Diagnostic Codes That Will Now Be Accepted for Medicare Part B in 13 States

Diagnostic Codes that will now be accepted for Medicare Part B in 13 States

(Changes to Local Coverage Determination L35101, effective retroactively to December 31, 2015)

Claims for the below diagnostic codes submitted by mental health practitioners participating in the Medicare Part B program in 13 states will no longer be denied. Moreover, claims submitted since December 31, 2015, when the policy was enacted, that have been denied will be retroactively approved and paid. These have been updated to reflect DSM-5, the standard manual used in the U.S. to diagnose mental health conditions.

The affected states are Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, and three jurisdictions in Virginia: Arlington and Fairfax Counties, and the City of Alexandria.

Code Disorder Title in DSM-5 Disorder Title in ICD-10-CM

Alcohol withdrawal, without perceptual F10.239 Alcohol dependence with withdrawal, unspeciﬁed disturbances

Tobacco Use Disorder, Moderate F17.200 Nicotine dependence, unspeciﬁed, uncomplicated Tobacco Use Disorder, Severe

F20.9 Schizophrenia Schizophrenia unspeciﬁed

Bipolar 1 Disorder, Current or most recent episode depressed, unspecified Bipolar 1 Disorder, Current or most recent episode hypomanic, unspecified F31.9 Bipolar disorder, unspecified Bipolar 1 Disorder, Current or most recent episode manic, unspecified Bipolar 1 Disorder, Current or most recent episode, unspecified

F32.8 Other speciﬁed depressive disorder Other depressive episodes

Major Depressive Disorder, single Major depressive disorder, single episode, F32.9 episode, unspeciﬁed unspeciﬁed

Major Depressive Disorder, Recurrent F33.9 Major depressive disorder, recurrent, unspeciﬁed episode, unspeciﬁed

F40.00 Agoraphobia Agoraphobia, unspeciﬁed

F40.10 Social Anxiety Disorder (social phobia) Social phobia, unspeciﬁed

F41.9 Unspeciﬁed Anxiety Disorder Anxiety disorder, unspeciﬁed

F43.10 Posttraumatic Stress Disorder Post-traumatic stress disorder, unspeciﬁed

F43.20 Adjustment Disorder, Unspeciﬁed Adjustment disorder, unspeciﬁed

Unspeciﬁed Trauma and Stressor F43.9 Reaction to severe stress, unspeciﬁed Related Disorder

F60.9 Unspeciﬁed Personality Disorder Personality disorder, unspeciﬁed

F68.10 Factitious Disorder Factitious disorder, unspeciﬁed

Developmental disorder of speech and language, F80.9 Language Disorder unspeciﬁed

Unspecified attention- Attention-deficit hyperactivity disorder, unspecified F90.9 deficit/hyperactivity disorder type

F91.9 Conduct disorder, unspeciﬁed onset Conduct disorder, unspeciﬁed

G25.81 Restless Legs Syndrome Restless legs syndrome

Circadian rhythm sleep-wake Circadian rhythm sleep disorder, delayed sleep G47.21 disorders, Delayed sleep phase type phase type

Circadian rhythm sleep-wake Circadian rhythm sleep disorder, advanced sleep G47.22 disorders, Advanced sleep phase type phase type

Circadian rhythm sleep-wake Circadian rhythm sleep disorder, irregular sleep wake G47.23 disorders, Irregular sleep-wake type type

Circadian rhythm sleep-wake G47.24 disorders, Non-24-hour sleep-wake Circadian rhythm sleep disorder, free running type type

Circadian rhythm sleep-wake G47.26 Circadian rhythm sleep disorder, shift work type disorders, Shift work type

Central sleep apnea, Idiopathic central G47.31 Primary central sleep apnea sleep apnea

G47.33 Obstructive sleep apnea hypopnea Obstructive sleep apnea (adult) (pediatric)

Sleep-related hypoventilation, Idiopathic sleep related nonobstructive alveolar G47.34 Idiopathic hypoventilation hypoventilation

Sleep-related hypoventilation, Congenital central alveolar hypoventilation G47.35 Congenital central alveolar syndrome hypoventilation

Sleep-related hypoventilation, Sleep related hypoventilation in conditions classiﬁed G47.36 Comorbid sleep-related elsewhere hypoventilation

Central sleep apnea comorbid with Central sleep apnea in conditions classiﬁed G47.37 opioid use elsewhere

Narcolepsy with cataplexy but without G47.411 Narcolepsy with cataplexy hypocretin deﬁciency

Autosomal dominant cerebellar ataxia, deafness, and narcolepsy Autosomal dominant narcolepsy, G47.419 Narcolepsy without cataplexy obesity, and type 2 diabetes Narcolepsy without cataplexy but with hypocretin deﬁciency

L98.1 Excoriation (skin-picking) Disorder Factitial dermatitis

N94.3 Premenstrual Dysphoric Disorder Premenstrual tension syndrome

Central Sleep Apnea, Cheyne-Stokes R06.3 Periodic breathing Breathing

R41.83 Borderline Intellectual Functioning Borderline intellectual functioning

Antidepressant discontinuation Adverse effect of unspeciﬁed antidepressants, initial T43.205A syndrome, Initial encounter encounter T43.205D Antidepressant discontinuation Adverse effect of unspeciﬁed antidepressants, syndrome, Subsequent encounter subsequent encounter

Antidepressant discontinuation Adverse effect of unspeciﬁed antidepressants, T43.205S syndrome, Sequelae sequela

Other adverse effect of medication, Adverse effect of unspeciﬁed drugs, medicaments T50.905A Initial encounter and biological substances, initial encounter

Other adverse effect of a medication, Adverse effect of unspeciﬁed drugs, medicaments T50.905D Subsequent encounter and biological substances, subsequent encounter

Other adverse effect of a medication, Adverse effect of unspeciﬁed drugs, medicaments T50.905S Sequelae and biological substances, sequela

These additions are reflected in Local Coverage Determination (LCD) L35101. The entire LCD can be found at cms.gov.

To view the full list of psychiatric codes covered, you will ﬁrst be required to accept the terms and conditions of the website. Once you have accepted the conditions, and the LCD page appears, scroll down to the section titled: ICD-10 Codes that Support Medical Necessity. Next to “show entries”, choose “show entries 1-1500.”