict, not elsewhere classified Z73.6 Limitation of activities due to disability Z76.5 Malingerer [conscious simulation]

Z91.11 Patient's noncompliance with dietary regimen

Z91.120 Patient's intentional underdosing of medication regimen due to financial hardship Z91.128 Patient's intentional underdosing of medication regimen for other reason

Z91.130 Patient's unintentional underdosing of medication regimen due to age-related _debility Z91.138 Patient's unintentional underdosing of medication regimen for other reason

Z91.14 Patient's other noncompliance with medication regimen

Z91.19 Patient's noncompliance with other medical treatment and regimen Applicable ICD-10 Diagnosis Codes - NY Parity – Biologically Based Mental Illness

ICD-10 Code Range (Effective 10/01/14) Description F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.5 Residual schizophrenia F20.81 Schizophreniform disorder F20.89 Other schizophrenia F20.9 Schizophrenia, unspecified F22 Delusional disorders F23 Brief psychotic disorder F24 Shared psychotic disorder

F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type

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ICD-10 Code Range (Effective 10/01/14) Description

F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified

F28 Other psychotic disorder not due to a substance or known physiological _condition F29 Unspecified psychosis not due to a substance or known physiological condition F30.10 Manic episode without psychotic symptoms, unspecified

F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms

F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission

F30.4 Manic episode in full remission F30.8 Other manic episodes

F30.9 Manic episode, unspecified

F31.0 Bipolar disorder, current episode hypomanic

F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe

F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, _unspecified F31.31 Bipolar disorder, current episode depressed, mild

F31.32 Bipolar disorder, current episode depressed, moderate

F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified

F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate

F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic

F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31.77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in full remission, most recent episode mixed F31.81 Bipolar II disorder

F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified

F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) ICD-10 Code Range (Effective 10/01/14) Description

F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission

F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes

F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressive disorder, recurrent, mild

F33.1 Major depressive disorder, recurrent, moderate

F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified

F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission

F33.8 Other recurrent depressive disorders

F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified

F39 Unspecified mood [affective] disorder F40.01 Agoraphobia with panic disorder

F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia F42 Obsessive-compulsive disorder

F50.00 Anorexia nervosa, unspecified F50.01 Anorexia nervosa, restricting type

F50.02 Anorexia nervosa, binge eating/purging type F50.2 Bulimia nervosa

Applicable ICD-10 Diagnosis Codes - NY Parity –Children with Serious Emotional Disturbances ICD-10 Code Range (Effective 10/01/14) Description F63.0 Pathological gambling F63.1 Pyromania F63.2 Kleptomania F63.3 Trichotillomania

F63.81 Intermittent explosive disorder F63.89 Other impulse disorders

F63.9 Impulse disorder, unspecified F84.0 Autistic disorder

F84.3 Other childhood disintegrative disorder F84.5 Asperger's syndrome

F84.8 Other pervasive developmental disorders

F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type F90.2 Attention-deficit hyperactivity disorder, combined type

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ICD-10 Code Range (Effective 10/01/14) Description

F90.8 Attention-deficit hyperactivity disorder, other type F90.9 Attention-deficit hyperactivity disorder, unspecified type F91.0 Conduct disorder confined to family context

F91.1 Conduct disorder, childhood-onset type F91.2 Conduct disorder, adolescent-onset type F91.3 Oppositional defiant disorder

F91.8 Other conduct disorders F91.9 Conduct disorder, unspecified

Applicable ICD-10 Diagnosis Codes - NJ Parity – Biologically Based Mental Illness ICD-10 Code

Range (Effective

10/01/14)

Description F03.90 Unspecified dementia without behavioral disturbance

F05 Delirium due to known physiological condition F10.10 Alcohol abuse, uncomplicated

F10.120 Alcohol abuse with intoxication, uncomplicated F10.121 Alcohol abuse with intoxication delirium F10.129 Alcohol abuse with intoxication, unspecified

F10.14 Alcohol abuse with alcohol-induced mood disorder

F10.150 Alcohol abuse with alcohol-induced psychotic disorder with delusions F10.151 Alcohol abuse with alcohol-induced psychotic disorder with hallucinations F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified F10.180 Alcohol abuse with alcohol-induced anxiety disorder

F10.181 Alcohol abuse with alcohol-induced sexual dysfunction F10.182 Alcohol abuse with alcohol-induced sleep disorder F10.188 Alcohol abuse with other alcohol-induced disorder

F10.19 Alcohol abuse with unspecified alcohol-induced disorder F10.20 Alcohol dependence, uncomplicated

F10.21 Alcohol dependence, in remission

F10.220 Alcohol dependence with intoxication, uncomplicated F10.221 Alcohol dependence with intoxication delirium F10.229 Alcohol dependence with intoxication, unspecified F10.230 Alcohol dependence with withdrawal, uncomplicated F10.231 Alcohol dependence with withdrawal delirium

F10.232 Alcohol dependence with withdrawal with perceptual disturbance F10.239 Alcohol dependence with withdrawal, unspecified

F10.24 Alcohol dependence with alcohol-induced mood disorder

F10.250 Alcohol dependence with alcohol-induced psychotic disorder with delusions F10.251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations F10.259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified

F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder F10.27 Alcohol dependence with alcohol-induced persisting dementia

F10.280 Alcohol dependence with alcohol-induced anxiety disorder F10.281 Alcohol dependence with alcohol-induced sexual dysfunction

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Residential Treatment for Mental Health and Substance Abuse Disorders: Clinical Policy (Effective 03/01/2013) ICD-10 Code Range (Effective 10/01/14) Description

F10.282 Alcohol dependence with alcohol-induced sleep disorder F10.288 Alcohol dependence with other alcohol-induced disorder

F10.29 Alcohol dependence with unspecified alcohol-induced disorder F10.920 Alcohol use, unspecified with intoxication, uncomplicated F10.921 Alcohol use, unspecified with intoxication delirium F10.929 Alcohol use, unspecified with intoxication, unspecified

F10.94 Alcohol use, unspecified with alcohol-induced mood disorder

F10.950 Alcohol use, unspecified with alcohol-induced psychotic disorder with delusions F10.951 Alcohol use, unspecified with alcohol-induced psychotic disorder with _{hallucinations}

F10.959 Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified F10.96 Alcohol use, unspecified with alcohol-induced persisting amnestic disorder F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia

F10.980 Alcohol use, unspecified with alcohol-induced anxiety disorder F10.981 Alcohol use, unspecified with alcohol-induced sexual dysfunction F10.982 Alcohol use, unspecified with alcohol-induced sleep disorder F10.988 Alcohol use, unspecified with other alcohol-induced disorder

F10.99 Alcohol use, unspecified with unspecified alcohol-induced disorder F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.5 Residual schizophrenia F20.81 Schizophreniform disorder F20.89 Other schizophrenia F20.9 Schizophrenia, unspecified F22 Delusional disorders F23 Brief psychotic disorder F24 Shared psychotic disorder

F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type F25.8 Other schizoaffective disorders

F25.9 Schizoaffective disorder, unspecified

F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms

F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission

F30.4 Manic episode in full remission F30.8 Other manic episodes

F30.9 Manic episode, unspecified

F31.0 Bipolar disorder, current episode hypomanic

F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe

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ICD-10 Code Range (Effective

10/01/14)

Description