CSHCS Qualifying Diagnoses Effective 10/01/2021

Medical Review Code Begin ICD-10 Code Description Period Code End Date Date A1854 Tuberculous iridocyclitis 2 A507 Late congenital syphilis, unspecified 5 A925 Zika virus disease 2 01/01/2016 B20 Human immunodeficiency virus [HIV] disease 5 B259 Cytomegaloviral disease, unspecified 5 B393 Disseminated histoplasmosis capsulati 2 B399 Histoplasmosis, unspecified 2 B900 Sequelae of central nervous system tuberculosis 5 B902 Sequelae of tuberculosis of and joints 3 B909 Sequelae of respiratory and unspecified tuberculosis 3 B91 Sequelae of poliomyelitis 5 B941 Sequelae of viral encephalitis 5 B942 Sequelae of viral hepatitis 2 B948 Sequelae of other specified infectious and parasitic diseases 2 C029 Malignant neoplasm of tongue, unspecified 5 C039 Malignant neoplasm of gum, unspecified 5 C051 Malignant neoplasm of soft palate 5 C080 Malignant neoplasm of submandibular gland 5 C089 Malignant neoplasm of major salivary gland, unspecified 5 C118 Malignant neoplasm of overlapping sites of nasopharynx 5 C119 Malignant neoplasm of nasopharynx, unspecified 5 C169 Malignant neoplasm of stomach, unspecified 5 C179 Malignant neoplasm of small intestine, unspecified 5 C188 Malignant neoplasm of overlapping sites of colon 5 C189 Malignant neoplasm of colon, unspecified 5 C19 Malignant neoplasm of rectosigmoid junction 5 C210 Malignant neoplasm of anus, unspecified 5 C220 Liver cell carcinoma 5 C222 Hepatoblastoma 5 C223 Angiosarcoma of liver 5 C224 Other sarcomas of liver 5 C227 Other specified carcinomas of liver 5 C228 Malignant neoplasm of liver, primary, unspecified as to type 5 C229 Malignant neoplasm of liver, not specified as primary or secondary 5 C249 Malignant neoplasm of biliary tract, unspecified 5 C252 Malignant neoplasm of tail of pancreas 5 C254 Malignant neoplasm of endocrine pancreas 5 C259 Malignant neoplasm of pancreas, unspecified 5

1 CSHCS Qualifying Diagnoses Effective 10/01/2021

C300 Malignant neoplasm of nasal cavity 5 C319 Malignant neoplasm of acessory sinus, unspecified 5 C329 Malignant neoplasm of larynx, unspecified 5 C3490 Malignant neoplasm of unspecified part of unspecified bronchus or lung 5 C380 Malignant neoplasm of heart 5 C383 Malignant neoplasm of mediastinum, part unspecified 5 C384 Malignant neoplasm of pleura 5 C4010 Malignant neoplasm of short bones of unspecified upper limb 5 C4020 Malignant neoplasm of long bones of unspecified lower limb 5 C4030 Malignant neoplasm of short bones of unspecified lower limb 5

C4080 Malignant neoplasm of overlapping sites of and articular cartilage of unspecified limb 5 C410 Malignant neoplasm of bones of skull and face 5 C411 Malignant neoplasm of mandible 5 C412 Malignant neoplasm of vertebral column 5 C413 Malignant neoplasm of ribs, sternum and clavicle 5 C414 Malignant neoplasm of pelvic bones, sacrum and coccyx 5 C419 Malignant neoplasm of bone and articular cartilage, unspecified 5 C4370 Malignant melanoma of unspecified lower limb, including hip 5 C439 Malignant melanoma of skin, unspecified 5 C44201 Unspecified malignant neoplasm of skin of unspecified ear and external auricular canal 5 C44291 Other specified malignant neoplasm of skin of unspecified ear and external auricular canal 5 C44300 Unspecified malignant neoplasm of skin of unspecified part of face 5 C44301 Unspecified malignant neoplasm of skin of nose 5 C44309 Unspecified malignant neoplasm of skin of other parts of face 5 C44390 Other specified malignant neoplasm of skin of unspecified parts of face 5 C44391 Other specified malignant neoplasm of skin of nose 5 C44399 Other specified malignant neoplasm of skin of other parts of face 5 C4490 Unspecified malignant neoplasm of skin, unspecified 5 C4491 Basal cell carcinoma of skin, unspecified 5 C4492 Squamous cell carcinoma of skin, unspecified 5 C4499 Other specified malignant neoplasm of skin, unspecified 5 C457 Mesothelioma of other sites 5 C459 Mesothelioma, unspecified 2 C470 Malignant neoplasm of peripheral nerves of head, face and neck 5 C4710 Malignant neoplasm of peripheral nerves of unspecified upper limb, including shoulder 5 C4720 Malignant neoplasm of peripheral nerves of unspecified lower limb, including hip 5 C473 Malignant neoplasm of peripheral nerves of thorax 5 C474 Malignant neoplasm of peripheral nerves of abdomen 5 C475 Malignant neoplasm of peripheral nerves of pelvis 5

2 CSHCS Qualifying Diagnoses Effective 10/01/2021

C476 Malignant neoplasm of peripheral nerves of trunk, unspecified 5

C478 Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system 5 C479 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified 5 C480 Malignant neoplasm of retroperitoneum 5 C490 Malignant neoplasm of connective and soft tissue of head, face and neck 5

C4910 Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder 5 C4920 Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip 5 C493 Malignant neoplasm of connective and soft tissue of thorax 5 C494 Malignant neoplasm of connective and soft tissue of abdomen 5 C495 Malignant neoplasm of connective and soft tissue of pelvis 5 C496 Malignant neoplasm of connective and soft tissue of trunk, unspecified 5 C498 Malignant neoplasm of overlapping sites of connective and soft tissue 5 C499 Malignant neoplasm of connective and soft tissue, unspecified 5 C50919 Malignant neoplasm of unspecified site of unspecified female breast 5 C519 Malignant neoplasm of vulva, unspecified 5 C52 Malignant neoplasm of vagina 5 C538 Malignant neoplasm of overlapping sites of cervix uteri 5 C539 Malignant neoplasm of cervix uteri, unspecified 5 C569 Malignant neoplasm of unspecified ovary 5 C574 Malignant neoplasm of uterine adnexa, unspecified 5 C58 Malignant neoplasm of placenta 5

C6290 Malignant neoplasm of unspecified testis, unspecified whether descended or undescended 5 C639 Malignant neoplasm of male genital organ, unspecified 5 C649 Malignant neoplasm of unspecified kidney, except renal pelvis 5 C679 Malignant neoplasm of bladder, unspecified 5 C6920 Malignant neoplasm of unspecified retina 5 C6960 Malignant neoplasm of unspecified orbit 5 C6980 Malignant neoplasm of overlapping sites of unspecified eye and adnexa 5 C6990 Malignant neoplasm of unspecified site of unspecified eye 5 C701 Malignant neoplasm of spinal meninges 5 C710 Malignant neoplasm of cerebrum, except lobes and ventricles 5 C717 Malignant neoplasm of brain stem 5 C718 Malignant neoplasm of overlapping sites of brain 5 C719 Malignant neoplasm of brain, unspecified 5 C720 Malignant neoplasm of spinal cord 5 C7230 Malignant neoplasm of unspecified optic nerve 5 C7250 Malignant neoplasm of unspecified cranial nerve 5

3 CSHCS Qualifying Diagnoses Effective 10/01/2021

C7259 Malignant neoplasm of other cranial nerves 5 C729 Malignant neoplasm of central nervous system, unspecified 5 C73 Malignant neoplasm of thyroid gland 5 C7400 Malignant neoplasm of cortex of unspecified adrenal gland 5 C7410 Malignant neoplasm of medulla of unspecified adrenal gland 5 C7490 Malignant neoplasm of unspecified part of unspecified adrenal gland 5 C751 Malignant neoplasm of pituitary gland 5 C752 Malignant neoplasm of craniopharyngeal duct 5 C753 Malignant neoplasm of pineal gland 5 C755 Malignant neoplasm of aortic body and other paraganglia 5 C760 Malignant neoplasm of head, face and neck 5 C761 Malignant neoplasm of thorax 5 C762 Malignant neoplasm of abdomen 5 C763 Malignant neoplasm of pelvis 5 C7640 Malignant neoplasm of unspecified upper limb 5 C7650 Malignant neoplasm of unspecified lower limb 5 C768 Malignant neoplasm of other specified ill-defined sites 5 C775 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes 5 C778 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions 5 C779 Secondary and unspecified malignant neoplasm of lymph node, unspecified 5 C7800 Secondary malignant neoplasm of unspecified lung 5 C787 Secondary malignant neoplasm of liver and intrahepatic bile duct 5 C7931 Secondary malignant neoplasm of brain 5 C7989 Secondary malignant neoplasm of other specified sites 5 C799 Secondary malignant neoplasm of unspecified site 5 C7A090 Malignant carcinoid tumor of the bronchus and lung 5 C7A095 Malignant carcinoid tumor of the midgut NOS 5 C800 Disseminated malignant neoplasm, unspecified 5 C801 Malignant (primary) neoplasm, unspecified 2 C8100 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site 5 C8109 Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites 5 C8110 Nodular sclerosis classical Hodgkin lymphoma, unspecified site 5 C8121 Mixed cellular classical Hodgkin lymphoma, lymph nodes of head, face, and neck 5 C8130 Lymphocyte depleted classical Hodgkin lymphoma, unspecified site 5 C8140 Lymphocyte-rich classical Hodgkin lymphoma, unspecified site 5 C8190 Hodgkin lymphoma, unspecified, unspecified site 5 C8200 Follicular lymphoma grade I, unspecified site 5 C8210 Follicular lymphoma grade II, unspecified site 5 C8220 Follicular lymphoma grade III, unspecified, unspecified site 5 C8230 Follicular lymphoma grade IIIa, unspecified site 5

4 CSHCS Qualifying Diagnoses Effective 10/01/2021

C8240 Follicular lymphoma grade IIIb, unspecified site 5 C8250 Diffuse follicle center lymphoma, unspecified site 5 C8260 Cutaneous follicle center lymphoma, unspecified site 5 C8280 Other types of follicular lymphoma, unspecified site 5 C8290 Follicular lymphoma, unspecified, unspecified site 5 C8300 Small cell B-cell lymphoma, unspecified site 5 C8330 Diffuse large B-cell lymphoma, unspecified site 5 C8350 Lymphoblastic (diffuse) lymphoma, unspecified site 5 C8351 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck 5 C8352 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes 5 C8370 Burkitt lymphoma, unspecified site 5 C8378 Burkitt lymphoma, lymph nodes of multiple sites 5 C8380 Other non-follicular lymphoma, unspecified site 5 C8390 Non-follicular (diffuse) lymphoma, unspecified, unspecified site 5 C8400 Mycosis fungoides, unspecified site 5 C8408 Mycosis fungoides, lymph nodes of multiple sites 5 C8410 Sezary disease, unspecified site 5 C8440 Peripheral T-cell lymphoma, not classified, unspecified site 5 C8448 Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites 5 C8460 Anaplastic large cell lymphoma, ALK-positive, unspecified site 5 C8470 Anaplastic large cell lymphoma, ALK-negative, unspecified site 5 C8490 Mature T/NK-cell lymphomas, unspecified, unspecified site 5 C84A0 Cutaneous T-cell lymphoma, unspecified, unspecified site 5 C84Z0 Other mature T/NK-cell lymphomas, unspecified site 5 C8510 Unspecified B-cell lymphoma, unspecified site 5 C8520 Mediastinal (thymic) large B-cell lymphoma, unspecified site 5 C8580 Other specified types of non-Hodgkin lymphoma, unspecified site 5 C8590 Non-Hodgkin lymphoma, unspecified, unspecified site 5 C860 Extranodal NK/T-cell lymphoma, nasal type 5 C861 Hepatosplenic T-cell lymphoma 5 C862 Enteropathy-type (intestinal) T-cell lymphoma 5 C863 Subcutaneous panniculitis-like T-cell lymphoma 5 C864 Blastic NK-cell lymphoma 5 C865 Angioimmunoblastic T-cell lymphoma 5 C866 Primary cutaneous CD30-positive T-cell proliferations 5 C882 Heavy chain disease 5 C883 Immunoproliferative small intestinal disease 5 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT- C884 lymphoma] 5 C888 Other malignant immunoproliferative diseases 2

5 CSHCS Qualifying Diagnoses Effective 10/01/2021

C889 Malignant immunoproliferative disease, unspecified 5 C9000 Multiple myeloma not having achieved remission 5 C9001 Multiple myeloma in remission 5 C9002 Multiple myeloma in relapse 5 C9010 Plasma cell leukemia not having achieved remission 5 C9011 Plasma cell leukemia in remission 5 C9012 Plasma cell leukemia in relapse 5 C9020 Extramedullary plasmacytoma not having achieved remission 5 C9021 Extramedullary plasmacytoma in remission 5 C9022 Extramedullary plasmacytoma in relapse 5 C9030 Solitary plasmacytoma not having achieved remission 5 C9031 Solitary plasmacytoma in remission 5 C9032 Solitary plasmacytoma in relapse 5 C9100 Acute lymphoblastic leukemia not having achieved remission 5 C9101 Acute lymphoblastic leukemia, in remission 5 C9102 Acute lymphoblastic leukemia, in relapse 5 C9110 Chronic lymphocytic leukemia of B-cell type not having achieved remission 5 C9111 Chronic lymphocytic leukemia of B-cell type in remission 5 C9112 Chronic lymphocytic leukemia of B-cell type in relapse 5 C9130 Prolymphocytic leucemia of B-cell tympe not having achieved remission 5 C9131 Prolymphocytic leukemia of B-cell type, in remission 5 C9132 Prolymphocytic leukemia of B-cell type, in relapse 5 C9140 Hairy cell leukemia, not having achieved remission 5 C9141 Hairy cell leukemia, in remission 5 C9142 Hairy cell leukemia, in relapse 5 C9190 Lymphoid leukemia, unspecified not having achieved remission 5 C9191 Lymphoid leukemia, unspecified, in remission 5 C9192 Lymphoid leukemia, uspecified, in relapse 5 C91Z0 Other lymphoid leukemia not having achieved remission 5 C9200 Acute myeloblastic leukemia, not having achieved remission 5 C9201 Acute myeloblastic leukemia, in remission 5 C9202 Acute myeloblastic leukemia, in relapse 5 C9210 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission 5 C9211 Chronic myeloid leukemia, BCR/ABL-positive, in remission 5 C9212 Chronic myeloid leukemia, BCR/ABL-positive in relapse 5 C9220 Atypical chronic myeloid leukemia BCR/ABL-negative, not having achieved remission 5 C9221 Atypical chronic myeloid leukemia BCR/ABL-negative, in remission 5 C9222 Atypical chronic myeloid leukemia BCR/ABL-negative, in relapse 5 C9230 Myeloid sarcoma, not having achieved remission 5 C9240 Acute promyelocytic leukemia, not having achieved remission 5

6 CSHCS Qualifying Diagnoses Effective 10/01/2021

C9241 Acute promyelocytic leukemia, in remission 5 C9242 Acute promyelocytic leukemia, in relapse 5 C9250 Acute myelomonocytic leukemia, not having achieved remission 5 C9251 Acute myelomonocytic leukemia, in remission 5 C9252 Acute myelomonocytic leukemia, in relapse 5 C9260 Acute myeloid leukemia with 11q23-abnormality not having achieved remission 5 C9261 Acute myeloid leukemia with 11q23-abnormality in remission 5 C9262 Acute myeloid leukemia with 11q23-abnormality in relapse 5 C9290 Myeloid leukemia, unspecified, not having achieved remission 5 C9291 Myeloid leukemia, unspecified in remission 5 C9292 Myeloid leukemia, unspecified in relapse 5 C92A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission 5 C92A1 Acute myeloid leukemia with multilineage dysplasia, in remission 5 C92A2 Acute myeloid leukemia with multilineage dysplasia, in relapse 5 C92Z0 Other myeloid leukemia not having achieved remission 5 C92Z1 Other myeloid leukemia, in remission 5 C9300 Acute monoblastic/monocytic leukemia, not having achieved remission 5 C9301 Acute monoblastic/monocytic leukemia, in remission 5 C9302 Acute monoblastic/monocytic leukemia, in relapse 5 C9390 Monocytic leukemia, unspecified, not having achieved remission 5 C9391 Monocytic leukemia, unspecified, in remission 5 C9392 Monocytic leukemia, unspecified, in relapse 5 C9400 Acute erythroid leukemia, not having achieved remission 5 C9401 Acute erythroid leukemia, in remission 5 C9402 Acute erythroid leukemia, in relapse 5 C9420 Acute megakaryoblastic leukemia not having achieved remission 5 C9421 Acute megakaryoblastic leukemia, in remission 5 C9422 Acute megakaryoblastic leukemia, in relapse 5 C9430 Mast cell leukemia not having achieved remission 5 C9431 Mast cell leukemia, in remission 5 C9432 Mast cell leukemia, in relapse 5 C9440 Acute panmyelosis with myelofibrosis not having achieved remission 2 C9441 Acute panmyelosis with myelofibrosis, in remission 2 C9442 Acute panmyelosis with myelofibrosis, in relapse 2 C946 Myelodysplastic disease, not classified 2 C9480 Other specified leukemias not having achieved remission 5 C9481 Other specified leukemias, in remission 5 C9482 Other specified leukemias, in relapse 5 C9500 Acute leukemia of unspecified cell type not having achieved remission 5 C9501 Acute leukemia of unspecified cell type, in remission 5

7 CSHCS Qualifying Diagnoses Effective 10/01/2021

C9502 Acute leukemia of unspecified cell type, in relapse 5 C9510 Chronic leukemia of unspecified cell type, not having achieved remission 5 C9511 Chronic leukemia of unspecified cell type, in remission 5 C9512 Chronic leukemia of unspecified cell type, in relapse 5 C9590 Leukemia, unspecified not having achieved remission 5 C9591 Leukemia, unspecified, in remission 5 C9592 Leukemiaunspecified, in relapse 5 C960 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis 5 C962 Malignant mast cell tumor 5 9/30/2017 C9620 Malignant mast cell neoplasm, unspecified 5 10/1/2017 C9622 Mast cell sarcoma 5 10/1/2017 C9629 Other malignant mast cell neoplasm 5 10/1/2017 C964 Sarcoma of dendritic cells (accessory cells) 5 C965 Multifocal and unisystemic Langerhans-cell histiocytosis 3 C966 Unifocal Langerhans-cell histiocytosis 3 C969 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified 5 C96A Histiocytic sarcoma 5 C96Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue 5 D0000 Carcinoma in situ of oral cavity, unspecified site 5 D019 Carcinoma in situ of digestive oragan, unspecified 5 D024 Carcinoma in situ of respiratory system, unspecified 5 D039 Melanoma in situ, unspecified 5 D049 Carcinoma in situ of skin, unspecified 5 D0590 Unspecified type of carcinoma in situ of unspecified breast 5 D0730 Carcinoma in situ of unspecified female genital organs 5 D0760 Carcinoma in situ of unspecified male genital organs 5 D099 Carcinoma in situ, unspecified 5 D1030 Benign neoplasm of unspecified part of mouth 2 D107 Benign neoplasm of the hypopharynx, unspecified 2 D109 Benign neoplasm of pharynx, unspecified 2 D119 Benign neoplasm of major salivary gland, unspecified 2 D126 Benign neoplasm of colon, unspecified 2 D1330 Benign neoplasm of unspecified part of small intestine 2 D139 Benign neoplasm of ill-defined sites within the digestive system 2 D140 Benign neoplasm of middle ear, nasal cavity and accessory sinuses 2 D141 Benign neoplasm of larynx 2 D142 Benign neoplasm of trachea 2 D144 Benign neoplasm of respiratory system, unspecified 2 D169 Benign neoplasm of bone and articular cartilage, unspecified 2 D1800 Hemangioma unspecified sites 2

8 CSHCS Qualifying Diagnoses Effective 10/01/2021

D1801 Hemangioma of skin and subcutaneous tissue 2 D1802 Hemangioma of intracranial structures 2 D1803 Hemangioma of intra-abdominal structures 2 D1809 Hemangioma of other sites 2 D181 Lymphangioma, any site 2 D215 Benign neoplasm of connective and other soft tissue of pelvis 2 D219 Benign neoplasm of connective and other soft tissue, unspecified 2 D309 Benign neoplasm of urinary organ, unspecified 2 D3120 Benign neoplasm of unspecified retina 2 D3140 Benign neoplasm of unspecified ciliary body 2 D3160 Benign neoplasm of unspecified site of unspecified orbit 2 D3190 Benign neoplasm of unspecified part of unspecified eye 2 D320 Benign neoplasm of cerebral meninges 2 D321 Benign neoplasm of spinal meninges 2 D329 Benign neoplasm of meninges, unspecified 2 D330 Benign neoplasm of brain, supratentorial 2 D331 Benign neoplasm of brain, infratentorial 2 D332 Benign neoplasm of brain, unspecified 2 D333 Benign neoplasm of cranial nerves 2 D334 Benign neoplasm of spinal cord 2 D337 Benign neoplasm of other specified parts of central nervous system 2 D339 Benign neoplasm of central nervous system, unspecified 2 D3500 Benign neoplasm of unspecified adrenal gland 2 D352 Benign neoplasm of pituitary gland 2 D353 Benign neoplasm of craniopharyngeal duct 2 D354 Benign neoplasm of pineal gland 2 D359 Benign neoplasm of endocrine gland, unspecified 2 D3610 Benign neoplasm of peripheral nerves and autonomic nervous system, unspecified 2 D433 Neoplasm of uncertain behavior of cranial nerves 2 D438 Neoplasm of uncertain behavior of other specified parts of central nervous system 2 D439 Neoplasm of uncertain behavior of central nervous system, unspecified 2 D440 Neoplasm of uncertain behavior of thyroid gland 2 D4410 Neoplasm of uncertain behavior of unspecified adrenal gland 2 D442 Neoplasm of uncertain behavior of parathyroid gland 2 D443 Neoplasm of uncertain behavior of pituitary gland 3 D444 Neoplasm of uncertain behavior of craniopharyngeal duct 3 D445 Neoplasm of uncertain behavior of pineal gland 3 D446 Neoplasm of uncertain behavior of carotid body 2 D447 Neoplasm of uncertain behavior of aortic body and other paraganglia 2 D449 Neoplasm of uncertain behavior of unspecified endocrine gland 2

9 CSHCS Qualifying Diagnoses Effective 10/01/2021

D45 Polycythemia vera 2 D469 Myelodysplastic syndrome, unspecified 2 D4702 Systemic mastocytosis 5 10/1/2017 D473 Essential (hemorrhagic) thrombocythemia 2 D47Z1 Post-transplant lymphoproliferative disorder (PTLD) 2

D47Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue 2 D481 Neoplasm of uncertain behavior of connective and other soft tissue 2 D487 Neoplasm of uncertain behavior of other specified sites 2 D489 Neoplasm of uncertain behavior, unspecified 1 D4989 Neoplasm of unspecified behavior of other specified sites 2 D499 Neoplasm of unspecified behavior of unspecified site 2 D519 Vitamin B12 deficiency anemia, unspecified 2 D550 Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency 3 9/30/2019 D551 Anemia due to other disorders of glutathione metabolism 3 D558 Other anemias due to enzyme disorders 5 D559 Anemia due to enzyme disorder, unspecified 5 D560 Alpha thalassemia 5 D561 Beta thalassemia 5 D568 Other thalassemias 5 D571 Sickle-cell disease without crisis 5 D5720 Sickle-cell/Hb-C disease without crisis 5 D5740 Sickle-cell thalassemia without crisis 5 D57419 Sickle-cell thalassemia with crisis, unspecified 5 9/30/2020 D5780 Other sickle-cell disorders without crisis 5 D580 3 D581 Hereditary elliptocytosis 3 D582 Other hemoglobinopathies 2 D590 Drug-induced autoimmune hemolytic anemia 2 D591 Other autoimmune hemolytic anemias 2 9/30/2020 D5910 Autoimmune hemolytic anemia, unspecified 2 10/1/2020 D5919 Other autoimmune hemolytic anemia 2 10/1/2020 D593 Hemolytic-uremic syndrome 2 D594 Other nonautoimmune hemolytic anemias 2 D595 Paroxysmal nocturnal hemoglobinuria 2 D600 Chronic acquired pure red cell aplasia 5 D608 Other acquired pure red cell aplasias 5 D609 Acquired pure red cell aplasia, unspecified 5 D6101 Constitutional (pure) red blood cell aplasia 5 D6109 Other constitutional aplastic anemia 5

10 CSHCS Qualifying Diagnoses Effective 10/01/2021

D611 Drug-induced aplastic anemia 5 D612 Aplastic anemia due to other external agents 5 D613 Idiopathic aplastic anemia 5 D61818 Other pancytopenia 5 D6189 Other specified aplastic anemias and other bone marrow failure syndromes 5 D619 Aplastic anemia, unspecified 2 D631 Anemia in chronic kidney disease 3 D643 Other sideroblastic anemias 3 D65 Disseminated intravascular coagulation [defibrination syndrome] 3 D66 Hereditary factor VIII deficiency 5 D67 Hereditary factor IX deficiency 5 D680 Von Willebrand's disease 5 D681 Hereditary factor XI deficiency 5 D682 Hereditary deficiency of other clotting factors 5 D6832 Hemorrhagic disorder due to extrinsic circulating anticoagulants 3 D684 Acquired coagulation factor deficiency 3 D6851 Activated protein C resistance 5 D6852 Prothrombin gene mutation 5 D6859 Other primary thrombophilia 5 D6861 Antiphospholipid syndrome 5 D6862 anticoagulant syndrome 5 D688 Other specified coagulation defects 3 D689 Coagulation defect, unspecified 3 D693 Immune thrombocytopenic purpura 2 D6941 Evans syndrome 2 D6942 Congenital and hereditary thrombocytopenia purpura 2 D6949 Other primary thrombocytopenia 2 D699 Hemorrhagic condition, unspecified 2 D700 Congenital agranulocytosis 2 D704 Cyclic neutropenia 2 D708 Other neutropenia 2 D709 Neutropenia, unspecified 2 D71 Functional disorders of polymorphonuclear neutrophils 3 D72118 Other hypereosinophilic syndrome 1 10/1/2020 D75839 Thrombocytosis, unspecified 2 10/1/2021 D75A Glucose-6-phosphate dehydrgnse (G6PD) defic without anemia 3 10/1/2019 D761 Hemophagocytic lymphohistiocytosis 2 D762 Hemophagocytic syndrome, infection associated 2 D800 Hereditary hypogammaglobulinemia 3 D801 Nonfamilial hypogammaglobulinemia 3

11 CSHCS Qualifying Diagnoses Effective 10/01/2021

D802 Selective deficiency of immunoglobulin A [IgA] 3 D803 Selective deficiency of immunoglobulin G [IgG] subclasses 3 D804 Selective deficiency of immunoglobulin M [IgM] 3 D805 Immunodeficiency with increased immunoglobulin M [IgM] 3 D806 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia 2 D807 Transient hypogammaglobulinemia of infancy 2 D808 Other immunodeficiencies with predominantly antibody defects 2 D809 Immunodeficiency with predominantly antibody defects, unspecified 2 D810 Severe combined immunodeficiency [SCID] with reticular dysgenesis 5 D811 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers 5 D812 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers 5 D813 Adenosine deaminase [ADA] deficiency 3 9/30/2019 D8130 Adenosine deaminase deficiency, unspecified 3 10/1/2019 D8131 Severe combined immunodef due to adenosine deaminase defic 3 10/1/2019 D815 Purine nucleoside phosphorylase [PNP] deficiency 3 D816 Major histocompatibility complex class I deficiency 5 D817 Major histocompatibility complex class II deficiency 5 D81810 Biotinidase deficiency 3 D8189 Other combined immunodeficiencies 5 D819 Combined immunodeficiency, unspecified 5 D820 Wiskott-Aldrich syndrome 5 D821 *Phase Out* Di George's syndrome 5 *Phase Out* D824 Hyperimmunoglobulin E syndrome 2 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and D830 function 3 D831 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders 2 D832 Common variable immunodeficiency with autoantibodies to B- or T-cells 3 D838 Other common variable immunodeficiencies 3 D839 Common variable immunodeficiency, unspecified 2 D848 Other specified immunodeficiencies 2 9/30/2020 D8481 Immunodeficiency due to conditions classified elsewhere 2 10/1/2020 D8489 Other immunodeficiencies 2 10/1/2020 D849 Immunodeficiency, unspecified 2 D869 Sarcoidosis, unspecified 3 D89811 Chronic graft-versus-host disease 5 D89813 Graft-versus-host disease, unspecified 5 D8982 Autoimmune lymphoproliferative syndrome [ALPS] 2 D89839 Cytokine release syndrome, grade unspecified 1 10/1/2020 D8989 Other specified disorders involving the immune mechanism, not elsewhere classified 2 D899 Disorder involving the immune mechanism, unspecified 2

12 CSHCS Qualifying Diagnoses Effective 10/01/2021

E009 Congenital iodine-deficiency syndrome, unspecified 5 E030 Congenital hypothyroidism with diffuse goiter 5 E031 Congenital hypothyroidism without goiter 5 E039 Hypothyroidism, unspecified 3 E0510 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm 3 E0520 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm 3 E0590 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm 3 E063 Autoimmune thyroiditis 2 E0840 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified 3

E0849 Diabetes mellitus due to underlying condition with other diabetic neurological complication 3 E08610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy 2 E088 Diabetes mellitus due to underlying condition with unspecified complications 2 E1021 Type 1 diabetes mellitus with diabetic nephropathy 5 E1022 Type 1 diabetes mellitus with diabetic chronic kidney disease 5 E1029 Type 1 diabetes mellitus with other diabetic kidney complication 5 E1039 Type 1 diabetes mellitus with other diabetic ophthalmic complication 5 E1040 Type 1 diabetes mellitus with diabetic neuropathy, unspecified 3 E1043 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy 5 E1049 Type 1 diabetes mellitus with other diabetic neurological complication 3 E1059 Type 1 diabetes mellitus with other circulatory complications 5 E1069 Type 1 diabetes mellitus with other specified complication 5 E108 Type 1 diabetes mellitus with unspecified complications 2 E109 Type 1 diabetes mellitus without complications 5 E1140 Type 2 diabetes mellitus with diabetic neuropathy, unspecified 3 E118 Type 2 diabetes mellitus with unspecified complications 2 E161 Other hypoglycemia 2 E200 Idiopathic hypoparathyroidism 3 E201 Pseudohypoparathyroidism 3 E208 Other hypoparathyroidism 3 E209 Hypoparathyroidism, unspecified 3 E210 Primary hyperparathyroidism 5 E211 Secondary hyperparathyroidism, not elsewhere classified 2 E213 Hyperparathyroidism, unspecified 1 E215 Disorder of parathyroid gland, unspecified 2 E220 Acromegaly and pituitary gigantism 5 E221 Hyperprolactinemia 3 E228 Other hyperfunction of pituitary gland 3 E229 Hyperfunction of pituitary gland, unspecified 3 E230 Hypopituitarism 3

13 CSHCS Qualifying Diagnoses Effective 10/01/2021

E232 Diabetes insipidus 5 E233 Hypothalamic dysfunction, not elsewhere classified 3 E236 Other disorders of pituitary gland 3 E237 Disorder of pituitary gland, unspecified 3 E240 Pituitary-dependent Cushing's disease 3 E248 Other Cushing's syndrome 3 E249 Cushing's syndrome, unspecified 3 E250 Congenital adrenogenital disorders associated with enzyme deficiency 5 E258 Other adrenogenital disorders 5 E259 Adrenogenital disorder, unspecified 5 E2609 Other primary hyperaldosteronism 3 E2681 Bartter's Syndrome 2 E269 Hyperaldosteronism, unspecified 3 E271 Primary adrenocortical insufficiency 3 E2740 Unspecified adrenocortical insufficiency 3 E2749 Other adrenocortical insufficiency 3 E275 Adrenomedullary hyperfunction 3 E2839 Other primary ovarian failure 3 E299 Testicular dysfunction, unspecified 3 E301 Precocious puberty 2 E309 Disorder of puberty, unspecified 3 E310 Autoimmune polyglandular failure 3 E311 Polyglandular hyperfunction 3 E3120 Multiple endocrine neoplasia [MEN] syndrome, unspecified 3 E3121 Multiple endocrine neoplasia [MEN] type I 3 E3122 Multiple endocrine neoplasia [MEN] type IIA 3 E3123 Multiple endocrine neoplasia [MEN] type IIB 3 E318 Other polyglandular dysfunction 3 E319 Polyglandular dysfunction, unspecified 3 E340 Carcinoid syndrome 3 E343 Short stature due to endocrine disorder 3 E3450 Androgen insensitivity syndrome, unspecified 2 E348 Other specified endocrine disorders 2 E349 Endocrine disorder, unspecified 3 E43 Unspecified severe protein-calorie malnutrition 2 E440 Moderate protein-calorie malnutrition 2 E46 Unspecified protein-calorie malnutrition 2 E618 Deficiency of other specified nutrient elements 3 E619 Deficiency of nutrient element, unspecified 1 E638 Other specified nutritional deficiencies 3

14 CSHCS Qualifying Diagnoses Effective 10/01/2021

E639 Nutritional deficiency, unspecified 1 E640 Sequelae of protein-calorie malnutrition 2 E643 Sequelae of rickets 3 E648 Sequelae of other nutritional deficiencies 3 E649 Sequelae of unspecified nutritional deficiency 1 E662 Morbid (severe) obesity with alveolar hypoventilation 2 E700 Classical 5 E701 Other hyperphenylalaninemias 5 E7020 Disorder of metabolism, unspecified 5 E7021 5 E7029 Other disorders of tyrosine metabolism 5 E7030 Albinism, unspecified 5 E70319 , unspecified 5 E70329 , unspecified 5 E7039 Other specified albinism 5 E705 Disorders of metabolism 5 E708 Other disorders of aromatic amino-acid metabolism 5 9/30/2020 E7081 Aromatic L- decarboxylase deficiency 5 10/1/2020 E7089 Other disorders of aromatic amino-acid metabolism 5 10/1/2020 E709 Disorder of aromatic amino-acid metabolism, unspecified 5 E710 Maple-syrup-urine disease 5 E71110 5 E71111 3-methylglutaconic aciduria 5 E71118 Other branched-chain organic acidurias 5 E71120 5 E71121 5 E71128 Other disorders of propionate metabolism 5 E7119 Other disorders of branched-chain amino-acid metabolism 5 E712 Disorder of branched-chain amino-acid metabolism, unspecified 5 E7130 Disorder of fatty-acid metabolism, unspecified 3 E71310 Long chain/very long chain acyl CoA dehydrogenase deficiency 5 E71311 Medium chain acyl CoA dehydrogenase deficiency 5 E71312 Short chain acyl CoA dehydrogenase deficiency 5 E71313 Glutaric aciduria type II 5 E71314 Muscle carnitine palmitoyltransferase deficiency 5 E71318 Other disorders of fatty-acid oxidation 5 E7132 Disorders of ketone metabolism 5 E7139 Other disorders of fatty-acid metabolism 3 E7141 Primary carnitine deficiency 3 E7142 Carnitine deficiency due to inborn errors of metabolism 5

15 CSHCS Qualifying Diagnoses Effective 10/01/2021

E7150 Peroxisomal disorder, unspecified 5 E71510 Zellweger syndrome 5 E71511 Neonatal adrenoleukodystrophy 5 E71518 Other disorders of peroxisome biogenesis 5 E71520 Childhood cerebral X-linked adrenoleukodystrophy 5 E71521 Adolescent X-linked adrenoleukodystrophy 5 E71522 Adrenomyeloneuropathy 5 E71528 Other X-linked adrenoleukodystrophy 5 E71529 X-linked adrenoleukodystrophy, unspecified type 5 E7153 Other group 2 peroxisomal disorders 5 E71540 Rhizomelic chondrodysplasia punctata 5 E71541 Zellweger-like syndrome 5 E71542 Other group 3 peroxisomal disorders 5 E71548 Other peroxisomal disorders 5 E7200 Disorders of amino-acid transport, unspecified 3 E7201 3 E7202 Hartnup's disease 3 E7203 Lowe's syndrome 5 E7204 3 E7209 Other disorders of amino-acid transport 3 E7210 Disorders of sulfur-bearing amino-acid metabolism, unspecified 5 E7211 5 E7212 Methylenetetrahydrofolate reductase deficiency 5 E7219 Other disorders of sulfur-bearing amino-acid metabolism 5 E7220 Disorder of metabolism, unspecified 5 E7221 5 E7222 Arginosuccinic aciduria 5 E7223 5 E7229 Other disorders of urea cycle metabolism 5 E723 Disorders of and hydroxylysine metabolism 5 E724 Disorders of ornithine metabolism 5 E7250 Disorder of metabolism, unspecified 5 E7251 Non-ketotic hyperglycinemia 5 E7253 Hyperoxaluria 3 E7259 Other disorders of glycine metabolism 5 E728 Other specified disorders of amino-acid metabolism 5 9/30/2018 E7281 Disorders of gamma aminobutyric acid metabolism 5 10/1/2018 E7289 Other specified disorders of amino-acid metabolism 5 10/1/2018 E729 Disorder of amino-acid metabolism, unspecified 3 E7400 Glycogen storage disease, unspecified 5

16 CSHCS Qualifying Diagnoses Effective 10/01/2021

E7401 von Gierke disease 5 E7402 Pompe disease 5 E7403 Cori disease 5 E7404 McArdle disease 5 E7409 Other glycogen storage disease 5 E7420 Disorders of galactose metabolism, unspecified 5 E7421 Galactosemia 5 E7429 Other disorders of galactose metabolism 5 E744 Disorders of pyruvate metabolism and gluconeogenesis 3 E748 Other specified disorders of carbohydrate metabolism 3 9/30/2020 E74810 Glucose transporter protein type 1 deficiency 3 10/1/2020 E74818 Other disorders of glucose transport 3 10/1/2020 E74819 Disorders of glucose transport, unspecified 3 10/1/2020 E7489 Other specified disorders of carbohydrate metabolism 3 10/1/2020 E749 Disorder of carbohydrate metabolism, unspecified 3 E7500 GM2 gangliosidosis, unspecified 5 E7501 Sandhoff disease 5 E7502 Tay-Sachs disease 5 E7509 Other GM2 gangliosidosis 5 E7510 Unspecified gangliosidosis 5 E7511 Mucolipidosis IV 5 E7519 Other gangliosidosis 5 E7521 Fabry (-Anderson) disease 5 E7522 Gaucher disease 5 E75240 Niemann-Pick disease type A 5 E75241 Niemann-Pick disease type B 5 E75242 Niemann-Pick disease type C 5 E75243 Niemann-Pick disease type D 5 E75248 Other Niemann-Pick disease 5 E75249 Niemann-Pick disease, unspecified 5 E753 Sphingolipidosis, unspecified 5 E754 Neuronal ceroid lipofuscinosis 5 E755 Other lipid storage disorders 3 E756 Lipid storage disorder, unspecified 3 E7601 Hurler's syndrome 5 E7602 Hurler-Scheie syndrome 5 E7603 Scheie's syndrome 5 E761 Mucopolysaccharidosis, type II 5 E76210 Morquio A mucopolysaccharidoses 5 E76211 Morquio B mucopolysaccharidoses 5

17 CSHCS Qualifying Diagnoses Effective 10/01/2021

E76219 Morquio mucopolysaccharidoses, unspecified 5 E7622 Sanfilippo mucopolysaccharidoses 5 E7629 Other mucopolysaccharidoses 5 E763 Mucopolysaccharidosis, unspecified 5 E768 Other disorders of glucosaminoglycan metabolism 5 E769 Glucosaminoglycan metabolism disorder, unspecified 5 E770 Defects in post-translational modification of lysosomal enzymes 5 E771 Defects in glycoprotein degradation 3 E778 Other disorders of glycoprotein metabolism 5 E779 Disorder of glycoprotein metabolism, unspecified 5 E780 Pure hypercholesterolemia 3 9/30/2016 E7800 Pure hypercholesterolemia unspecified 3 10/1/2016 E781 Pure hyperglyceridemia 3 E782 Mixed hyperlipidemia 3 E784 Other hyperlipidemia 3 9/30/2018 E7841 Elevated Lipoprotein(a) 3 10/1/2018 E7849 Other hyperlipidemia 3 10/1/2018 E785 Hyperlipidemia, unspecified 3 E786 Lipoprotein deficiency 3 E7870 Disorder of bile acid and cholesterol metabolism, unspecified 3 E7871 Barth syndrome 3 E7879 Other disorders of bile acid and cholesterol metabolism 3 E7881 Lipoid dermatoarthritis 3 E7889 Other lipoprotein metabolism disorders 3 E789 Disorder of lipoprotein metabolism, unspecified 3 E791 Lesch-Nyhan syndrome 3 E792 Myoadenylate deaminase deficiency 3 E798 Other disorders of purine and pyrimidine metabolism 3 E799 Disorder of purine and pyrimidine metabolism, unspecified 3 E800 Hereditary erythropoietic porphyria 5 E801 Porphyria cutanea tarda 5 E8020 Unspecified porphyria 5 E8021 Acute intermittent (hepatic) porphyria 5 E8029 Other porphyria 5 E803 Defects of catalase and peroxidase 3 E8300 Disorder of copper metabolism, unspecified 5 E8301 Wilson's disease 5 E8309 Other disorders of copper metabolism 5 E83110 Hereditary Hemochromatosis 2 10/1/2017 E832 Disorders of zinc metabolism 3

18 CSHCS Qualifying Diagnoses Effective 10/01/2021

E8330 Disorder of phosphorus metabolism, unspecified 3 E8331 Familial hypophosphatemia 3 E8332 Hereditary vitamin D-dependent rickets (type 1) (type 2) 3 E8339 Other disorders of phosphorus metabolism 3 E8350 Unspecified disorder of calcium metabolism 2 E8351 Hypocalcemia 2 E8352 Hypercalcemia 2 E8359 Other disorders of calcium metabolism 3 E8389 Other disorders of mineral metabolism 3 E839 Disorder of mineral metabolism, unspecified 3 E849 Cystic fibrosis, unspecified 5 E850 Non-neuropathic heredofamilial amyloidosis 3 E859 Amyloidosis, unspecified 3 E8801 Alpha-1-antitrypsin deficiency 3 E882 Lipomatosis, not elsewhere classified 3 E8840 Mitochondrial metabolism disorder, unspecified 5 E8841 MELAS Syndrome 5 E8842 MERRF Syndrome 5 E8889 Other specified metabolic disorders 3 E889 , unspecified 2 E892 Postprocedural hypoparathyroidism 3 E896 Postprocedural adrenocortical (-medullary) hypofunction 3 F842 *Phase Out* Rett's syndrome 5 *Phase Out* G009 Bacterial meningitis, unspecified 2 G032 Benign recurrent meningitis [Mollaret] 2 G039 Meningitis, unspecified 2 G0400 Acute disseminated encephalitis and encephalomyelitis (ADEM), unspecified 2 G041 Tropical spastic paraplegia 5 G0430 Acute necrotizing hemorrhagic encephalopathy, unspecified 2 G0482 Acute flaccid myelitis 2 10/1/2021 G0490 Encephalitis and encephalomyelitis, unspecified 2 G0491 Myelitis, unspecified 2 G09 Sequelae of inflammatory diseases of central nervous system 3 G10 Huntington's disease 5 G111 Early-onset cerebellar ataxia 5 9/30/2020 G1110 Early-onset cerebellar ataxia, unspecified 5 10/1/2020 G1111 Friedreich ataxia 5 10/1/2020 G1119 Other early-onset cerebellar ataxia 5 10/1/2020 G112 Late-onset cerebellar ataxia 3 G113 Cerebellar ataxia with defective DNA repair 3

19 CSHCS Qualifying Diagnoses Effective 10/01/2021

G114 Hereditary spastic paraplegia 3 G118 Other hereditary ataxias 3 G120 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] 5 G121 Other inherited spinal muscular atrophy 3 G1220 Motor neuron disease, unspecified 2 G1221 Amyotrophic lateral sclerosis 5 G1223 Primary lateral sclerosis 2 10/1/2017 G1224 Familial motor neuron disease 2 10/1/2017 G1225 Progressive spinal muscle atrophy 2 10/1/2017 G1229 Other motor neuron disease 2 G128 Other spinal muscular atrophies and related syndromes 5 G129 Spinal muscular atrophy, unspecified 5 G130 Paraneoplastic neuromyopathy and neuropathy 3 G14 Postpolio syndrome 5 G230 Hallervorden-Spatz disease 3 G231 Progressive supranuclear ophthalmoplegia [Steele-Richardson-Olszewski] 3 G232 Striatonigral degeneration 3 G238 Other specified degenerative diseases of basal ganglia 3 G239 Degenerative disease of basal ganglia, unspecified 3 G241 Genetic torsion dystonia 3 G242 Idiopathic nonfamilial dystonia 3 G244 Idiopathic orofacial dystonia 2 G248 Other dystonia 2 G249 Dystonia, unspecified 2 G253 Myoclonus 2 G2589 Other specified extrapyramidal and movement disorders 3 G259 Extrapyramidal and movement disorder, unspecified 3 G3181 Alpers disease 5 G3182 Leigh's disease 5 G3189 Other specified degenerative diseases of nervous system 3 G319 Degenerative disease of nervous system, unspecified 3 G3289 Other specified degenerative disorders of nervous system in diseases classified elsewhere 3 G35 Multiple sclerosis 5 G360 Neuromyelitis optica [Devic] 2 G361 Acute and subacute hemorrhagic leukoencephalitis [Hurst] 3 G368 Other specified acute disseminated demyelination 3 G369 Acute disseminated demyelination, unspecified 3 G371 Central demyelination of corpus callosum 3 G372 Central pontine myelinolysis 3 G373 Acute transverse myelitis in demyelinating disease of central nervous system 3

20 CSHCS Qualifying Diagnoses Effective 10/01/2021

G374 Subacute necrotizing myelitis of central nervous system 2 G378 Other specified demyelinating diseases of central nervous system 3 G379 Demyelinating disease of central nervous system, unspecified 3 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of G40009 localized onset, not intractable, without status epilepticus 3 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of G40019 localized onset, intractable, without status epilepticus 5 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple G40109 partial seizures, not intractable, without status epilepticus 3 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple G40119 partial seizures, intractable, without status epilepticus 5 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex G40209 partial seizures, not intractable, without status epilepticus 3 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex G40219 partial seizures, intractable, without status epilepticus 5

G40309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus 2

G40319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus 5

G40409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus 3

G40419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus 5 G4042 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder 5 10/1/2020 G40822 Epileptic spasms, not intractable, without status epilepticus 2 G40824 Epileptic spasms, intractable, without status epilepticus 5 G40834 Dravet syndrome, intractable, without status epilepticus 5 10/1/2020 G43A1 Cyclical vomiting, intractable 2 G459 Transient cerebral ischemic attack, unspecified 2 G4730 Sleep apnea, unspecified 2 G4731 Primary central sleep apnea 2 G4733 Obstructive sleep apnea 2 G4735 Congenital central alveolar hypoventilation 5 G508 Other disorders of trigeminal nerve 3 G509 Disorder of trigeminal nerve, unspecified 2 G510 Bell's palsy 2 G512 Melkersson's syndrome 3 G514 Facial myokymia 3 G518 Other disorders of facial nerve 3 G519 Disorder of facial nerve, unspecified 2

21 CSHCS Qualifying Diagnoses Effective 10/01/2021

G527 Disorders of multiple cranial nerves 3 G529 Cranial nerve disorder, unspecified 2 G53 Cranial nerve disorders in diseases classified elsewhere 2 G540 Brachial plexus disorders 3 G600 Hereditary motor and sensory neuropathy 3 G601 Refsum's disease 5 G602 Neuropathy in association with hereditary ataxia 3 G609 Hereditary and Idiopathic Neuropathy, Unspecified 3 10/1/2017 G610 Guillain-Barre syndrome 2 G6181 Chronic inflammatory demyelinating polyneuritis 3 G629 Polyneuropathy, unspecified 2 G63 Polyneuropathy in diseases classified elsewhere 3 G7000 Myasthenia gravis without (acute) exacerbation 5 G7001 Myasthenia gravis with (acute) exacerbation 5 G702 Congenital and developmental myasthenia 5 G7089 Other specified myoneural disorders 5 G709 Myoneural disorder, unspecified 2 G710 Muscular dystrophy 5 9/30/2018 G7100 Muscular dystrophy, unspecified 5 10/1/2018 G7101 Duchenne or Becker muscular dystrophy 5 10/1/2018 G7102 Facioscapulohumeral muscular dystrophy 5 10/1/2018 G7109 Other specified muscular dystrophies 5 10/1/2018 G7111 Myotonic muscular dystrophy 5 G7112 Myotonia congenita 5 G7119 Other specified myotonic disorders 5 G712 Congenital 5 9/30/2020 G7120 Congenital , unspecifed 5 10/1/2020 G7121 Nemaline myopathy 5 10/1/2020 G71220 X-linked myotubular myopathy 5 10/1/2020 G71228 Other centronuclear myopathy 5 10/1/2020 G7129 Other congenital myopathy 5 10/1/2020 G718 Other primary disorders of muscles 2 G723 Periodic paralysis 5 G729 Myopathy, unspecified 2 G800 Spastic quadriplegic cerebral palsy 5 G801 Spastic diplegic cerebral palsy 5 G802 Spastic hemiplegic cerebral palsy 5 G803 Athetoid cerebral palsy 3 G804 Ataxic cerebral palsy 3 G808 Other cerebral palsy 5

22 CSHCS Qualifying Diagnoses Effective 10/01/2021

G809 Cerebral palsy, unspecified 3 G8190 Hemiplegia, unspecified affecting unspecified side 5 G8220 Paraplegia, unspecified 5 G8250 Quadriplegia, unspecified 5 G8330 Monoplegia, unspecified affecting unspecified side 3 G834 Cauda equina syndrome 3 G8381 Brown-Sequard syndrome 2 G8382 Anterior cord syndrome 2 G8383 Posterior cord syndrome 2 G8389 Other specified paralytic syndromes 2 G839 Paralytic syndrome, unspecified 2 G901 Familial dysautonomia [Riley-Day] 2 G903 Multi-system degeneration of the autonomic nervous system 3 G910 Communicating hydrocephalus 3 G911 Obstructive hydrocephalus 3 G913 Post-traumatic hydrocephalus, unspecified 3 G914 Hydrocephalus in diseases classified elsewhere 3 G918 Other hydrocephalus 3 G919 Hydrocephalus, unspecified 3 G930 Cerebral cysts 3 G931 Anoxic brain damage, not elsewhere classified 2 G935 Compression of brain 2 G9389 Other specified disorders of brain 5 G939 Disorder of brain, unspecified 2 G94 Other disorders of brain in diseases classified elsewhere 3 G950 Syringomyelia and syringobulbia 3 G9511 Acute infarction of spinal cord (embolic) (nonembolic) 2 G9519 Other vascular myelopathies 2 G9520 Unspecified cord compression 3 G9529 Other cord compression 3 G9581 Conus medullaris syndrome 2 G9589 Other specified diseases of spinal cord 2 G959 Disease of spinal cord, unspecified 3 G960 Cerebrospinal fluid leak 2 9/30/2020 G9600 Cerebrospinal fluid leak, unspecified 2 10/1/2020 G9619 Other disorders of meninges, not elsewhere classified 2 9/30/2020 G96191 Perineural cyst 2 10/1/2020 G96198 Other disorders of meninges, not elsewhere classified 2 10/1/2020 G968 Other specified disorders of central nervous system 3 9/30/2020 G96810 Intracranial hypotension, unspecified 3 10/1/2020

23 CSHCS Qualifying Diagnoses Effective 10/01/2021

G96819 Other intracranial hypotension 3 10/1/2020 G9689 Other specified disorders of central nervous system 3 10/1/2020 G969 Disorder of central nervous system, unspecified 2 G9781 Other intraoperative complications of nervous system 2 G9782 Other postprocedural complications and disorders of nervous system 3 9/30/2020 G988 Other disorders of nervous system 2 G992 Myelopathy in diseases classified elsewhere 2 G998 Other specified disorders of nervous system in diseases classified elsewhere 3 H0260 Xanthelasma of unspecified eye, unspecified eyelid 2 H15849 Scleral ectasia, unspecified eye 2 H1589 Other disorders of sclera 2 H159 Unspecified disorder of sclera 2 H16019 Central corneal ulcer, unspecified eye 2 H16079 Perforated corneal ulcer, unspecified eye 2 H16239 Neurotrophic keratoconjunctivitis, unspecified eye 2 H16309 Unspecified interstitial keratitis, unspecified eye 2 H16409 Unspecified corneal neovascularization, unspecified eye 2 H16429 Pannus (corneal), unspecified eye 2 H1710 Central corneal opacity, unspecified eye 2 H17829 Peripheral opacity of cornea, unspecified eye 2 H1789 Other corneal scars and opacities 2 H179 Unspecified corneal scar and opacity 2 H1840 Unspecified corneal degeneration 2 H18449 Keratomalacia, unspecified eye 2 H18503 Unspecified hereditary corneal dystrophies, bilateral 3 10/1/2020 H18509 Unspecified hereditary corneal dystrophies, unspecified eye 3 10/1/2020 H18513 Endothelial corneal dystrophy, bilateral 3 10/1/2020 H18519 Endothelial corneal dystrophy, unspecified eye 3 10/1/2020 H1852 Epithelial (juvenile) corneal dystrophy 3 9/30/2020 H1853 Granular corneal dystrophy 3 9/30/2020 H18533 Granular corneal dystrophy, bilateral 3 10/1/2020 H18539 Granular corneal dystrophy, unspecified eye 3 10/1/2020 H18543 Lattice corneal dystrophy, bilateral 3 10/1/2020 H18549 Lattice corneal dystrophy, unspecified eye 3 10/1/2020 H18553 Macular corneal dystrophy, bilateral 3 10/1/2020 H18559 Macular corneal dystrophy, unspecified eye 3 10/1/2020 H1859 Other hereditary corneal dystrophies 2 9/30/2020 H18593 Other hereditary corneal dystrophies, bilateral 2 10/1/2020 H18599 Other hereditary corneal dystrophies, unspecified eye 2 10/1/2020 H18609 Keratoconus, unspecified, unspecified eye 2

24 CSHCS Qualifying Diagnoses Effective 10/01/2021

H18719 Corneal ectasia, unspecified eye 2 H18799 Other corneal deformities, unspecified eye 3 H18839 Recurrent erosion of cornea, unspecified eye 2 H18899 Other specified disorders of cornea, unspecified eye 2 H189 Unspecified disorder of cornea 2 H209 Unspecified iridocyclitis 2 H211X9 Other vascular disorders of iris and ciliary body, unspecified eye 2 H21259 Iridoschisis, unspecified eye 2 H21309 Idiopathic cysts of iris, ciliary body or anterior chamber, unspecified eye 2 H2140 Pupillary membranes, unspecified eye 2 H21539 Iridodialysis, unspecified eye 2 H21549 Posterior synechiae (iris), unspecified eye 2 H2189 Other specified disorders of iris and ciliary body 2 H219 Unspecified disorder of iris and ciliary body 2 H22 Disorders of iris and ciliary body in diseases classified elsewhere 2 H26009 Unspecified infantile and juvenile cataract, unspecified eye 2 H26019 Infantile and juvenile cortical, lamellar, or zonular cataract, unspecified eye 2 H26059 Posterior subcapsular polar infantile and juvenile cataract, unspecified eye 2 H26069 Combined forms of infantile and juvenile cataract, unspecified eye 2 H2609 Other infantile and juvenile cataract 2 H26109 Unspecified traumatic cataract, unspecified eye 2 H26129 Partially resolved traumatic cataract, unspecified eye 2 H26139 Total traumatic cataract, unspecified eye 2 H26219 Cataract with neovascularization, unspecified eye 2 H26229 Cataract secondary to ocular disorders (degenerative) (inflammatory), unspecified eye 2 H2630 Drug-induced cataract, unspecified eye 2 H2640 Unspecified secondary cataract 2 H268 Other specified cataract 2 H269 Unspecified cataract 2 H2700 Aphakia, unspecified eye 3 H2710 Unspecified dislocation of lens 2 H27119 Subluxation of lens, unspecified eye 2 H278 Other specified disorders of lens 2 H279 Unspecified disorder of lens 2 H28 Cataract in diseases classified elsewhere 2 H30149 Acute posterior multifocal placoid pigment epitheliopathy, unspecified eye 2 H3020 Posterior cyclitis, unspecified eye 2 H30819 Harada's disease, unspecified eye 2 H30899 Other chorioretinal inflammations, unspecified eye 2 H3090 Unspecified chorioretinal inflammation, unspecified eye 2

25 CSHCS Qualifying Diagnoses Effective 10/01/2021

H31119 Age-related choroidal atrophy, unspecified eye 2 H3121 Choroideremia 2 H3129 Other hereditary choroidal dystrophy 2 H33009 Unspecified retinal detachment with retinal break, unspecified eye 2 H33109 Unspecified retinoschisis, unspecified eye 2 H33199 Other retinoschisis and retinal cysts, unspecified eye 2 H3320 Serous retinal detachment, unspecified eye 2 H3340 Traction detachment of retina, unspecified eye 2 H338 Other retinal detachments 2 H349 Unspecified retinal vascular occlusion 2 H35019 Changes in retinal vascular appearance, unspecified eye 2 H35029 Exudative retinopathy, unspecified eye 2 H35059 Retinal neovascularization, unspecified, unspecified eye 2 H35069 Retinal , unspecified eye 2 H35109 Retinopathy of prematurity, unspecified, unspecified eye 5 H35169 Retinopathy of prematurity, stage 5, unspecified eye 2 9/30/2020 H35179 Retrolental fibroplasia, unspecified eye 2 H3520 Other non-diabetic proliferative retinopathy, unspecified eye 2 H3540 Unspecified peripheral retinal degeneration 2 H35419 Lattice degeneration of retina, unspecified eye 2 H35429 Microcystoid degeneration of retina, unspecified eye 2 H35459 Secondary pigmentary degeneration, unspecified eye 2 H35469 Secondary vitreoretinal degeneration, unspecified eye 2 H3550 Unspecified hereditary retinal dystrophy 2 H3551 Vitreoretinal dystrophy 2 H3552 Pigmentary retinal dystrophy 5 H3553 Other dystrophies primarily involving the sensory retina 2 H3554 Dystrophies primarily involving the retinal pigment epithelium 2 H3560 Retinal hemorrhage, unspecified eye 2 H35739 Hemorrhagic detachment of retinal pigment epithelium, unspecified eye 2 H3582 Retinal ischemia 2 H36 Retinal disorders in diseases classified elsewhere 2 H40009 Preglaucoma, unspecified , unspecified eye 2 H4010x0 Unspecified open-angle glaucoma, stage unspecified 2 H401190 Primary open-angle glaucoma unspecified eye, stage unspecified 2 10/1/2016 H4011x0 Primary open-angle glaucoma, stage unspecified 2 9/30/2016 H401290 Low-tension glaucoma, unspecified eye, stage unspecified 2 H4020x0 Unspecified primary angle-closure glaucoma, stage unspecified 2 H4030x0 Glaucoma secondary to eye trauma, unspecified eye, stage unspecified 2 H4040x0 Glaucoma secondary to eye inflammation, unspecified eye, stage unspecified 2

26 CSHCS Qualifying Diagnoses Effective 10/01/2021

H4050x0 Glaucoma secondary to other eye disorders, unspecified eye, stage unspecified 2 H4089 Other specified glaucoma 2 H409 Unspecified glaucoma 2 H42 Glaucoma in diseases classified elsewhere 3 H4310 Vitreous hemorrhage, unspecified eye 2 H44009 Unspecified purulent endophthalmitis, unspecified eye 2 H44119 Panuveitis, unspecified eye 2 H44139 Sympathetic uveitis, unspecified eye 2 H442A9 Degenerative myopia with choroidal neovascularization, unspecified eye 2 10/1/2017 H442C9 Degenerative myopia with retinal detachment, unspecified eye 2 10/1/2017 H449 Unspecified disorder of globe 2 H47019 Ischemic optic neuropathy, unspecified eye 2 H47029 Hemorrhage in optic nerve sheath, unspecified eye 2 H47039 Optic nerve hypoplasia, unspecified eye 2 H47099 Other disorders of optic nerve, not elsewhere classified, unspecified eye 2 H4720 Unspecified optic atrophy 2 H47219 Primary optic atrophy, unspecified eye 2 H4722 Hereditary optic atrophy 2 H47239 Glaucomatous optic atrophy, unspecified eye 2 H47299 Other optic atrophy, unspecified eye 2 H47319 Coloboma of optic disc, unspecified eye 2 H47329 Drusen of optic disc, unspecified eye 2 H4742 Disorders of optic chiasm in (due to) neoplasm 2 H47529 Disorders of visual pathways in (due to) neoplasm, unspecified side 2 H47619 Cortical blindness, unspecified side of brain 2 H479 Unspecified disorder of visual pathways 2 H4900 Third [oculomotor] nerve palsy, unspecified eye 2 H4910 Fourth [trochlear] nerve palsy, unspecified eye 2 H4920 Sixth [abducent] nerve palsy, unspecified eye 2 H4940 Progressive external ophthalmoplegia, unspecified eye 2 H49889 Other paralytic strabismus, unspecified eye 2 H499 Unspecified paralytic strabismus 2 H5000 Unspecified esotropia 2 H5005 Alternating esotropia 2 H5006 Alternating esotropia with A pattern 2 H5007 Alternating esotropia with V pattern 2 H5010 Unspecified exotropia 2 H5015 Alternating exotropia 2 H5017 Alternating exotropia with V pattern 2 H5021 Vertical strabismus, right eye 2

27 CSHCS Qualifying Diagnoses Effective 10/01/2021

H5030 Unspecified intermittent heterotropia 2 H5034 Intermittent alternating exotropia 2 H5042 Monofixation syndrome 2 H5043 Accommodative component in esotropia 2 H5051 *Phase Out* Esophoria 2 *Phase Out* H5060 Mechanical strabismus, unspecified 2 H5069 Other mechanical strabismus 2 H50811 Duane's syndrome, right eye 3 H509 Unspecified strabismus 2 H5111 Convergence insufficiency 2 H518 Other specified disorders of binocular movement 2 H519 Unspecified disorder of binocular movement 2 H5501 Congenital 2 H61309 Acquired stenosis of external ear canal, unspecified, unspecified ear 2 H61399 Other acquired stenosis of external ear canal, unspecified ear 2 H6520 Chronic serous otitis media, unspecified ear 2 H6530 Chronic mucoid otitis media, unspecified ear 2 H65499 Other chronic nonsuppurative otitis media, unspecified ear 2 H6610 Chronic tubotympanic suppurative otitis media, unspecified 2 H6620 Chronic atticoantral suppurative otitis media, unspecified ear 2 H663X9 Other chronic suppurative otitis media, unspecified ear 2 H68109 Unspecified obstruction of Eustachian tube, unspecified ear 2 H6980 Other specified disorders of Eustachian tube, unspecified ear 2 H7010 Chronic mastoiditis, unspecified ear 2 H70229 Chronic petrositis, unspecified ear 2 H70899 Other mastoiditis and related conditions, unspecified ear 2 H7190 Unspecified cholesteatoma, unspecified ear 2 H7310 Chronic myringitis, unspecified ear 2 H7390 Unspecified disorder of tympanic membrane, unspecified ear 2 H7409 Tympanosclerosis, unspecified ear 2 H7419 Adhesive middle ear disease, unspecified ear 2 H74319 Ankylosis of ear ossicles, unspecified ear 2 H748X9 Other specified disorders of middle ear and mastoid, unspecified ear 2 H7490 Unspecified disorder of middle ear and mastoid, unspecified ear 2 H7500 Mastoiditis in infectious and parasitic diseases classified elsewhere, unspecified ear 2 Other specified disorders of middle ear and mastoid in diseases classified elsewhere, unspecified H7580 ear 2 H818X9 Other disorders of vestibular function, unspecified ear 2 H829 Vertiginous syndromes in diseases classified elsewhere, unspecified ear 2 H8319 Labyrinthine fistula, unspecified ear 2

28 CSHCS Qualifying Diagnoses Effective 10/01/2021

H838X9 Other specified diseases of inner ear, unspecified ear 2 H902 Conductive hearing loss, unspecified 5 H905 Unspecified sensorineural hearing loss 5 H908 Mixed conductive and sensorineural hearing loss, unspecified 5 H93219 Auditory recruitment, unspecified ear 2 H9390 Unspecified disorder of ear, unspecified ear 2 H9500 Recurrent cholesteatoma of postmastoidectomy cavity, unspecified ear 2 H95119 Chronic inflammation of postmastoidectomy cavity, unspecified ear 2 H95139 Mucosal cyst of postmastoidectomy cavity, unspecified ear 2 H95199 Other disorders following mastoidectomy, unspecified ear 2 I018 Other acute rheumatic heart disease 3 I019 Acute rheumatic heart disease, unspecified 3 I020 Rheumatic chorea with heart involvement 3 I029 Rheumatic chorea without heart involvement 3 I050 Rheumatic mitral stenosis 3 I051 Rheumatic mitral insufficiency 3 I052 Rheumatic mitral stenosis with insufficiency 3 I058 Other rheumatic mitral valve diseases 3 I059 Rheumatic mitral valve disease, unspecified 3 I061 Rheumatic aortic insufficiency 3 I070 Rheumatic tricuspid stenosis 3 I071 Rheumatic tricuspid insufficiency 3 I072 Rheumatic tricuspid stenosis and insufficiency 3 I078 Other rheumatic tricuspid valve diseases 3 I079 Rheumatic tricuspid valve disease, unspecified 3 I080 Rheumatic disorders of both mitral and aortic valves 3 I089 Rheumatic multiple valve disease, unspecified 3 I10 Essential (primary) hypertension 2 I110 Hypertensive heart disease with heart failure 3 I119 Hypertensive heart disease without heart failure 2

I120 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease 3 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or I129 unspecified chronic kidney disease 3 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 I1310 chronic kidney disease, or unspecified chronic kidney disease 3 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney I1311 disease, or end stage renal disease 3 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney I132 disease, or end stage renal disease 3

29 CSHCS Qualifying Diagnoses Effective 10/01/2021

I150 Renovascular hypertension 2 I151 Hypertension secondary to other renal disorders 2 I152 Hypertension secondary to endocrine disorders 2 I158 Other secondary hypertension 2 I159 Secondary hypertension, unspecified 2 I213 ST elevation (STEMI) myocardial infarction of unspecified site 2 I219 Acute myocardial infarction, unspecified 2 10/1/2017 I21A9 Other myocardial infarction type 2 10/1/2017 I229 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site 2 I2541 Coronary artery aneurysm 2 I255 Ischemic cardiomyopathy 2 I256 Silent myocardial ischemia 2 I2589 Other forms of chronic ischemic heart disease 2 I259 Chronic ischemic heart disease, unspecified 2 I270 Primary pulmonary hypertension 2 I272 Other secondary pulmonary hypertension 2 9/30/2017 I2720 Pulmonary hypertension, unspecified 2 10/1/2017 I2721 Secondary pulmonary arterial hypertension 2 10/1/2017 I2781 Cor pulmonale (chronic) 2 I2782 Chronic pulmonary embolism 2 I2783 Eisenmenger's syndrome 2 10/1/2017 I2789 Other specified pulmonary heart diseases 2 I279 Pulmonary heart disease, unspecified 2 I288 Other diseases of pulmonary vessels 2 I289 Disease of pulmonary vessels, unspecified 2 I311 Chronic constrictive pericarditis 2 I313 Pericardial effusion (noninflammatory) 2 I318 Other specified diseases of pericardium 2 I319 Disease of pericardium, unspecified 2 I330 Acute and subacute infective endocarditis 2 I339 Acute and subacute endocarditis, unspecified 2 I340 Nonrheumatic mitral (valve) insufficiency 3 I341 Nonrheumatic mitral (valve) prolapse 3 I342 Nonrheumatic mitral (valve) stenosis 3 I348 Other nonrheumatic mitral valve disorders 3 I349 Nonrheumatic mitral valve disorder, unspecified 3 I350 Nonrheumatic aortic (valve) stenosis 3 I351 Nonrheumatic aortic (valve) insufficiency 3 I352 Nonrheumatic aortic (valve) stenosis with insufficiency 3 I358 Other nonrheumatic aortic valve disorders 3

30 CSHCS Qualifying Diagnoses Effective 10/01/2021

I359 Nonrheumatic aortic valve disorder, unspecified 3 I360 Nonrheumatic tricuspid (valve) stenosis 3 I361 Nonrheumatic tricuspid (valve) insufficiency 3 I362 Nonrheumatic tricuspid (valve) stenosis with insufficiency 3 I368 Other nonrheumatic tricuspid valve disorders 3 I369 Nonrheumatic tricuspid valve disorder, unspecified 3 I370 Nonrheumatic pulmonary valve stenosis 3 I371 Nonrheumatic pulmonary valve insufficiency 3 I372 Nonrheumatic pulmonary valve stenosis with insufficiency 3 I378 Other nonrheumatic pulmonary valve disorders 3 I379 Nonrheumatic pulmonary valve disorder, unspecified 3 I38 Endocarditis, valve unspecified 3 I400 Infective myocarditis 2 I401 Isolated myocarditis 2 I408 Other acute myocarditis 2 I409 Acute myocarditis, unspecified 2 I420 Dilated cardiomyopathy 3 I421 Obstructive hypertrophic cardiomyopathy 3 I422 Other hypertrophic cardiomyopathy 3 I423 Endomyocardial (eosinophilic) disease 3 I424 Endocardial fibroelastosis 3 I425 Other restrictive cardiomyopathy 3 I427 Cardiomyopathy due to drug and external agent 3 I428 Other cardiomyopathies 3 I429 Cardiomyopathy, unspecified 3 I43 Cardiomyopathy in diseases classified elsewhere 3 I440 Atrioventricular block, first degree 3 I441 Atrioventricular block, second degree 3 I442 Atrioventricular block, complete 3 I4430 Unspecified atrioventricular block 3 I4439 Other atrioventricular block 3 I450 Right fascicular block 3 I4510 Unspecified right bundle-branch block 3 I4519 Other right bundle-branch block 3 I454 Nonspecific intraventricular block 3 I455 Other specified heart block 3 I456 Pre-excitation syndrome 3 I4589 Other specified conduction disorders 3 I459 Conduction disorder, unspecified 2 I471 Supraventricular tachycardia 3

31 CSHCS Qualifying Diagnoses Effective 10/01/2021

I480 Paroxysmal atrial fibrillation 3 I481 Persistent atrial fibrillation 3 9/30/2019 I4819 Other persistent atrial fibrillation 3 10/1/2019 I482 Chronic atrial fibrillation 3 9/30/2019 I4820 Chronic atrial fibrillation, unspecified 3 10/1/2019 I483 Typical atrial flutter 3 I484 Atypical atrial flutter 3 I4891 Unspecified atrial fibrillation 3 I4892 Unspecified atrial flutter 3 I492 Junctional premature depolarization 3 I501 Left ventricular failure 2 I5020 Unspecified systolic (congestive) heart failure 2 I5030 Unspecified diastolic (congestive) heart failure 2 I5040 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure 2 I50810 Right heart failure, unspecified 2 10/1/2017 I5082 Biventricular heart failure 2 10/1/2017 I5083 High output heart failure 2 10/1/2017 I5084 End stage heart failure 2 10/1/2017 I5089 Other heart failure 2 10/1/2017 I509 Heart failure, unspecified 2 I514 Myocarditis, unspecified 2 I515 Myocardial degeneration 2 I517 Cardiomegaly 2 I519 Heart disease, unspecified 2 I52 Other heart disorders in diseases classified elsewhere 2 I609 Nontraumatic subarachnoid hemorrhage, unspecified 2 I619 Nontraumatic intracerebral hemorrhage, unspecified 2 I6200 Nontraumatic subdural hemorrhage, unspecified 2 I669 Occlusion and stenosis of unspecified cerebral artery 2 I671 Cerebral aneurysm, nonruptured 2 I675 Moyamoya disease 5 I677 Cerebral , not elsewhere classified 2 I67841 Reversible cerebrovascular vasoconstriction syndrome 2 I67848 Other cerebrovascular vasospasm and vasoconstriction 2 I6789 Other cerebrovascular disease 2 I6900 Unspecified sequelae of nontraumatic subarachnoid hemorrhage 2 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting I69059 unspecified side 2 I69098 Other sequelae following nontraumatic subarachnoid hemorrhage 2 I6910 Unspecified sequelae of nontraumatic intracerebral hemorrhage 2

32 CSHCS Qualifying Diagnoses Effective 10/01/2021

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting I69159 unspecified side 5 I69198 Other sequelae of nontraumatic intracerebral hemorrhage 5 I6920 Unspecified sequelae of other nontraumatic intracranial hemorrhage 2 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting I69259 unspecified side 5 I69298 Other sequelae of other nontraumatic intracranial hemorrhage 5 I6930 Unspecified sequelae of cerebral infarction 2 I69359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side 5 I69398 Other sequelae of cerebral infarction 5 I6980 Unspecified sequelae of other cerebrovascular disease 2

I69859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side 5 I69898 Other sequelae of other cerebrovascular disease 5 I6990 Unspecified sequelae of unspecified cerebrovascular disease 2 I6991 Cognitive deficits following unspecified cerebrovascular disease 2 9/30/2016 I69919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular 2 10/1/2016 I69920 Aphasia following unspecified cerebrovascular disease 2 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified I69959 side 5 I69998 Other sequelae following unspecified cerebrovascular disease 5 I728 Aneurysm of other specified arteries 2 I739 Peripheral vascular disease, unspecified 2 I748 Embolism and thrombosis of other arteries 2 I749 Embolism and thrombosis of unspecified artery 2 I776 Arteritis, unspecified 3 I780 Hereditary hemorrhagic telangiectasia 3 I823 Embolism and thrombosis of renal vein 2 I82891 Chronic embolism and thrombosis of other specified veins 2 I8291 Chronic embolism and thrombosis of unspecified vein 2 I890 Lymphedema, not elsewhere classified 3 I96 Gangrene, not elsewhere classified 2 J3800 Paralysis of vocal cords and larynx, unspecified 2 J3801 Paralysis of vocal cords and larynx, unilateral 3 J381 Polyp of vocal cord and larynx 2 J386 Stenosis of larynx 2 J42 Unspecified chronic bronchitis 2 J439 Emphysema, unspecified 3 J4540 Moderate persistent asthma, uncomplicated 3 J4550 Severe persistent asthma, uncomplicated 3

33 CSHCS Qualifying Diagnoses Effective 10/01/2021

J45998 Other asthma 2 J479 Bronchiectasis, uncomplicated 2 J8281 Chronic eosinophilic pneumonia 1 10/1/2020 J8283 Eosinophilic asthma 1 10/1/2020 J8289 Other pulmonary eosinophilia, not elsewhere classified 1 10/1/2020 J8403 Idiopathic pulmonary hemosiderosis 3 J8409 Other alveolar and parieto-alveolar conditions 3 J8410 Pulmonary fibrosis, unspecified 3 J84111 Idiopathic interstitial pneumonia, not otherwise specified 3 J84112 Idiopathic pulmonary fibrosis 3 J84113 Idiopathic non-specific interstitial pneumonitis 3 J84114 Acute interstitial pneumonitis 3 J84115 Respiratory bronchiolitis interstitial lung disease 3 J84116 Cryptogenic organizing pneumonia 2 J8417 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere 3 9/30/2020 J84178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere 3 10/1/2020 J8489 Other specified interstitial pulmonary diseases 3 J853 Abscess of mediastinum 2 J860 Pyothorax with fistula 2 J869 Pyothorax without fistula 2 J9500 Unspecified tracheostomy complication 2 J951 Acute pulmonary insufficiency following thoracic surgery 2 J952 Acute pulmonary insufficiency following nonthoracic surgery 2 J953 Chronic pulmonary insufficiency following surgery 2 J95821 Acute postprocedural respiratory failure 2 J95822 Acute and chronic postprocedural respiratory failure 2 J982 Interstitial emphysema 3 J984 Other disorders of lung 2 J989 Respiratory disorder, unspecified 2 K000 Anodontia 3 K004 Disturbances in tooth formation 3 K005 Hereditary disturbances in tooth structure, not elsewhere classified 3 K0389 Other specified diseases of hard tissues of teeth 3 K222 Esophageal obstruction 2 K5000 Crohn's disease of small intestine without complications 3 K50019 Crohn's disease of small intestine with unspecified complications 3 K5010 Crohn's disease of large intestine without complications 3 K50119 Crohn's disease of large intestine with unspecified complications 3 K5080 Crohn's disease of both small and large intestine without complications 3 K50819 Crohn's disease of both small and large intestine with unspecified complications 3

34 CSHCS Qualifying Diagnoses Effective 10/01/2021

K5090 Crohn's disease, unspecified, without complications 3 K50919 Crohn's disease, unspecified, with unspecified complications 3 K5100 Ulcerative (chronic) pancolitis without complications 5 K5190 Ulcerative colitis, unspecified, without complications 3 K51919 Ulcerative colitis, unspecified with unspecified complications 3 K522 Allergic and dietetic gastroenteritis and colitis 2 9/30/2016 K5221 Allergic & Dietetic Gastroenteritis and Colitis 2 10/1/2017 K5229 Other allergic dietetic gastroenteritis colitis 2 10/1/2016 K5281 Eosinophilic gastritis or gastroenteritis 2 K5282 Eosinophilic colitis 2 K529 Noninfective gastroenteritis and colitis, unspecified 2 K550 Acute vascular disorders of intestine 2 9/30/2016 K551 Chronic vascular disorders of intestine 2 10/1/2016 K592 Neurogenic bowel, not elsewhere classified 1 K717 Toxic liver disease with fibrosis and cirrhosis of liver 3 K7290 Hepatitic failure, unspecified without coma 3 K7291 Hepatitic failure, unspecified with coma 3 K730 Chronic persistent hepatitis, not elsewhere classified 3 K731 Chronic lobular hepatitis, not elsewhere classified 3 K732 Chronic active hepatitis, not elsewhere classified 3 K738 Other chronic hepatitis, not elsewhere classified 3 K739 Chronic hepatitis, unspecified 2 K740 Hepatic fibrosis 3 9/30/2020 K7400 Hepatic fibrosis, unspecified 3 10/1/2020 K745 Biliary cirrhosis, unspecified 3 K7460 Unspecified cirrhosis of liver 3 K7469 Other cirrhosis of liver 3 K754 Autoimmune hepatitis 3 K766 Portal hypertension 3 K835 Biliary cyst 2 K838 Other specified diseases of biliary tract 2 K861 Other chronic pancreatitis 2 K868 Other specified diseases of pancreas 2 9/30/2016 K8681 Exocrine pancreatic insufficiency 2 10/1/2016 K8689 Other specified diseases of pancreas 2 10/1/2016 K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere 2 K900 Celiac disease 3 K902 Blind loop syndrome, not elsewhere classified 2 K903 Pancreatic steatorrhea 3 K904 due to intolerance, not elsewhere classified 2 9/30/2016

35 CSHCS Qualifying Diagnoses Effective 10/01/2021

K9049 Malabsorption due to intolerance not elswhere classified 2 10/1/2016 K9089 Other intestinal malabsorption 2 K909 Intestinal malabsorption, unspecified 3 K912 Postsurgical malabsorption, not elsewhere classified 3 L109 Pemphigus, unspecified 5 L400 Psoriasis vulgaris 3 L404 Guttate psoriasis 3 L4050 Arthropathic psoriasis, unspecified 5 L4059 Other psoriatic arthropathy 5 L408 Other psoriasis 3 L409 Psoriasis, unspecified 3 L511 Stevens-Johnson syndrome 2 L512 Toxic epidermal necrolysis [Lyell] 2 L518 Other erythema multiforme 3 L599 Disorder of the skin and subcutaneous tissue related to radiation, unspecified 2 L905 Scar conditions and fibrosis of skin 2 L930 Discoid lupus erythematosus 3 L931 Subacute cutaneous lupus erythematosus 3 L932 Other local lupus erythematosus 3 L940 Localized 5 M009 Pyogenic arthritis, unspecified 2

M01X0 Direct infection of unspecified joint in infectious and parasitic diseases classified elsewhere 2 M029 Reactive arthropathy, unspecified 2 M041 Periodic fever syndromes 3 10/1/2016 M0520 Rheumatoid vasculitis with rheumatoid arthritis of unspecified site 3 M0530 Rheumatoid heart disease with rheumatoid arthritis of unspecified site 3 M0540 Rheumatoid myopathy with rheumatoid arthritis of unspecified site 3 M0550 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site 3 M0560 Rheumatoid arthritis of unspecified site with involvement of other organs and systems 3 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems M0570 involvement 3 M057A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement 3 9/30/2021 10/1/2020 M0580 Other rheumatoid arthritis with rheumatoid factor of unspecified site 3 M058A Other rheumatoid arthritis with rheumatoid factor of other specified site 3 9/30/2021 10/1/2020 M059 Rheumatoid arthritis with rheumatoid factor, unspecified 3 M0600 Rheumatoid arthritis without rheumatoid factor, unspecified site 3 M060A Rheumatoid arthritis without rheumatoid factor, other specified site 3 9/30/2021 10/1/2020 M061 *Phase Out* Adult-onset Still's disease 3 *Phase Out*

36 CSHCS Qualifying Diagnoses Effective 10/01/2021

M0620 Rheumatoid bursitis, unspecified site 3 M0630 Rheumatoid nodule, unspecified site 3 M064 Inflammatory polyarthropathy 2 M0680 Other specified rheumatoid arthritis, unspecified site 3 M068A Other specified rheumatoid arthritis, other specified site 3 9/30/2021 10/1/2020 M069 Rheumatoid arthritis, unspecified 3 M0760 Enteropathic arthropathies, unspecified site 2 M0800 Unspecified juvenile rheumatoid arthritis of unspecified site 3 M080A Unspecified juvenile rheumatoid arthritis, other specified site 3 9/30/2021 10/1/2020 M081 Juvenile ankylosing spondylitis 5 M0820 Juvenile rheumatoid arthritis with systemic onset, unspecified site 3 M082A Juvenile rheumatoid arthritis with systemic onset, other specified site 3 9/30/2021 10/1/2020 M083 Juvenile rheumatoid polyarthritis (seronegative) 3 M0840 Pauciarticular juvenile rheumatoid arthritis, unspecified site 3 M084A Pauciarticular juvenile rheumatoid arthritis, other specified site 3 9/30/2021 10/1/2020 M0880 Other juvenile arthritis, unspecified site 3 M0890 Juvenile arthritis, unspecified, unspecified site 3 M089A Juvenile arthritis, unspecified, other specified site 3 9/30/2021 10/1/2020 M1280 Other specific arthropathies, not elsewhere classified, unspecified site 2 M1460 Charcot's joint, unspecified site 2 M1480 Arthropathies in other specified diseases classified elsewhere, unspecified site 2 M151 *Phase Out* Heberden's nodes (with arthropathy) 2 *Phase Out* M152 *Phase Out* Bouchard's nodes (with arthropathy) 3 *Phase Out* M1990 Unspecified osteoarthritis, unspecified site 2 M1A10x0 Lead-induced chronic gout, unspecified site, without tophus (tophi) 2 M1A10x1 Lead-induced chronic gout, unspecified site, with tophus (tophi) 2 M2100 Valgus deformity, not elsewhere classified, unspecified site 3 M21059 Valgus deformity, not elsewhere classified, unspecified hip 2 M21069 Valgus deformity, not elsewhere classified, unspecified knee 2 M21129 Varus deformity, not elsewhere classified, unspecified elbow 2 M21159 Varus deformity, not elsewhere classified, unspecified 2 M21169 Varus deformity, not elsewhere classified, unspecified knee 2 M2120 Flexion deformity, unspecified site 3 M21379 Foot drop, unspecified foot 2 M21519 Acquired clawhand, unspecified hand 2 M21539 Acquired clawfoot, unspecified foot 2 M21549 Acquired clubfoot, unspecified foot 2 M216X9 Other acquired deformities of unspecified foot 2 M2170 Unequal limb length (acquired), unspecified site 3 M2180 Other specified acquired deformities of unspecified limb 2

37 CSHCS Qualifying Diagnoses Effective 10/01/2021

M21859 Other specified acquired deformities of unspecified thigh 2 M21869 Other specified acquired deformities of unspecified lower leg 2 M2190 Unspecified acquired deformity of unspecified limb 3 M21939 Unspecified acquired deformity of unspecified forearm 2 M21959 Unspecified acquired deformity of unspecified thigh 2 M21969 Unspecified acquired deformity of unspecified lower leg 2 M2410 Other articular cartilage disorders, unspecified site 2 M2419 Other articular cartilage disorders, other specified site 2 10/1/2020 M2430 Pathological dislocation of unspecified joint, not elsewhere classified 2 M2439 Pathological dislocation of other specified joint, not elsewhere classified 2 10/1/2020 M2440 Recurrent dislocation, unspecified joint 2 M2449 Recurrent dislocation, other specified joint 2 10/1/2020 M2450 Contracture, unspecified joint 2 M2459 Contracture, other specified joint 2 10/1/2020 M24659 Ankylosis, unspecified hip 2 9/30/2020 M2469 Ankylosis, other specified joint 2 10/1/2020 M2480 Other specific joint derangements of unspecified joint, not elsewhere classified 2 M24859 Other specific joint derangements of unspecified hip, not elsewhere classified 3 M2489 Other specific joint derangement of other specified joint, not elsewhere classified 2 10/1/2020 M2510 Fistula, unspecified joint 2 M2518 Fistula, vertebrae 2 M2520 Flail joint, unspecified joint 2 M2530 Other instability, unspecified joint 2 M2539 Other instability, other specified joint 2 10/1/2020 M2580 Other specified joint disorders, unspecified joint 2 M25859 Other specified joint disorders, unspecified hip 2 M25869 Other specified joint disorders, unspecified knee 2 M259 Joint disorder, unspecified 2 M2600 Unspecified anomaly of jaw size 3 M2610 Unspecified anomaly of jaw-cranial base relationship 3 M2620 Unspecified anomaly of dental arch relationship 3 M26212 *Phase Out* Malocclusion, Angle's class II 3 *Phase Out* M26213 *Phase Out* Malocclusion, Angle's class III 3 *Phase Out* M26219 *Phase Out* Malocclusion, Angle's class, unspecified 3 *Phase Out* M264 *Phase Out* Malocclusion, unspecified 3 *Phase Out* M2650 Dentofacial functional abnormalities, unspecified 2 M2659 Other dentofacial functional abnormalities 2 M2660 Temporomandibular joint disorder, unspecified 2 9/30/2016 M26609 Unspecified temporomandibular joint disorder unspecfied side 2 10/1/2016 M2662 Arthralgia of temporomandibular joint 2 9/30/2016

38 CSHCS Qualifying Diagnoses Effective 10/01/2021

M26643 Arthritis of bilateral temporomandibular joint 2 10/1/2020 M26649 Arthritis of unspecified temporomandibular joint 2 10/1/2020 M26653 Arthropathy of bilateral temporomandibular joint 2 10/1/2020 M26659 Arthropathy of unspecified temporomandibular joint 2 10/1/2020 M2669 Other specified disorders of temporomandibular joint 2 M2689 Other dentofacial anomalies 3 M269 Dentofacial anomaly, unspecified 3 M300 Polyarteritis nodosa 5 M301 Polyarteritis with lung involvement [Churg-Strauss] 5 M302 Juvenile polyarteritis 3 M303 Mucocutaneous lymph node syndrome [Kawasaki] 2 M311 Thrombotic microangiopathy 5 M311 Thrombotic microangiopathy 5 9/30/2021 M3110 Thrombotic microangiopathy, unspecified 5 10/1/2021 M3130 Wegener's granulomatosis without renal involvement 5 M3131 Wegener's granulomatosis with renal involvement 5 M314 Aortic arch syndrome [Takayasu] 5 M329 Systemic lupus erythematosus, unspecified 5 M3300 Juvenile dermatopolymyositis, organ involvement unspecified 5 M3303 Juvenile without myopathy 5 10/1/2017 M3310 Other dermatopolymyositis, organ involvement unspecified 5 M3313 Other dermatomyositis without myopathy 5 10/1/2017 M3320 , organ involvement unspecified 5 M3390 Dermatopolymyositis, unspecified, organ involvement unspecified 5 M3393 Dermatopolymyositis, unspecified without myopathy 5 10/1/2017 M340 Progressive systemic sclerosis 5 M341 CR(E)ST syndrome 5 M3481 Systemic sclerosis with lung involvement 5 M349 Systemic sclerosis, unspecified 5 M3500 Sicca syndrome (Sjogren), unspecified 5 M351 Other overlap syndromes 3 M352 Behcet's disease 2 M354 Diffuse (eosinophilic) fasciitis 2 M355 Multifocal fibrosclerosis 3 M358 Other specified systemic involvement of connective tissue 3 12/31/2020 M3581 Multi Inflammatory Syndrome (MIS) 1 1/1/2021 M359 Systemic involvement of connective tissue, unspecified 2 M360 Dermato(poly) in neoplastic disease 5 M361 Arthropathy in neoplastic disease 2 M362 Hemophilic arthropathy 2

39 CSHCS Qualifying Diagnoses Effective 10/01/2021

M363 Arthropathy in other blood disorder 2 M368 Systemic disorders of connective tissue in other diseases classified elsewhere 2 M4000 Postural kyphosis, site unspecified 2 M4010 Other secondary kyphosis, site unspecified 3 M40209 Unspecified kyphosis, site unspecified 2 M40299 Other kyphosis, site unspecified 2 M4100 Infantile idiopathic scoliosis, site unspecified 2 M41119 Juvenile idiopathic scoliosis, site unspecified 2 M41129 Adolescent idiopathic scoliosis, site unspecified 2 M4120 Other idiopathic scoliosis, site unspecified 2 M4130 Thoracogenic scoliosis, site unspecified 2 M4140 Neuromuscular scoliosis, site unspecified 3 M4150 Other secondary scoliosis, site unspecified 3 M4180 Other forms of scoliosis, site unspecified 2 M419 Scoliosis, unspecified 2 M4200 Juvenile of spine, site unspecified 2 M429 Spinal osteochondrosis, unspecified 2 M435X9 Other recurrent vertebral dislocation, site unspecified 2 M438X9 Other specified deforming dorsopathies, site unspecified 3 M439 Deforming dorsopathy, unspecified 2 M459 Ankylosing spondylitis of unspecified sites in spine 5 M4690 Unspecified inflammatory spondylopathy, site unspecified 2 M4699 Unspecified inflammatory spondylopathy, multiple sites in spine 2 M4720 Other spondylosis with radiculopathy, site unspecified 2 M47819 Spondylosis without myelopathy or radiculopathy, site unspecified 2 M47892 Other spondylosis, cervical region 2 M47897 Other spondylosis, lumbosacral region 2 M47899 Other spondylosis, site unspecified 2 M479 Spondylosis, unspecified 2 M4800 Spinal stenosis, site unspecified 2 M4840xS Fatigue fracture of vertebra, site unspecified, sequela of fracture 2 M4850xS Collapsed vertebra, not elsewhere classified, site unspecified, sequela of fracture 2 M488X9 Other specified spondylopathies, site unspecified 5 M489 Spondylopathy, unspecified 2 M5106 Intervertebral disc disorders with myelopathy, lumbar region 2 M5127 Other intervertebral disc displacement, lumbosacral region 2 M519 Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder 2 M532X9 Spinal instabilities, site unspecified 2 M5381 Other specified dorsopathies, occipito-atlanto-axial region 2 M6110 Myositis ossificans progressiva, unspecified site 5

40 CSHCS Qualifying Diagnoses Effective 10/01/2021

M6220 Nontraumatic ischemic infarction of muscle, unspecified site 2 M623 Immobility syndrome (paraplegic) 2 M6250 Muscle wasting and atrophy, not elsewhere classified, unspecified site 2 M6289 Other specified disorders of muscle 2 M6700 Short Achilles tendon (acquired), unspecified ankle 2 Other with current pathological fracture, unspecified site, subsequent encounter for M8080xK fracture with 2 M8430xK , unspecified site, subsequent encounter for fracture with nonunion 2 M8430xS Stress fracture, unspecified site, sequela 2 M8438xK Stress fracture, other site, subsequent encounter for fracture with nonunion 2 M8440xK Pathological fracture, unspecified site, subsequent encounter for fracture with nonunion 2 M8440xS Pathological fracture, unspecified site, sequela 2 M84550S Pathological fracture in neoplastic disease, pelvis, sequela 2 M8458xS Pathological fracture in neoplastic disease, vertebrae, sequela 2 Pathological fracture in other disease, unspecified site, subsequent encounter for fracture with M8460xK nonunion 2 M84669S Pathological fracture in other disease, unspecified tibia and fibula, sequela 2 M84673S Pathological fracture in other disease, unspecified ankle, sequela 2 M84676S Pathological fracture in other disease, unspecified foot, sequela 2 M8560 Other cyst of bone, unspecified site 2 M8630 Chronic multifocal , unspecified site 2 M8640 Chronic osteomyelitis with draining sinus, unspecified site 2 M8650 Other chronic hematogenous osteomyelitis, unspecified site 2 M8660 Other chronic osteomyelitis, unspecified site 2 M868X9 Other osteomyelitis, unspecified sites 2 M8700 Idiopathic aseptic necrosis of unspecified bone 2 M8710 Osteonecrosis due to drugs, unspecified bone 2 M8720 Osteonecrosis due to previous trauma, unspecified bone 2 M8730 Other secondary osteonecrosis, unspecified bone 2 M8780 Other osteonecrosis, unspecified bone 2 M879 Osteonecrosis, unspecified 2 M9058 Osteonecrosis in diseases classified elsewhere, other site 2 M910 Juvenile osteochondrosis of pelvis 2 M9110 Juvenile osteochondrosis of head of femur [Legg-Calve-Perthes], unspecified leg 2 M9120 Coxa plana, unspecified hip 2 M9130 Pseudocoxalgia, unspecified hip 2 M9140 Coxa magna, unspecified hip 2 M9180 Other juvenile osteochondrosis of hip and pelvis, unspecified leg 2 M9190 Juvenile osteochondrosis of hip and pelvis, unspecified, unspecified leg 2 M9200 Juvenile osteochondrosis of humerus, unspecified arm 2

41 CSHCS Qualifying Diagnoses Effective 10/01/2021

M9210 Juvenile osteochondrosis of radius and ulna, unspecified arm 2 M92209 Unspecified juvenile osteochondrosis, unspecified hand 2 M92219 Osteochondrosis (juvenile) of carpal lunate [Kienbock], unspecified hand 2 M92229 Osteochondrosis (juvenile) of metacarpal heads [Mauclaire], unspecified hand 2 M92299 Other juvenile osteochondrosis, unspecified hand 2 M9230 Other juvenile osteochondrosis, unspecified upper limb 2 M9240 Juvenile osteochondrosis of patella, unspecified knee 2 M9250 Juvenile osteochondrosis of tibia and fibula, unspecified leg 2 9/30/2020 M92503 Unspecified juvenile osteochondrosis, bilateral leg 2 10/1/2020 M92509 Unspecified juvenile osteochondrosis, unspecified leg 2 10/1/2020 M92513 Juvenile osteochondrosis of proximal tibia, bilateral 2 10/1/2020 M92519 Juvenile osteochondrosis of proximal tibia, unspecified leg 2 10/1/2020 M92523 Juvenile osteochondrosis of tibia tubercle, bilateral 2 10/1/2020 M92529 Juvenile osteochondrosis of tibia tubercle, unspecified leg 2 10/1/2020 M92593 Other juvenile osteochondrosis of tibia and fibula, bilateral 2 10/1/2020 M92599 Other juvenile osteochondrosis of tibia and fibula, unspecified leg 2 10/1/2020 M9260 Juvenile osteochondrosis of tarsus, unspecified ankle 2 M9270 Juvenile osteochondrosis of metatarsus, unspecified foot 2 M93003 Unspecified slipped upper femoral epiphysis (nontraumatic), unspecified hip 2 M93013 Acute slipped upper femoral epiphysis (nontraumatic), unspecified hip 2 M93023 Chronic slipped upper femoral epiphysis (nontraumatic), unspecified hip 2 M93033 Acute on chronic slipped upper femoral epiphysis (nontraumatic), unspecified hip 2 M9320 dissecans of unspecified site 2 M9328 Osteochondritis dissecans other site 2 M9329 Osteochondritis dissecans multiple sites 2 M9390 Osteochondropathy, unspecified of unspecified site 2 M950 Acquired deformity of nose 2 M959 Acquired deformity of musculoskeletal system, unspecified 2 M963 Postlaminectomy kyphosis 2 M9920 Subluxation stenosis of neural canal of head region 2 M9921 Subluxation stenosis of neural canal of cervical region 2 M9923 Subluxation stenosis of neural canal of lumbar region 2 M9930 Osseous stenosis of neural canal of head region 2 M9931 Osseous stenosis of neural canal of cervical region 2 M9933 Osseous stenosis of neural canal of lumbar region 2 M9940 Connective tissue stenosis of neural canal of head region 2 M9941 Connective tissue stenosis of neural canal of cervical region 2 M9943 Connective tissue stenosis of neural canal of lumbar region 2 M9950 Intervertebral disc stenosis of neural canal of head region 2 M9951 Intervertebral disc stenosis of neural canal of cervical region 2

42 CSHCS Qualifying Diagnoses Effective 10/01/2021

M9953 Intervertebral disc stenosis of neural canal of lumbar region 2 M9960 Osseous and subluxation stenosis of intervertebral foramina of head region 2 M9961 Osseous and subluxation stenosis of intervertebral foramina of cervical region 2 M9963 Osseous and subluxation stenosis of intervertebral foramina of lumbar region 2 M9970 Connective tissue and disc stenosis of intervertebral foramina of head region 2 M9971 Connective tissue and disc stenosis of intervertebral foramina of cervical region 2 M9973 Connective tissue and disc stenosis of intervertebral foramina of lumbar region 2 M999 Biomechanical lesion, unspecified 2 N019 Rapidly progressive nephritic syndrome with unspecified morphologic changes 3 N020 Recurrent and persistent hematuria with minor glomerular abnormality 3 N025 Recurrent and persistent hematuria with diffuse mesangiocapillary glomerulonephritis 3 N026 Recurrent and persistent hematuria with dense deposit disease 3 N038 Chronic nephritic syndrome with other morphologic changes 3 N039 Chronic nephritic syndrome with unspecified morphologic changes 3 N03A Chronic nephritic syndrome with C3 glomerulonephritis 3 10/1/2020 N040 Nephrotic syndrome with minor glomerular abnormality 3 N043 Nephrotic syndrome with diffuse mesangial proliferative glomerulonephritis 3 N044 Nephrotic syndrome with diffuse endocapillary proliferative glomerulonephritis 3 N045 Nephrotic syndrome with diffuse mesangiocapillary glomerulonephritis 3 N046 Nephrotic syndrome with dense deposit disease 3 N048 Nephrotic syndrome with other morphologic changes 3 N049 Nephrotic syndrome with unspecified morphologic changes 3 N04A Nephrotic syndrome with C3 glomerulonephritis 3 10/1/2020 N052 Unspecified nephritic syndrome with diffuse membranous glomerulonephritis 3 N055 Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis 3 N059 Unspecified nephritic syndrome with unspecified morphologic changes 3 N079 Hereditary nephropathy, not elsewhere classified with unspecified morphologic lesions 3 N08 Glomerular disorders in diseases classified elsewhere 3 N131 Hydronephrosis with ureteral stricture, not elsewhere classified 2 N132 Hydronephrosis with renal and ureteral calculous obstruction 2 N1330 Unspecified hydronephrosis 2 N1339 Other hydronephrosis 2 N134 Hydroureter 2 N1370 Vesicoureteral-reflux, unspecified 2 N13729 Vesicoureteral-reflux with reflux nephropathy without hydroureter, unspecified 3 N13731 Vesicoureteral-reflux with reflux nephropathy with hydroureter, unilateral 2 N13732 Vesicoureteral-reflux with reflux nephropathy with hydroureter, bilateral 2 N13739 Vesicoureteral-reflux with reflux nephropathy with hydroureter, unspecified 3 N138 Other obstructive and reflux uropathy 2 N139 Obstructive and reflux uropathy, unspecified 3

43 CSHCS Qualifying Diagnoses Effective 10/01/2021

N159 Renal tubulo-interstitial disease, unspecified 3 N171 Acute kidney failure with acute cortical necrosis 2 N178 Other acute kidney failure 2 N179 Acute kidney failure, unspecified 2 N181 *Phase Out* Chronic kidney disease, stage 1 5 *Phase Out* N182 *Phase Out* Chronic kidney disease, stage 2 (mild) 5 *Phase Out* N183 Chronic kidney disease, stage 3 (moderate) 5 9/30/2020 N1830 Chronic kidney disease, stage 3 unspecified 5 10/1/2020 N184 Chronic kidney disease, stage 4 (severe) 5 N185 Chronic kidney disease, stage 5 5 N186 End stage renal disease 5 N189 Chronic kidney disease, unspecified 5 N19 Unspecified kidney failure 2 N250 3 N251 Nephrogenic diabetes insipidus 2 N2589 Other disorders resulting from impaired renal tubular function 2 N262 Page kidney 2 N280 Ischemia and infarction of kidney 3 N2889 Other specified disorders of kidney and ureter 2 N289 Disorder of kidney and ureter, unspecified 2 N29 Other disorders of kidney and ureter in diseases classified elsewhere 2 N319 Neuromuscular dysfunction of bladder, unspecified 3 N320 Bladder-neck obstruction 3 N329 Bladder disorder, unspecified 2 N990 Postprocedural (acute) (chronic) kidney failure 2 N9981 Other intraoperative complications of genitourinary system 2 N9989 Other postprocedural complications and disorders of genitourinary system 2 P0701 Extremely low birth weight newborn, less than 500 grams 1 P0702 Extremely low birth weight newborn, 500-749 grams 1 P0703 Extremely low birth weight newborn, 750-999 grams 1 P099 Abnormal findings on neonatal screening, unspecified 1 10/1/2021 P114 Birth injury to other cranial nerves 2 P115 Birth injury to spine and spinal cord 5 P140 Erb's paralysis due to birth injury 3 P141 Klumpke's paralysis due to birth injury 3 P142 Phrenic nerve paralysis due to birth injury 2 P143 Other brachial plexus birth injuries 3 P148 Birth injuries to other parts of peripheral nervous system 2 P149 Birth injury to peripheral nervous system, unspecified 2 P220 Respiratory distress syndrome of newborn 1

44 CSHCS Qualifying Diagnoses Effective 10/01/2021

P270 Wilson-Mikity syndrome 2 P271 Bronchopulmonary dysplasia originating in the perinatal period 2 P278 Other chronic respiratory diseases originating in the perinatal period 2 P279 Unspecified chronic respiratory disease originating in the perinatal period 2 P284 Other apnea of newborn 1 P293 Persistent fetal circulation 1 9/30/2017 P2930 Pulmonary hypertension of newborn 1 10/1/2017 P2938 Other persistent fetal circulation 1 10/1/2017 P350 Congenital rubella syndrome 5 P351 Congenital cytomegalovirus infection 2 P352 Congenital herpesviral [herpes simplex] infection 2 P353 Congenital viral hepatitis 2 P359 Congenital viral disease, unspecified 2 P370 Congenital tuberculosis 2 P371 Congenital toxoplasmosis 2 P372 Neonatal (disseminated) listeriosis 2 P373 Congenital falciparum malaria 2 P374 Other congenital malaria 2 P378 Other specified congenital infectious and parasitic diseases 2 P379 Congenital infectious or parasitic disease, unspecified 2 P399 Infection specific to the perinatal period, unspecified 1 P5221 Intraventricular (nontraumatic) hemorrhage, grade 3, of newborn 1 P5222 Intraventricular (nontraumatic) hemorrhage, grade 4, of newborn 1 P591 Inspissated bile syndrome 2 P5920 Neonatal jaundice from unspecified hepatocellular damage 2 P60 Disseminated intravascular coagulation of newborn 2 P704 Other neonatal hypoglycemia 2 P771 Stage 1 necrotizing enterocolitis in newborn 2 P772 Stage 2 necrotizing enterocolitis in newborn 2 P773 Stage 3 necrotizing enterocolitis in newborn 2 P779 Necrotizing enterocolitis in newborn, unspecified 2 P8388 Other specified conditions of integument specific to newborn 1 10/1/2017 P84 Other problems with newborn 2 P9160 Hypoxic ischemic encephalopathy [HIE], unspecified 1 P9163 Severe hypoxic ischemic encephalopathy [HIE] 2 P91823 Neonatal cerebral infarction, bilateral 1 10/1/2020 P91829 Neonatal cerebral infarction, unspecified side 1 10/1/2020 P940 Transient neonatal myasthenia gravis 2 Q019 Encephalocele, unspecified 5 Q039 Congenital hydrocephalus, unspecified 3

45 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q040 Congenital malformations of corpus callosum 3 Q042 Holoprosencephaly 3 Q043 Other reduction deformities of brain 3 Q044 Septo-optic dysplasia of brain 2 Q045 Megalencephaly 2 Q046 Congenital cerebral cysts 2 Q048 Other specified congenital malformations of brain 2 Q049 Congenital malformation of brain, unspecified 3 Q050 Cervical spina bifida with hydrocephalus 5 Q051 Thoracic spina bifida with hydrocephalus 5 Q052 Lumbar spina bifida with hydrocephalus 5 Q053 Sacral spina bifida with hydrocephalus 5 Q054 Unspecified spina bifida with hydrocephalus 5 Q055 Cervical spina bifida without hydrocephalus 5 Q056 Thoracic spina bifida without hydrocephalus 5 Q057 Lumbar spina bifida without hydrocephalus 5 Q058 Sacral spina bifida without hydrocephalus 5 Q059 Spina bifida, unspecified 5 Q060 Amyelia 3 Q061 Hypoplasia and dysplasia of spinal cord 3 Q062 Diastematomyelia 2 Q063 Other congenital cauda equina malformations 3 Q064 Hydromyelia 2 Q069 Congenital malformation of spinal cord, unspecified 3 Q0701 Arnold-Chiari syndrome with spina bifida 5 Q0702 Arnold-Chiari syndrome with hydrocephalus 5 Q0703 Arnold-Chiari syndrome with spina bifida and hydrocephalus 5 Q078 Other specified congenital malformations of nervous system 2 Q079 Congenital malformation of nervous system, unspecified 3 Q100 Congenital ptosis 3 Q103 Other congenital malformations of eyelid 2 Q107 Congenital malformation of orbit 2 Q110 Cystic eyeball 3 Q111 Other anophthalmos 3 Q112 Microphthalmos 3 Q113 Macrophthalmos 2 Q120 Congenital cataract 2 Q121 Congenital displaced lens 3 Q122 Coloboma of lens 3 Q123 Congenital aphakia 3

46 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q124 Spherophakia 3 Q128 Other congenital lens malformations 3 Q129 Congenital lens malformation, unspecified 3 Q130 Coloboma of iris 3 Q131 Absence of iris 3 Q132 Other congenital malformations of iris 3 Q133 Congenital corneal opacity 2 Q134 Other congenital corneal malformations 2 Q1381 Rieger's anomaly 3 Q139 Congenital malformation of anterior segment of eye, unspecified 2 Q140 Congenital malformation of vitreous humor 2 Q141 Congenital malformation of retina 2 Q142 Congenital malformation of optic disc 2 Q143 Congenital malformation of choroid 2 Q148 Other congenital malformations of posterior segment of eye 2 Q149 Congenital malformation of posterior segment of eye, unspecified 2 Q150 Congenital glaucoma 2 Q158 Other specified congenital malformations of eye 2 Q159 Congenital malformation of eye, unspecified 3 Q160 Congenital absence of (ear) auricle 5 Q161 Congenital absence, atresia and stricture of auditory canal (external) 5 Q162 Absence of eustachian tube 2 Q163 Congenital malformation of ear ossicles 2 Q164 Other congenital malformations of middle ear 2 Q165 Congenital malformation of inner ear 2 Q169 Congenital malformation of ear causing impairment of hearing, unspecified 3 Q172 Microtia 5 Q178 Other specified congenital malformations of ear 2 Q180 Sinus, fistula and cyst of branchial cleft 2 Q185 Microstomia 2 Q188 Other specified congenital malformations of face and neck 2 Q189 Congenital malformation of face and neck, unspecified 3 Q200 Common arterial trunk 5 Q201 Double outlet right ventricle 5 Q202 Double outlet left ventricle 5 Q203 Discordant ventriculoarterial connection 5 Q204 Double inlet ventricle 5 Q205 Discordant atrioventricular connection 5 Q208 Other congenital malformations of cardiac chambers and connections 5 Q209 Congenital malformation of cardiac chambers and connections, unspecified 5

47 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q210 Ventricular septal defect 3 Q211 Atrial septal defect 5 Q212 Atrioventricular septal defect 5 Q213 Tetralogy of Fallot 5 Q218 Other congenital malformations of cardiac septa 5 Q219 Congenital malformation of cardiac septum, unspecified 5 Q220 Pulmonary valve atresia 5 Q221 Congenital pulmonary valve stenosis 5 Q222 Congenital pulmonary valve insufficiency 5 Q223 Other congenital malformations of pulmonary valve 5 Q224 Congenital tricuspid stenosis 5 Q225 Ebstein's anomaly 5 Q226 Hypoplastic right heart syndrome 5 Q228 Other congenital malformations of tricuspid valve 5 Q229 Congenital malformation of tricuspid valve, unspecified 5 Q230 Congenital stenosis of aortic valve 5 Q231 Congenital insufficiency of aortic valve 5 Q232 Congenital mitral stenosis 5 Q233 Congenital mitral insufficiency 5 Q234 Hypoplastic left heart syndrome 5 Q238 Other congenital malformations of aortic and mitral valves 5 Q239 Congenital malformation of aortic and mitral valves, unspecified 5 Q242 Cor triatriatum 5 Q243 Pulmonary infundibular stenosis 5 Q244 Congenital subaortic stenosis 5 Q245 Malformation of coronary vessels 5 Q246 Congenital heart block 5 Q248 Other specified congenital malformations of heart 5 Q249 Congenital malformation of heart, unspecified 5 Q250 Patent ductus arteriosus 3 Q251 Coarctation of aorta 5 Q252 Atresia of aorta 5 9/30/2016 Q2521 Interruption of aortic arch 5 10/1/2016 Q2529 Other atresia of aorta 5 10/1/2016 Q253 Supravalvular aortic stenosis 5 Q254 Other congenital malformations of aorta 5 9/30/2016 Q2549 Other congenital malformations of aorta 5 10/1/2016 Q255 Atresia of pulmonary artery 5 Q256 Stenosis of pulmonary artery 5 Q2571 Coarctation of pulmonary artery 5

48 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q2572 Congenital pulmonary arteriovenous malformation 5 Q2579 Other congenital malformations of pulmonary artery 5 Q258 Other congenital malformations of other great arteries 5 Q259 Congenital malformation of great arteries, unspecified 5 Q260 Congenital stenosis of vena cava 5 Q261 Persistent left superior vena cava 5 Q262 Total anomalous pulmonary venous connection 5 Q264 Anomalous pulmonary venous connection, unspecified 5 Q265 Anomalous portal venous connection 2 Q266 Portal vein-hepatic artery fistula 2 Q271 Congenital renal artery stenosis 2 Q272 Other congenital malformations of renal artery 2 Q2730 Arteriovenous malformation, site unspecified 2 Q2731 Arteriovenous malformation of vessel of upper limb 2 Q2732 Arteriovenous malformation of vessel of lower limb 2 Q274 Congenital phlebectasia 2 Q278 Other specified congenital malformations of peripheral vascular system 2 Q279 Congenital malformation of peripheral vascular system, unspecified 2 Q280 Arteriovenous malformation of precerebral vessels 2 Q281 Other malformations of precerebral vessels 2 Q282 Arteriovenous malformation of cerebral vessels 2 Q283 Other malformations of cerebral vessels 2 Q288 Other specified congenital malformations of circulatory system 2 Q300 Choanal atresia 2 Q310 Web of larynx 2 Q319 Congenital malformation of larynx, unspecified 2 Q321 Other congenital malformations of trachea 2 Q323 Congenital stenosis of bronchus 2 Q324 Other congenital malformations of bronchus 2 Q330 Congenital cystic lung 3 Q332 Sequestration of lung 3 Q333 Agenesis of lung 3 Q334 Congenital bronchiectasis 3 Q335 Ectopic tissue in lung 3 Q336 Congenital hypoplasia and dysplasia of lung 3 Q338 Other congenital malformations of lung 3 Q339 Congenital malformation of lung, unspecified 2 Q340 Anomaly of pleura 2 Q341 Congenital cyst of mediastinum 2 Q349 Congenital malformation of respiratory system, unspecified 3

49 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q359 Cleft palate, unspecified 5 Q360 Cleft lip, bilateral 5 Q361 Cleft lip, median 5 Q369 Cleft lip, unilateral 5 Q378 Unspecified cleft palate with bilateral cleft lip 5 Q379 Unspecified cleft palate with unilateral cleft lip 5 Q383 Other congenital malformations of tongue 2 Q386 Other congenital malformations of mouth 2 Q388 Other congenital malformations of pharynx 3 Q390 Atresia of esophagus without fistula 5 Q391 Atresia of esophagus with tracheo-esophageal fistula 5 Q392 Congenital tracheo-esophageal fistula without atresia 5 Q393 Congenital stenosis and stricture of esophagus 5 Q394 Esophageal web 5 Q399 Congenital malformation of esophagus, unspecified 2 Q419 Congenital absence, atresia and stenosis of small intestine, part unspecified 2 Q429 Congenital absence, atresia and stenosis of large intestine, part unspecified 2 Q431 Hirschsprung's disease 5 Q432 Other congenital functional disorders of colon 5 Q439 Congenital malformation of intestine, unspecified 2 Q441 Other congenital malformations of gallbladder 2 Q442 Atresia of bile ducts 5 Q443 Congenital stenosis and stricture of bile ducts 5 Q444 Choledochal cyst 2 Q445 Other congenital malformations of bile ducts 2 Q447 Other congenital malformations of liver 2 Q458 Other specified congenital malformations of digestive system 2 Q506 Other congenital malformations of fallopian tube and broad ligament 2 Q528 Other specified congenital malformations of female genitalia 2 Q529 Congenital malformation of female genitalia, unspecified 2 Q539 Undescended testicle, unspecified 1 Q548 Other hypospadias 3 Q549 Hypospadias, unspecified 3 Q5520 Unspecified congenital malformations of testis and scrotum 2 Q5529 Other congenital malformations of testis and scrotum 2 Q5569 Other congenital malformation of penis 2 Q559 Congenital malformation of male genital organ, unspecified 2 Q560 Hermaphroditism, not elsewhere classified 3 Q563 Pseudohermaphroditism, unspecified 3 Q564 Indeterminate sex, unspecified 3

50 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q602 Renal agenesis, unspecified 5 Q605 Renal hypoplasia, unspecified 5 Q6100 Congenital renal cyst, unspecified 3 Q6101 Congenital single renal cyst 2 Q6119 Other polycystic kidney, infantile type 5 Q612 Polycystic kidney, adult type 5 Q613 Polycystic kidney, unspecified 5 Q614 Renal dysplasia 5 Q615 Medullary cystic kidney 5 Q618 Other cystic kidney diseases 5 Q619 Cystic kidney disease, unspecified 3 Q6239 Other obstructive defects of renal pelvis and ureter 2 Q640 Epispadias 3 Q6410 Exstrophy of urinary bladder, unspecified 5 Q6412 Cloacal extrophy of urinary bladder 5 Q644 Malformation of urachus 2 Q645 Congenital absence of bladder and urethra 2 Q646 Congenital diverticulum of bladder 2 Q6470 Unspecified congenital malformation of bladder and urethra 2 Q6479 Other congenital malformations of bladder and urethra 2 Q648 Other specified congenital malformations of urinary system 2 Q649 Congenital malformation of urinary system, unspecified 2 Q6500 Congenital dislocation of unspecified hip, unilateral 2 Q651 Congenital dislocation of hip, bilateral 2 Q652 Congenital dislocation of hip, unspecified 2 Q6530 Congenital partial dislocation of unspecified hip, unilateral 2 Q654 Congenital partial dislocation of hip, bilateral 2 Q655 Congenital partial dislocation of hip, unspecified 2 Q6589 Other specified congenital deformities of hip 2 Q660 Congenital talipes equinovarus 2 9/30/2019 Q6600 Congenital talipes equinovarus, unspecified foot 2 10/1/2019 Q661 Congenital talipes calcaneovarus 2 9/30/2019 Q6610 Congenital talipes calcaneovarus, unspecified foot 2 10/1/2019 Q663 Other congenital varus deformities of feet 2 9/30/2019 Q664 Congenital talipes calcaneovalgus 2 9/30/2019 Q6640 Congenital talipes calcaneovalgus, unspecified foot 2 10/1/2019 Q666 Other congenital valgus deformities of feet 2 Q667 Congenital pes cavus 2 9/30/2019 Q6670 Congenital pes cavus, unspecified foot 2 10/1/2019 Q6689 Other specified congenital deformities of feet 2

51 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q669 Congenital deformity of feet, unspecified 2 9/30/2019 Q6690 Congenital deformity of feet, unspecified, unspecified foot 2 10/1/2019 Q6691 Congenital deformity of feet, unspecified, right foot 2 10/1/2019 Q6692 Congenital deformity of feet, unspecified, left foot 2 10/1/2019 Q670 Congenital facial asymmetry 3 Q674 Other congenital deformities of skull, face and jaw 3 Q675 Congenital deformity of spine 3 Q676 Pectus excavatum 2 Q678 Other congenital deformities of chest 3 Q680 Congenital deformity of sternocleidomastoid muscle 2 Q681 Congenital deformity of finger(s) and hand 3 Q682 Congenital deformity of knee 2 Q688 Other specified congenital musculoskeletal deformities 2 Q690 Accessory finger(s) 2 Q691 Accessory thumb(s) 2 Q692 Accessory toe(s) 2 Q699 Polydactyly, unspecified 2 Q7000 Fused fingers, unspecified hand 2 Q7010 Webbed fingers, unspecified hand 2 Q7020 Fused toes, unspecified foot 2 Q7030 Webbed toes, unspecified foot 2 Q704 Polysyndactyly, unspecified 2 Q709 Syndactyly, unspecified 2 Q7100 Congenital complete absence of unspecified upper limb 5 Q7110 Congenital absence of unspecified upper arm and forearm with hand present 5 Q7130 Congenital absence of unspecified hand and finger 5 Q7140 Longitudinal reduction defect of unspecified radius 3 Q7150 Longitudinal reduction defect of unspecified ulna 5 Q7160 Lobster-claw hand, unspecified hand 5 Q71819 Congenital shortening of unspecified upper limb 5 Q71899 Other reduction defects of unspecified upper limb 5 Q7190 Unspecified reduction defect of unspecified upper limb 5 Q7200 Congenital complete absence of unspecified lower limb 5 Q7210 Congenital absence of unspecified thigh and lower leg with foot present 5 Q7220 Congenital absence of both lower leg and foot, unspecified lower limb 5 Q7230 Congenital absence of unspecified foot and toe(s) 5 Q7240 Longitudinal reduction defect of unspecified femur 5 Q7250 Longitudinal reduction defect of unspecified tibia 5 Q7260 Longitudinal reduction defect of unspecified fibula 5 Q7270 Split foot, unspecified lower limb 5

52 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q72819 Congenital shortening of unspecified lower limb 5 Q72899 Other reduction defects of unspecified lower limb 5 Q7290 Unspecified reduction defect of unspecified lower limb 5 Q730 Congenital absence of unspecified limb(s) 2 Q731 Phocomelia, unspecified limb(s) 2 Q738 Other reduction defects of unspecified limb(s) 2 Q740 Other congenital malformations of upper limb(s), including shoulder girdle 3 Q742 Other congenital malformations of lower limb(s), including pelvic girdle 3 Q743 Arthrogryposis multiplex congenita 3 Q749 Unspecified congenital malformation of limb(s) 2 Q750 Craniosynostosis 5 Q758 Other specified congenital malformations of skull and face bones 5 Q759 Congenital malformation of skull and face bones, unspecified 5 Q760 Spina bifida occulta 3 Q761 *phase out* Klippel-Feil syndrome 5 *phase out* Q762 Congenital spondylolisthesis 3 Q76419 Congenital kyphosis, unspecified region 3 Q7649 Other congenital malformations of spine, not associated with scoliosis 3 Q770 5 Q771 Thanatophoric short stature 5 Q773 Chondrodysplasia punctata 3 Q774 Achondroplasia 5 Q776 Chondroectodermal dysplasia 5 Q778 Other osteochondrodysplasia with defects of growth of tubular bones and spine 5 Q779 Osteochondrodysplasia with defects of growth of tubular bones and spine, unspecified 5 Q780 Osteogenesis imperfecta 5 Q781 Polyostotic fibrous dysplasia 3 Q782 Osteopetrosis 5 Q783 Progressive diaphyseal dysplasia 5 Q784 Enchondromatosis 5 Q786 Multiple congenital exostoses 3 Q788 Other specified osteochondrodysplasias 3 Q789 Osteochondrodysplasia, unspecified 3 Q790 Congenital diaphragmatic hernia 2 Q791 Other congenital malformations of diaphragm 2 Q792 Exomphalos 1 Q793 Gastroschisis 1 Q794 Prune belly syndrome 2 Q7959 Other congenital malformations of abdominal wall 2 Q796 Ehlers-Danlos syndrome 2 9/30/2019 10/1/2016

53 CSHCS Qualifying Diagnoses Effective 10/01/2021

Q7960 *Phase out* Ehlers-Danlos syndrome, unspecified 2 *Phase out* 10/1/2019 Q798 Other congenital malformations of musculoskeletal system 2 Q799 Congenital malformation of musculoskeletal system, unspecified 2 Q804 HARLEQUIN FETUS 3 10/1/2019 Q819 Epidermolysis bullosa, unspecified 2 Q820 Hereditary lymphedema 3 Q821 Xeroderma pigmentosum 3 Q822 Mastocytosis 3 Q822 CONGENITAL CUTANEOUS MASTOCYTOSIS/urticaria pigmentosa 3 10/1/2019 Q823 Incontinentia pigmenti 3 Q824 Ectodermal dysplasia (anhidrotic) 3 Q825 CONGENITAL NON-NEOPLASTIC NEVUS 3 10/1/2019 Q828 Other specified congenital malformations of skin 2 Q829 Congenital malformation of skin, unspecified 2 Q848 Other specified congenital malformations of integument 2 Q8500 Neurofibromatosis, unspecified 5 Q8501 Neurofibromatosis, type 1 5 Q8502 Neurofibromatosis, type 2 5 Q8503 Schwannomatosis 5 Q851 Tuberous sclerosis 5 Q858 Other phakomatoses, not elsewhere classified 3 Q859 Phakomatosis, unspecified 3 Q870 Congenital malformation syndromes predominantly affecting facial appearance 5 Q871 Congenital malformation syndromes predominantly associated with short stature 3 9/30/2019 Q8711 *Phase Out* Prader-Willi syndrome 3 *Phase Out* 10/1/2019 Q8719 Other congen malform synd predom assoc with short stature 3 10/1/2019 Q873 Congenital malformation syndromes involving early overgrowth 2 Q8740 *Phase Out* Marfan's syndrome, unspecified 3 *Phase Out* Q8781 *Phase Out* Alport syndrome 3 *Phase Out* Q897 Multiple congenital malformations, not elsewhere classified 3 Q898 Other specified congenital malformations 3 Q899 Congenital malformation, unspecified 2 Q969 *Phase Out* Turner's syndrome, unspecified 3 *Phase Out* R0681 Apnea, not elsewhere classified 1 R0689 Other abnormalities of breathing 2 R1310 Dysphagia, unspecified 1 R1319 Other dysphagia 1 R17 Unspecified jaundice 2 R4701 Aphasia 2 R4702 Dysphasia 2

54 CSHCS Qualifying Diagnoses Effective 10/01/2021

R69 Illness, unspecified (code formerly used for diagnostic evaluations) 1 R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV] 2 S0100xS Unspecified open wound of scalp, sequela 2 S0109xS Unspecified open wound of other part of head, sequela 5 10/1/2019 S01109S Unspecified open wound of unspecified eyelid and periocular area, sequela 2 S0120xS Unspecified open wound of nose, sequela 2 S01309S Unspecified open wound of unspecified ear, sequela 2 S01409S Unspecified open wound of unspecified cheek and temporomandibular area, sequela 2 S01501S Unspecified open wound of lip, sequela 2 S01502S Unspecified open wound of oral cavity, sequela 2 S0180xS Unspecified open wound of other part of head, sequela 2 9/30/2019 S0190xS Unspecified open wound of unspecified part of head, sequela 2 S020xxS Fracture of vault of skull, sequela 2 S02109S Fracture base of skull unspecified side sequela 2 10/1/2016 S0210xS Unspecified fracture of base of skull, sequela 2 9/30/2016 S02113S Unspecified occipital condyle fracture, sequela 2 S02118S Other fracture of occiput, sequela 2 S022xxS Fracture of nasal bones, sequela 2 S0230XS Fracture of orbital floor unspecified side sequela 2 10/1/2016 S023xxS Fracture of orbital floor, sequela 2 9/30/2016 S02400S Malar fracture unspecified, sequela 2 S02401S Maxillary fracture, unspecified, sequela 2 S02402S Zygomatic fracture, unspecified, sequela 2 S025xxS Fracture of tooth (traumatic), sequela 2 S02609S Fracture of mandible, unspecified, sequela 2 S0280XS Fractures other specified skull facial bones unspecified side sequela 2 9/30/2019 10/1/2016 S02849S Fracture of lateral orbital wall, unspecified side, sequela 2 10/1/2019 S028xxS Fractures of other specified skull and facial bones, sequela 2 9/30/2016 S0291xK Unspecified fracture of skull, subsequent encounter for fracture with nonunion 2 S0291xS Unspecified fracture of skull, sequela 2 S0292xK Unspecified fracture of facial bones, subsequent encounter for fracture with nonunion 2 S0292xS Unspecified fracture of facial bones, sequela 2 S032xxS Dislocation of tooth, sequela 2 S04019S Injury of optic nerve, unspecified eye, sequela 2 S0402xS Injury of optic chiasm, sequela 2 S04039S Injury of optic tract and pathways, unspecified eye, sequela 2 S04049S Injury of visual cortex, unspecified eye, sequela 2 S0410xS Injury of oculomotor nerve, unspecified side, sequela 2 S0420xS Injury of trochlear nerve, unspecified side, sequela 2 S0430xS Injury of trigeminal nerve, unspecified side, sequela 2

55 CSHCS Qualifying Diagnoses Effective 10/01/2021

S0440xS Injury of abducent nerve, unspecified side, sequela 2 S0450xS Injury of facial nerve, unspecified side, sequela 2 S0460xS Injury of acoustic nerve, unspecified side, sequela 2 S0470xS Injury of accessory nerve, unspecified side, sequela 2 S04819S Injury of olfactory [1st ] nerve, unspecified side, sequela 2 S04899S Injury of other cranial nerves, unspecified side, sequela 2 9/30/2019 S049xxS Injury of unspecified cranial nerve, sequela 2 S0590xS Unspecified injury of unspecified eye and orbit, sequela 2 S064X0A Epidural hemorrhage without loss of consciousness, initial encounter 2 S065X0A Traumatic subdural hemorrhage without loss of consciousness, initial encounter 2 Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain S065X7A injury before regaining consciousness, initial encounter 2 9/30/2020 Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial S065X9A encounter 2 S066X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter 2 Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial S066X9A encounter 2 S069X0S Unspecified intracranial injury without loss of consciousness, sequela 2 S069X9S Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela 2 S06A0XS Traumatic brain compression without herniation, sequela 2 10/1/2021 S06A1XS Traumatic brain compression with herniation, sequela 2 10/1/2021 S070xxS Crushing injury of face, sequela 2 S071xxS Crushing injury of skull, sequela 2 S078xxS Crushing injury of other parts of head, sequela 2 S080xxS Avulsion of scalp, sequela 2 S08119S Complete traumatic amputation of unspecified ear, sequela 2 S08129S Partial traumatic amputation of unspecified ear, sequela 2 S08811S Complete traumatic amputation of nose, sequela 2 S08812S Partial traumatic amputation of nose, sequela 2 S0889xS Traumatic amputation of other parts of head, sequela 2 S0910xS Unspecified injury of muscle and tendon of head, sequela 2 S0920xS Traumatic rupture of unspecified ear drum, sequela 2 S09309S Unspecified injury of unspecified middle and inner ear, sequela 2 S0990xS Unspecified injury of head, sequela 2 S0991xS Unspecified injury of ear, sequela 2 S0992xS Unspecified injury of nose, sequela 2 S0993xS Unspecified injury of face, sequela 2 S11019S Unspecified open wound of larynx, sequela 2 S11029S Unspecified open wound of trachea, sequela 2 S11039S Unspecified open wound of vocal cord, sequela 2

56 CSHCS Qualifying Diagnoses Effective 10/01/2021

S1110xS Unspecified open wound of thyroid gland, sequela 2 S1120xS Unspecified open wound of pharynx and cervical esophagus, sequela 2 S1180xS Unspecified open wound of other specified part of neck, sequela 2 9/30/2019 S1190xS Unspecified open wound of unspecified part of neck, sequela 2 S128xxS Fracture of other parts of neck, sequela 2 S129xxA Fracture of neck, unspecified, initial encounter 5 S129xxS Fracture of neck, unspecified, sequela 2 S140xxS Concussion and edema of cervical spinal cord, sequela 2 S14109S Unspecified injury at unspecified level of cervical spinal cord, sequela 2 S14115A Complete lesion at C5 level of cervical spinal cord, initial encounter 5 S14116A Complete lesion at C6 level of cervical spinal cord, initial encounter 1 S14117A Complete lesion at C7 level of cervical spinal cord, initial encounter 1 S14119S Complete lesion at unspecified level of cervical spinal cord, sequela 2 S14121A Central cord syndrome at C1 level of cervical spinal cord, initial encounter 5 S14122A Central cord syndrome at C2 level of cervical spinal cord, initial encounter 5 S14123A Central cord syndrome at C3 level of cervical spinal cord, initial encounter 5 S14124A Central cord syndrome at C4 level of cervical spinal cord, initial encounter 5 S14129S Central cord syndrome at unspecified level of cervical spinal cord, sequela 2 S14139S Anterior cord syndrome at unspecified level of cervical spinal cord, sequela 2 S14149S Brown-Sequard syndrome at unspecified level of cervical spinal cord, sequela 2 S14159S Other incomplete lesion at unspecified level of cervical spinal cord, sequela 2 S143xxS Injury of brachial plexus, sequela 2 S149xxS Injury of unspecified nerves of neck, sequela 2 S15001S Unspecified injury of right carotid artery, sequela 2 9/30/2019 S15002S Unspecified injury of left carotid artery, sequela 2 9/30/2019 S15009S Unspecified injury of unspecified carotid artery, sequela 2 S15101S Unspecified injury of right vertebral artery, sequela 2 9/30/2019 S15102S Unspecified injury of left vertebral artery, sequela 2 9/30/2019 S15109S Unspecified injury of unspecified vertebral artery, sequela 2 S15199S Other specified injury of unspecified vertebral artery, sequela 2 9/30/2019 S15201S Unspecified injury of right external jugular vein, sequela 2 9/30/2019 S15202S Unspecified injury of left external jugular vein, sequela 2 9/30/2019 S15209S Unspecified injury of unspecified external jugular vein, sequela 2 S15301S Unspecified injury of right internal jugular vein, sequela 2 9/30/2019 S15302S Unspecified injury of left internal jugular vein, sequela 2 9/30/2019 S15309S Unspecified injury of unspecified internal jugular vein, sequela 2 S159xxS Injury of unspecified blood vessel at neck level, sequela 2 S169xxS Unspecified injury of muscle, fascia and tendon at neck level, sequela 2 S179xxS Crushing injury of neck, part unspecified, sequela 2 S1980xS Other specified injuries of unspecified part of neck, sequela 2

57 CSHCS Qualifying Diagnoses Effective 10/01/2021

S199xxS Unspecified injury of neck, sequela 2 9/30/2019 S21009S Unspecified open wound of unspecified breast, sequela 2 Unspecified open wound of unspecified front wall of thorax without penetration into thoracic S21109S cavity, sequela 2 9/30/2019 Unspecified open wound of unspecified back wall of thorax without penetration into thoracic S21209S cavity, sequela 2 9/30/2019 Unspecified open wound of unspecified front wall of thorax with penetration into thoracic cavity, S21309S sequela 2 9/30/2019 Unspecified open wound of unspecified back wall of thorax with penetration into thoracic cavity, S21409S sequela 2 9/30/2019 S2190xS Unspecified open wound of unspecified part of thorax, sequela 2 S22009A Unspecified fracture of unspecified thoracic vertebra, initial encounter for closed fracture 5 S22009B Unspecified fracture of unspecified thoracic vertebra, initial encounter for open fracture 5 Unspecified fracture of unspecified thoracic vertebra, subsequent encounter for fracture with S22009K nonunion 2 S22009S Unspecified fracture of unspecified thoracic vertebra, sequela 2 S2220xS Unspecified fracture of sternum, sequela 2 S2221xS Fracture of manubrium, sequela 2 S2222xS Fracture of body of sternum, sequela 2 S2223xS Sternal manubrial dissociation, sequela 2 S2224xS Fracture of xiphoid process, sequela 2 S2249xS Multiple fractures of ribs, unspecified side, sequela 2 S225xxS Flail chest, sequela 2 S229xxK Fracture of bony thorax, part unspecified, subsequent encounter for fracture with nonunion 2 S229xxS Fracture of bony thorax, part unspecified, sequela 2 S240xxS Concussion and edema of thoracic spinal cord, sequela 2 S24103A Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounter 5 9/30/2019 S24104A Unspecified injury at T11-T12 level of thoracic spinal cord, initial encounter 5 9/30/2019 S24109S Unspecified injury at unspecified level of thoracic spinal cord, sequela 5 S24111A Complete lesion at T1 level of thoracic spinal cord, initial encounter 5 9/30/2019 S24112A Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter 5 9/30/2019 S24119S Complete lesion at unspecified level of thoracic spinal cord, sequela 2 S24139S Anterior cord syndrome at unspecified level of thoracic spinal cord, sequela 2 S24149S Brown-Sequard syndrome at unspecified level of thoracic spinal cord, sequela 2 S24159S Other incomplete lesion at unspecified level of thoracic spinal cord, sequela 2 S25809S Unspecified injury of other blood vessels of thorax, unspecified side, sequela 2 S2690xS Unspecified injury of heart, unspecified with or without hemopericardium, sequela 2 S279xxS Injury of unspecified intrathorarcic organ, sequela 2 S280xxS Crushed chest, sequela 2 S281xxS Traumatic amputation (partial) of part of thorax, except breast, sequela 2

58 CSHCS Qualifying Diagnoses Effective 10/01/2021

S28219S Complete traumatic amputation of unspecified breast, sequela 2 S28229S Partial traumatic amputation of unspecified breast, sequela 2 S29001S Unspecified injury of muscle and tendon of front wall of thorax, sequela 2 9/30/2019 S29002S Unspecified injury of muscle and tendon of back wall of thorax, sequela 2 9/30/2019 S29009S Unspecified injury of muscle and tendon of unspecified wall of thorax, sequela 2 S29029S Laceration of muscle and tendon of unspecified wall of thorax, sequela 2 S29099S Other injury of muscle and tendon of unspecified wall of thorax, sequela 2 S298xxS Other specified injuries of thorax, sequela 2 S299xxS Unspecified injury of thorax, sequela 2 9/30/2019 S29xxS Unspecified injury of thorax, sequela 2 10/1/2019 Unspecified open wound of lower back and pelvis without penetration into retroperitoneum, S31000S sequela 2

S31001S Unspecified open wound of lower back and pelvis with penetration into retroperitoneum, sequela 2 Unspecified open wound of abdominal wall, epigastric region without penetration into peritoneal S31102S cavity, sequela 2 Unspecified open wound of abdominal wall, periumbilic region without penetration into peritoneal S31105S cavity, sequela 2 Unspecified open wound of abdominal wall, unspecified quadrant without penetration into S31109S peritoneal cavity, sequela 2 S3120xS Unspecified open wound of penis, sequela 2 S3130xS Unspecified open wound of scrotum and testes, sequela 2 S3140xS Unspecified open wound of vagina and vulva, sequela 2 Unspecified open wound of abdominal wall, epigastric region with penetration into peritoneal S31602S cavity, sequela 2 Unspecified open wound of abdominal wall, periumbilic region with penetration into peritoneal S31605S cavity, sequela 2 Unspecified open wound of abdominal wall, unspecified quadrant with penetration into peritoneal S31609S cavity, sequela 2 S31801S Laceration without foreign body of unspecified buttock, sequela 2 S31809S Unspecified open wound of unspecified buttock, sequela 2 S31839S Unspecified open wound of anus, sequela 2 S32000S Wedge compression fracture of unspecified lumbar vertebra, sequela 2 Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with S32009K nonunion 2 S32009S Unspecified fracture of unspecified lumbar vertebra, sequela 2 S3210xK Unspecified fracture of sacrum, subsequent encounter for fracture with nonunion 2 S3210xS Unspecified fracture of sacrum, sequela 2 S322xxK Fracture of coccyx, subsequent encounter for fracture with nonunion 2 S322xxS Fracture of coccyx, sequela 2

59 CSHCS Qualifying Diagnoses Effective 10/01/2021

S32309K Unspecified fracture of unspecified ilium, subsequent encounter for fracture with nonunion 2 S32309S Unspecified fracture of unspecified ilium, sequela 2

S32409K Unspecified fracture of unspecified acetabulum, subsequent encounter for fracture with nonunion 2 S32409S Unspecified fracture of unspecified acetabulum, sequela 2 S32509S Unspecified fracture of unspecified pubis, sequela 2 S32519S Fracture of superior rim of unspecified pubis, sequela 2 S32609S Unspecified fracture of unspecified ischium, sequela 2 S32810S Multiple fractures of pelvis with stable disruption of pelvic ring, sequela 2 S32811S Multiple fractures of pelvis with unstable disruption of pelvic ring, sequela 2 S3282xS Multiple fractures of pelvis without disruption of pelvic ring, sequela 2 S3289xS Fracture of other parts of pelvis, sequela 2 S329xxS Fracture of unspecified parts of lumbosacral spine and pelvis, sequela 2 S3401xS Concussion and edema of lumbar spinal cord, sequela 2 S3402xS Concussion and edema of sacral spinal cord, sequela 2 S34109A Unspecified injury to unspecified level of lumbar spinal cord, initial encounter 2 S34109S Unspecified injury to unspecified level of lumbar spinal cord, sequela 2 S34119A Complete lesion of unspecified level of lumbar spinal cord, initial encounter 5 S34129A Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter 5 S34139S Unspecified injury to sacral spinal cord, sequela 2 S358X9S Unspecified injury of other blood vessels at abdomen, lower back and pelvis level, sequela 2 S3600xS Unspecified injury of spleen, sequela 2 S36112S Contusion of liver, sequela 2 S36113S Laceration of liver, unspecified degree, sequela 2 S36118S Other injury of liver, sequela 2 S36119S Unspecified injury of liver, sequela 2 9/30/2019 S36129S Unspecified injury of gallbladder, sequela 2 S3613xS Injury of bile duct, sequela 2 S36209S Unspecified injury of unspecified part of pancreas, sequela 2 S3630xS Unspecified injury of stomach, sequela 2 S36400S Unspecified injury of duodenum, sequela 2 S36409S Unspecified injury of unspecified part of small intestine, sequela 2 S36509S Unspecified injury of unspecified part of colon, sequela 2 S3660xS Unspecified injury of rectum, sequela 2 S3681xS Injury of peritoneum, sequela 2 S3690xS Unspecified injury of unspecified intra-abdominal organ, sequela 2 S37009S Unspecified injury of unspecified kidney, sequela 2 S38001S Crushing injury of unspecified external genital organs, male, sequela 2 S38002S Crushing injury of unspecified external genital organs, female, sequela 2 S381xxS Crushing injury of abdomen, lower back, and pelvis, sequela 2

60 CSHCS Qualifying Diagnoses Effective 10/01/2021

S39001S Unspecified injury of muscle, fascia and tendon of abdomen, sequela 2 S39002S Unspecified injury of muscle, fascia and tendon of lower back, sequela 2 S39003S Unspecified injury of muscle, fascia and tendon of pelvis, sequela 2 S3991xS Unspecified injury of abdomen, sequela 2 S3992xS Unspecified injury of lower back, sequela 2 S3993xS Unspecified injury of pelvis, sequela 2 S3994xS Unspecified injury of external genitals, sequela 2 S41009S Unspecified open wound of unspecified shoulder, sequela 2 S41109S Unspecified open wound of unspecified upper arm, sequela 2 S42009S Fracture of unspecified part of unspecified clavicle, sequela 2 S42109S Fracture of unspecified part of scapula, unspecified shoulder, sequela 2 S42209S Unspecified fracture of upper end of unspecified humerus, sequela 2 S42309S Unspecified fracture of shaft of humerus, unspecified arm, sequela 2 S42409S Unspecified fracture of lower end of unspecified humerus, sequela 2 S4290xS Fracture of unspecified shoulder girdle, part unspecified, sequela 2 S4490xS Injury of unspecified nerve at shoulder and upper arm level, unspecified arm, sequela 2 S45109S Unspecified injury of brachial artery, unspecified side, sequela 2 S45209S Unspecified injury of axillary or brachial vein, unspecified side, sequela 2 Unspecified injury of unspecified blood vessel at shoulder and upper arm level, unspecified arm, S45909S sequela 2

S46009S Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, sequela 2

S46109S Unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela 2 S46229S Laceration of muscle, fascia and tendon of other parts of biceps, unspecified arm, sequela 2 S46309S Unspecified injury of muscle, fascia and tendon of triceps, unspecified arm, sequela 2 Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, S46909S unspecified arm, sequela 2 S479xxS Crushing injury of shoulder and upper arm, unspecified arm, sequela 2 S48019S Complete traumatic amputation at unspecified shoulder joint, sequela 2 S48029S Partial traumatic amputation at unspecified shoulder joint, sequela 2

S48119A Complete traumatic amputation at level between unspecified shoulder and elbow, initial encounter 5

S48129A Partial traumatic amputation at level between unspecified shoulder and elbow, initial encounter 5 Complete traumatic amputation of right shoulder and upper arm, level unspecified, initial S48911A encounter 5

S48912A Complete traumatic amputation of left shoulder and upper arm, level unspecified, initial encounter 5

61 CSHCS Qualifying Diagnoses Effective 10/01/2021

Complete traumatic amputation of unspecified shoulder and upper arm, level unspecified, initial S48919A encounter 5 Partial traumatic amputation of unspecified shoulder and upper arm, level unspecified, initial S48929A encounter 5 S49009S Unspecified physeal fracture of upper end of humerus, unspecified arm, sequela 2 S49109S Unspecified physeal fracture of lower end of humerus, unspecified arm, sequela 2 S4990xS Unspecified injury of shoulder and upper arm, unspecified arm, sequela 2 S51009S Unspecified open wound of unspecified elbow, sequela 2 S51809S Unspecified open wound of unspecified forearm, sequela 2 S52009S Unspecified fracture of upper end of unspecified ulna, sequela 2 S52209S Unspecified fracture of shaft of unspecified ulna, sequela 2 S52309S Unspecified fracture of shaft of unspecified radius, sequela 2 S52509S Unspecified fracture of the lower end of unspecified radius, sequela 2 S52609S Unspecified fracture of lower end of unspecified ulna, sequela 2 S5290xS Unspecified fracture of unspecified forearm, sequela 2 S5490xS Injury of unspecified nerve at forearm level, unspecified arm, sequela 2 S55909S Unspecified injury of unspecified blood vessel at forearm level, unspecified arm, sequela 2 Unspecified injury of flexor muscle, fascia and tendon of unspecified thumb at forearm level, S56009S sequela 2 Unspecified injury of flexor muscle, fascia and tendon of unspecified finger at forearm level, S56109S sequela 2 Unspecified injury of unspecified muscles, fascia and tendons at forearm level, unspecified arm, S56909S sequela 2 Complete traumatic amputation at level between elbow and wrist, unspecified arm, initial S58119A encounter 5

S58129A Partial traumatic amputation at level between elbow and wrist, unspecified arm, initial encounter 1 S58919A Complete traumatic amputation of unspecified forearm, level unspecified, initial encounter 1 S58929A Partial traumatic amputation of unspecified forearm, level unspecified, initial encounter 1 S59009S Unspecified physeal fracture of lower end of ulna, unspecified arm, sequela 2 S59109S Unspecified physeal fracture of upper end of radius, unspecified arm, sequela 2 S59209S Unspecified physeal fracture of lower end of radius, unspecified arm, sequela 2 S59909S Unspecified injury of unspecified elbow, sequela 2 S59919S Unspecified injury of unspecified forearm, sequela 2 S61509S Unspecified open wound of unspecified wrist, sequela 2 S6290xS Unspecified fracture of unspecified wrist and hand, sequela 2 S65209S Unspecified injury of superficial palmar arch of unspecified hand, sequela 2

S65909S Unspecified injury of unspecified blood vessel at wrist and hand level of unspecified arm, sequela 2

62 CSHCS Qualifying Diagnoses Effective 10/01/2021

S68019A Complete traumatic metacarpophalangeal amputation of unspecified thumb, initial encounter 5 S68029A Partial traumatic metacarpophalangeal amputation of unspecified thumb, initial encounter 1

S68119A Complete traumatic metacarpophalangeal amputation of unspecified finger, initial encounter 2 S68129A Partial traumatic metacarpophalangeal amputation of unspecified finger, initial encounter 1 S68419A Complete traumatic amputation of unspecified hand at wrist level, initial encounter 1 S68429A Partial traumatic amputation of unspecified hand at wrist level, initial encounter 1 S68519A Complete traumatic transphalangeal amputation of unspecified thumb, initial encounter 1 S68529A Partial traumatic transphalangeal amputation of unspecified thumb, initial encounter 1 S68619A Complete traumatic transphalangeal amputation of unspecified finger, initial encounter 1 S68629A Partial traumatic transphalangeal amputation of unspecified finger, initial encounter 1 S68719A Complete traumatic transmetacarpal amputation of unspecified hand, initial encounter 1 S68729A Partial traumatic transmetacarpal amputation of unspecified hand, initial encounter 1 S6990xS Unspecified injury of unspecified wrist, hand and finger(s), sequela 2 S71009S Unspecified open wound, unspecified hip, sequela 2 S71109S Unspecified open wound, unspecified thigh, sequela 2 S72309S Unspecified fracture of shaft of unspecified femur, sequela 2 S7290xS Unspecified fracture of unspecified femur, sequela 2 S7400xS Injury of sciatic nerve at hip and thigh level, unspecified leg, sequela 2 S7410xS Injury of femoral nerve at hip and thigh level, unspecified leg, sequela 2 S7490xA Injury of unspecified nerve at hip and thigh level, unspecified leg, initial encounter 2 9/30/2019 S7490xS Injury of unspecified nerve at hip and thigh level, unspecified leg, sequela 2 S749xS Injury of unspecified nerve at hip and thigh level, unspecified leg, initial encounter 2 10/1/2019

S75999S Other specified injury of unspecified blood vessel at hip and thigh level, unspecified leg, sequela 2 Unspecified injury of unspecified muscles, fascia and tendons at thigh level, unspecified thigh, S76909S sequela 2 9/30/2019 S78019A Complete traumatic amputation at unspecified hip joint, initial encounter 1 S78029A Partial traumatic amputation at unspecified hip joint, initial encounter 1

S78119A Complete traumatic amputation at level between unspecified hip and knee, initial encounter 1 S78129A Partial traumatic amputation at level between unspecified hip and knee, initial encounter 1

S78919A Complete traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter 5

S78929A Partial traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter 1 S82009S Unspecified fracture of unspecified patella, sequela 2 S82209S Unspecified fracture of shaft of unspecified tibia, sequela 2 S82409S Unspecified fracture of shaft of unspecified fibula, sequela 2

63 CSHCS Qualifying Diagnoses Effective 10/01/2021

S8290xS Unspecified fracture of unspecified lower leg, sequela 2 S8410xA Injury of peroneal nerve at lower leg level, unspecified leg, initial encounter 2 S8490xA Injury of unspecified nerve at lower leg level, unspecified leg, initial encounter 1 9/30/2019 S8490xS Injury of unspecified nerve at lower leg level, unspecified leg, sequela 2 S85909S Unspecified injury of unspecified blood vessel at lower leg level, unspecified leg, sequela 2 S86009S Unspecified injury of unspecified Achilles tendon, sequela 2 Unspecified injury of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, S86909S sequela 2 S88019A Complete traumatic amputation at knee level, unspecified lower leg, initial encounter 1 S88029A Partial traumatic amputation at knee level, unspecified lower leg, initial encounter 1 Complete traumatic amputation at level between knee and ankle, unspecified lower leg, initial S88119A encounter 5 Partial traumatic amputation at level between knee and ankle, unspecified lower leg, initial S88129A encounter 1 S88911A Complete traumatic amputation of right lower leg, level unspecified, initial encounter 5 9/30/2019 S88912A Complete traumatic amputation of left lower leg, level unspecified, initial encounter 1 9/30/2019 S88919S Complete traumatic amputation of unspecified lower leg, level unspecified, sequela 5 S88929A Partial traumatic amputation of unspecified lower leg, level unspecified, initial encounter 5 S88929S Partial traumatic amputation of unspecified lower leg, level unspecified, sequela 2 S8990xS Unspecified injury of unspecified lower leg, sequela 2 S92909S Unspecified fracture of unspecified foot, sequela 2 S98911A Complete traumatic amputation of right foot, level unspecified, initial encounter 5 9/30/2019 S98912A Complete traumatic amputation of left foot, level unspecified, initial encounter 1 9/30/2019 S98919A Complete traumatic amputation of unspecified foot, level unspecified, initial encounter 5 S98921A Partial traumatic amputation of right foot, level unspecified, initial encounter 1 9/30/2019 S98922A Partial traumatic amputation of left foot, level unspecified, initial encounter 1 9/30/2019 S98929A Partial traumatic amputation of unspecified foot, level unspecified, initial encounter 2 S99919S Unspecified injury of unspecified ankle, sequela 2 S99929S Unspecified injury of unspecified foot, sequela 2 T1490 Injury, unspecified 2 9/30/2017 T1490XS Injury, unspecified, sequela 1 10/1/2017 T2000xS Burn of unspecified degree of head, face, and neck, unspecified site, sequela 2 T20019S Burn of unspecified degree of unspecified ear [any part, except ear drum], sequela 2 T2002xS Burn of unspecified degree of lip(s), sequela 2 T2003xS Burn of unspecified degree of chin, sequela 2 T2004xS Burn of unspecified degree of nose (septum), sequela 2 T2005xS Burn of unspecified degree of scalp [any part], sequela 2 T2006xS Burn of unspecified degree of forehead and cheek, sequela 2 T2007xS Burn of unspecified degree of neck, sequela 2 T2009xS Burn of unspecified degree of multiple sites of head, face, and neck, sequela 2

64 CSHCS Qualifying Diagnoses Effective 10/01/2021

T2030xA Burn of third degree of head, face, and neck, unspecified site, initial encounter 5 T2070xA Corrosion of third degree of head, face, and neck, unspecified site, initial encounter 5 T2100xS Burn of unspecified degree of trunk, unspecified site, sequela 2 T2101xS Burn of unspecified degree of chest wall, sequela 2 T2102xS Burn of unspecified degree of abdominal wall, sequela 2 T2103xS Burn of unspecified degree of upper back, sequela 2 T2104xS Burn of unspecified degree of lower back, sequela 2 T2105xS Burn of unspecified degree of buttock, sequela 2 T2106xS Burn of unspecified degree of male genital region, sequela 2 T2107xS Burn of unspecified degree of female genital region, sequela 2 T2109xA Burn of unspecified degree of other site of trunk, initial encounter 5 T2109xS Burn of unspecified degree of other site of trunk, sequela 2 T2130xA Burn of third degree of trunk, unspecified site, initial encounter 5 T2170xA Corrosion of third degree of trunk, unspecified site, initial encounter 5 Burn of unspecified degree of shoulder and upper limb, except wrist and hand, unspecified site, T2200xS sequela 2 T22019S Burn of unspecified degree of unspecified forearm, sequela 2 T22029S Burn of unspecified degree of unspecified elbow, sequela 2 T22039S Burn of unspecified degree of unspecified upper arm, sequela 2 T22049S Burn of unspecified degree of unspecified axilla, sequela 2 T22059S Burn of unspecified degree of unspecified shoulder, sequela 2 T22069S Burn of unspecified degree of unspecified scapular region, sequela 2 Burn of unspecified degree of multiple sites of unspecified shoulder and upper limb, except wrist T22099A and hand, initial encounter 5 Burn of unspecified degree of multiple sites of unspecified shoulder and upper limb, except wrist T22099S and hand, sequela 2 Burn of third degree of shoulder and upper limb, except wrist and hand, unspecified site, initial T2230xA encounter 5 T22329A Burn of third degree of unspecified elbow, initial encounter 5 Corrosion of unspecified degree of multiple sites of unspecified shoulder and upper limb, except T22499A wrist and hand, initial encounter 1 Corrosion of third degree of shoulder and upper limb, except wrist and hand, unspecified site, T2270xA initial encounter 5 T22729A Corrosion of third degree of unspecified elbow, initial encounter 1 T23009S Burn of unspecified degree of unspecified hand, unspecified site, sequela 2 T23079S Burn of unspecified degree of unspecified wrist, sequela 2

T23099A Burn of unspecified degree of multiple sites of unspecified wrist and hand, initial encounter 5 T23099S Burn of unspecified degree of multiple sites of unspecified wrist and hand, sequela 2 T23309A Burn of third degree of unspecified hand, unspecified site, initial encounter 5

65 CSHCS Qualifying Diagnoses Effective 10/01/2021

T23329A Burn of third degree of unspecified single finger (nail) except thumb, initial encounter 5

T23339A Burn of third degree of unspecified multiple fingers (nail), not including thumb, initial encounter 5

T23349A Burn of third degree of unspecified multiple fingers (nail), including thumb, initial encounter 5 T23709A Corrosion of third degree of unspecified hand, unspecified site, initial encounter 1 T23729A Corrosion of third degree of unspecified single finger (nail) except thumb, initial encounter 1 Corrosion of third degree of unspecified multiple fingers (nail), not including thumb, initial T23739A encounter 1

T23749A Corrosion of third degree of unspecified multiple fingers (nail), including thumb, initial encounter 1 Burn of unspecified degree of unspecified site of unspecified lower limb, except ankle and foot, T24009S sequela 2 T24019S Burn of unspecified degree of unspecified thigh, sequela 2 T24029S Burn of unspecified degree of unspecified knee, sequela 2 T24039S Burn of unspecified degree of unspecified lower leg, sequela 2 Burn of unspecified degree of multiple sites of unspecified lower limb, except ankle and foot, initial T24099A encounter 5 Burn of unspecified degree of multiple sites of unspecified lower limb, except ankle and foot, T24099S sequela 2 Burn of third degree of unspecified site of unspecified lower limb, except ankle and foot, initial T24309A encounter 5 T24339A Burn of third degree of unspecified lower leg, initial encounter 5 Burn of third degree of multiple sites of unspecified lower limb, except ankle and foot, initial T24399A encounter 5 Corrosion of unspecified degree of multiple sites of unspecified lower limb, except ankle and foot, T24499A initial encounter 5 Corrosion of third degree of unspecified site of unspecified lower limb, except ankle and foot, initial T24709A encounter 5 T24739A Corrosion of third degree of unspecified lower leg, initial encounter 1 T25019S Burn of unspecified degree of unspecified ankle, sequela 2 T25029S Burn of unspecified degree of unspecified foot, sequela 2

T25099A Burn of unspecified degree of multiple sites of unspecified ankle and foot, initial encounter 5 T25099S Burn of unspecified degree of multiple sites of unspecified ankle and foot, sequela 2 T25319A Burn of third degree of unspecified ankle, initial encounter 5 T25329A Burn of third degree of unspecified foot, initial encounter 5 T25399A Burn of third degree of multiple sites of unspecified ankle and foot, initial encounter 5

T25499A Corrosion of unspecified degree of multiple sites of unspecified ankle and foot, initial encounter 5

66 CSHCS Qualifying Diagnoses Effective 10/01/2021

T25729A Corrosion of third degree of unspecified foot, initial encounter 5 T25799A Corrosion of third degree of multiple sites of unspecified ankle and foot, initial encounter 5 T2600xS Burn of unspecified eyelid and periocular area, sequela 2 T2610xS Burn of cornea and conjunctival sac, unspecified eye, sequela 2 T2640xS Burn of unspecified eye and adnexa, part unspecified, sequela 2 T273xxA Burn of respiratory tract, part unspecified, initial encounter 5 T277xxA Corrosion of respiratory tract, part unspecified, initial encounter 5 T280xxS Burn of mouth and pharynx, sequela 2 T281xxS Burn of esophagus, sequela 2 T282xxS Burn of other parts of alimentary tract, sequela 2 T283xxS Burn of internal genitourinary organs, sequela 2 T2840xA Burn of unspecified internal organ, initial encounter 5 T2840xS Burn of unspecified internal organ, sequela 2 T28419S Burn of unspecified ear drum, sequela 2 T2849xS Burn of other internal organ, sequela 2 T2890xA Corrosions of unspecified internal organs, initial encounter 5 T300 Burn of unspecified body region, unspecified degree 2 T304 Corrosion of unspecified body region, unspecified degree 2 T3111 Burns involving 10-19% of body surface with 10-19% third degree burns 5 T3122 Burns involving 20-29% of body surface with 20-29% third degree burns 5 T3143 Burns involving 40-49% of body surface with 30-39% third degree burns 5 T3151 Burns involving 50-59% of body surface with 10-19% third degree burns 5 T3155 Burns involving 50-59% of body surface with 50-59% third degree burns 5 T3164 Burns involving 60-69% of body surface with 40-49% third degree burns 5 T3166 Burns involving 60-69% of body surface with 60-69% third degree burns 5 T3211 Corrosions involving 10-19% of body surface with 10-19% third degree corrosion 5 T3222 Corrosions involving 20-29% of body surface with 20-29% third degree corrosion 5 T3243 Corrosions involving 40-49% of body surface with 30-39% third degree corrosion 1 T3251 Corrosions involving 50-59% of body surface with 10-19% third degree corrosion 1 T3255 Corrosions involving 50-59% of body surface with 50-59% third degree corrosion 5 T3264 Corrosions involving 60-69% of body surface with 40-49% third degree corrosion 5 T3266 Corrosions involving 60-69% of body surface with 60-69% third degree corrosion 1 T3490xS Frostbite with tissue necrosis of unspecified sites, sequela 2 T3691xS Poisoning by unspecified systemic antibiotic, accidental (unintentional), sequela 2 T3692xS Poisoning by unspecified systemic antibiotic, intentional self-harm, sequela 2 T3693xS Poisoning by unspecified systemic antibiotic, assault, sequela 2 T3694xS Poisoning by unspecified systemic antibiotic, undetermined, sequela 2 Poisoning by unspecified systemic anti-infective and antiparasitics, accidental (unintentional), T3791xS sequela 2

67 CSHCS Qualifying Diagnoses Effective 10/01/2021

T3792xS Poisoning by unspecified systemic anti-infective and antiparasitics, intentional self-harm, sequela 2 T3793xS Poisoning by unspecified systemic anti-infective and antiparasitics, assault, sequela 2 T3794xS Poisoning by unspecified systemic anti-infective and antiparasitics, undetermined, sequela 2

T38801S Poisoning by unspecified hormones and synthetic substitutes, accidental (unintentional), sequela 2

T38802S Poisoning by unspecified hormones and synthetic substitutes, intentional self-harm, sequela 2 T38803S Poisoning by unspecified hormones and synthetic substitutes, assault, sequela 2 T38804S Poisoning by unspecified hormones and synthetic substitutes, undetermined, sequela 2 T40902S Poisoning by unspecified psychodysleptics [hallucinogens], intentional self-harm, sequela 2 T40903S Poisoning by unspecified psychodysleptics [hallucinogens], assault, sequela 2 T40904S Poisoning by unspecified psychodysleptics [hallucinogens], undetermined, sequela 2 T410X4S Poisoning by inhaled anesthetics, undetermined, sequela 2 T41204S Poisoning by unspecified general anesthetics, undetermined, sequela 2 T413X4S Poisoning by local anesthetics, undetermined, sequela 2 T423X4S Poisoning by barbiturates, undetermined, sequela 2 T424X4S Poisoning by benzodiazepines, undetermined, sequela 2

T4274xS Poisoning by unspecified antiepileptic and sedative-hypnotic drugs, undetermined, sequela 2 Poisoning by antiparkinsonism drugs and other central muscle-tone depressants, undetermined, T428X4S sequela 2 T43024S Poisoning by tetracyclic antidepressants, undetermined, sequela 2 T431X4S Poisoning by monoamine-oxidase-inhibitor antidepressants, undetermined, sequela 2 T43204S Poisoning by unspecified antidepressants, undetermined, sequela 2 T452X4S Poisoning by vitamins, undetermined, sequela 2 T4994xS Poisoning by unspecified topical agent, undetermined, sequela 2

T50904S Poisoning by unspecified drugs, medicaments and biological substances, undetermined, sequela 2 T543X4A Toxic effect of corrosive alkalis and alkali-like substances, undetermined, initial encounter 2 T560X4A Toxic effect of lead and its compounds, undetermined, initial encounter 2 T66xxxS Radiation sickness, unspecified, sequela 2 T68xxxS Hypothermia, sequela 2 T700xxS Otitic barotrauma, sequela 2 T701xxS Sinus barotrauma, sequela 2 T7020xS Unspecified effects of high altitude, sequela 2 T719xxS Asphyxiation due to unspecified cause, sequela 2 T730xxS Starvation, sequela 2 T744xxS Shaken infant syndrome, sequela 2 T7500xS Unspecified effects of lightning, sequela 2

68 CSHCS Qualifying Diagnoses Effective 10/01/2021

T7692xS Unspecified child maltreatment, suspected, sequela 2 T7800xA Anaphylactic reaction due to unspecified food, initial encounter 2 T7801xA Anaphylactic reaction due to peanuts, initial encounter 2 T7802xA Anaphylactic reaction due to shellfish (crustaceans), initial encounter 2 T7803xA Anaphylactic reaction due to other fish, initial encounter 2 T7804xA Anaphylactic reaction due to fruits and vegetables, initial encounter 2 T7805xA Anaphylactic reaction due to tree nuts and seeds, initial encounter 2 T7807xA Anaphylactic reaction due to milk and dairy products, initial encounter 2 T7808xA Anaphylactic reaction due to eggs, initial encounter 2 T7809xA Anaphylactic reaction due to other food products, initial encounter 2 T782xxA Anaphylactic shock, unspecified, initial encounter 2 T79A0xS Compartment syndrome, unspecified, sequela 2 T819xxA Unspecified complication of procedure, initial encounter 2 Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, T827xxA initial encounter 3 Infection and inflammatory reaction due to internal fixation device of unspecified site, initial T8460xA encounter 2 Infection and inflammatory reaction due to internal fixation device of unspecified bone of arm, T84619A initial encounter 2 Infection and inflammatory reaction due to internal fixation device of unspecified bone of leg, T84629A initial encounter 2

T8463xA Infection and inflammatory reaction due to internal fixation device of spine, initial encounter 2 Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants T847xxA and grafts, initial encounter 2 Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, T8579xA initial encounter 3 T8600 Unspecified complication of bone marrow transplant 5 T8610 Unspecified complication of kidney transplant 5 T8620 Unspecified complication of heart transplant 5 T8630 Unspecified complication of heart-lung transplant 5 T8640 Unspecified complication of liver transplant 5 T865 Complications of stem cell transplant 5 T86819 Unspecified complication of lung transplant 5 T86839 Unspecified complication of bone graft 2 T86842 Corneal transplant infection 2 9/30/2020 T868483 Other complications of corneal transplant, bilateral 2 10/1/2020 T868489 Other complications of corneal transplant, unspecified eye 2 10/1/2020 T868493 Unspecified complication of corneal transplant, bilateral 2 10/1/2020 T868499 Unspecified complication of corneal transplant, unspecified eye 2 10/1/2020

69 CSHCS Qualifying Diagnoses Effective 10/01/2021

T86859 Unspecified complication of intestine transplant 5 T86890 Other transplanted tissue rejection 5 T8690 Unspecified complication of unspecified transplanted organ and tissue 2 T8699 Other complications of unspecified transplanted organ and tissue 2 T879 Unspecified complications of amputation stump 3 T889xxS Complication of surgical and medical care, unspecified, sequela 2

70