G 52.3 Attachment B Effective: 04/29/2016 Reviewed: 4/2019 Mental Health Therapeutic Diversion Program Eligibility Diagnoses ------- Attachment B ICD DESCRIPTION F06.0 PSYCHOTIC DISORDER DUE TO MEDICAL CONDITION, W/O HALLUCINATIONS F06.2 PSYCHOTIC DISORDER DUE TO PHYSIOLOGIC CONDITION F06.31 DEPRESSIVE DISORDER DUE TO MEDICAL CONDITION, W/ DEPRESSIVE FEATURES F10.94 ALCOHOL INDUCED BIPOLAR AND RELATED DISORDER, W/O USE DISORDER F10.95 ALCOHOL INDUCED DEPRESSIVE DISORDER, W/ USE DISORDER F10.959 ALCOHOL INDUCED PSYCHOTIC DISORDER, W/O USE DISORDER F12.959 PSYCHOTIC DISORDER,CANNABIS-INDUCED, W/O USE DISORDER SEDATIVE, HYPNOTIC, OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER, W/O USE F13.959 DISORDER NEUROCOGNITIVE DISORDER, SEDATIVE, HYPNOTIC, OR ANXIOLYTIC-INDUCED MAJOR, F13.97 W/O USE DISORDER F15.94 BIPOLAR AND RELATED DISORDER, STIMULANT-INDUCED W/O USE DISORDER F15.959 PSYCHOTIC DISORDER, STIMULANT-INDUCED, W/O USE DISORDER F20 SCHIZOPHRENIA F20.0 SCHIZOPHRENIA, W/ PARANOIA F20.2 SCHIZOPHRENIA W/ CATATONIA F20.81 SCHIZOPHRENIFORM DISORDER F21 SCHIZOTYPAL PERSONALITY DISORDER F22 DELUSIONAL DISORDER F23 BRIEF PSYCHOTIC DISORDER F24 SHARED PSYCHOTIC DISORDER F25.0 SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE F25.1 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE F25.9 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED F29 UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER F30.11 BIPOLAR I DISORDER, MANIC EPISODE, MILD F30.12 BIPOLAR I DISORDER, MANIC EPISODE, MODERATE F30.13 BIPOLAR I DISORDER, MANIC EPISODE W/O PSYCHOSIS, SEVERE F30.2 BIPOLAR I DISORDER, MANIC EPISODE W/ PSYCHOTIC SX, SEVERE F30.3 BIPOLAR I DISORDER, MANIC EPISODE, PARTIAL REMISION F30.4 BIPOLAR I DISORDER, MANIC EPISODE, FULL REMISSION F30.9 BIPOLAR I DISORDER, MANIC EPISODE, UNSPECIFIED F31.11 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE MANIC, MILD F31.12 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE MANIC, MODERATE F31.13 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE MANIC, SEVERE BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE MANIC, W/ PSYCHOTIC F31.2 FEATURES F31.30 BIPOLAR I DISORDER, DEPRESSED IN MOST RECENT EPISODE, UNSPECIFIED Page 1 G 52.3 Attachment B Effective: 04/29/2016 Reviewed: 4/2019 Mental Health Therapeutic Diversion Program Eligibility Diagnoses ------- Attachment B F31.31 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE DEPRESSED, MILD F31.32 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE DEPRESSED, MODERATE F31.4 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE DEPRESSED, SEVERE BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE DEPRESSED, W/ F31.5 PSYCHOTIC FEATURES F31.60 BIPOLAR I DISORDER, MIXED IN MOST RECENT EPISODE, UNSPECIFIED F31.61 BIPOLAR I DISORDER, MILD, MIXED IN MOST RECENT EPISODE F31.62 BIPOLAR I DISORDER MODERATE, MIXED IN MOST RECENT EPISODE F31.63 BIPOLAR I DISORDER, W/O PSYCHOTIC FEATURES, MIXED IN MOST RECENT EPISODE F31.64 BIPOLAR I DISORDER, W/ PSYCHOTIC FEATURES, MIXED IN MOST RECENT EPISODE F31.71 BIPOLAR I DISORDER, HYPOMANIC IN MOST RECENT EPISODE BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE HYPOMANIC, IN PARTIAL F31.73 REMISSION BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE HYPOMANIC, IN FULL F31.74 REMISSION F31.75 BIPOLAR I DISORDER, PARTIAL REMISSION, DEPRESSED IN MOST RECENT EPISODE F31.76 BIPOLAR I DISORDER,FULL REMISSION, DEPRESSED IN MOST RECENT EPISODE F31.77 BIPOLAR I DISORDER, PARTIAL REMISSION, MIXED IN MOST RECENT EPISODE F31.78 BIPOLAR I DISORDER,FULL REMISSION, MIXED IN MOST RECENT EPISODE F31.8 BIPOLAR II DISORDER F31.89 OTHER SPECIFIED BIPOLAR AND RELATED DISORDER F31.9 BIPOLAR I DISORDER, MOST RECENT EPISODE UNSPECIFIED F31.91 BIPOLAR I DISORDER, CURRENT OR MOST RECENT EPISODE MANIC, UNSPECIFIED F31.92 UNSPECIFIED BIPOLAR AND RELATED DISORDER F32.0 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD F32.1 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MODERATE F32.2 MAJOR DEPRESSIVE DISORDER, SEVERE W/O PSYCHOSIS, SINGLE EPISODE F32.3 MAJOR DEPRESSIVE DISORDER, SEVERE W/ PSYCHOSIS SINGLE EPISODE F32.4 MAJOR DEPRESSIVE DISORDER, PARTIAL REMISSION, SINGLE EPISODE F32.5 MAJOR DEPRESSIVE DISORDER, FULL REMISSION, SINGLE EPISODE F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED F32.91 UNSPECIFIED DEPRESSIVE DISORDER F33.0 MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD F33.1 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT, W/O PSYCHOSIS, SEVERE F33.3 MAJOR DEPRESSIVE DISORDER, RECURRENT, W/ PSYCHOSIS, SEVERE F33.41 MAJOR DEPRESSIVE DISORDER, RECURRENT, PARTIAL REMISSION F33.42 MAJOR DEPRESSIVE DISORDER, RECURRENT, FULL REMISSION F33.8 RECURRENT DEPRESSIVE DISORDER, UNSPECIFIED Page 2 G 52.3 Attachment B Effective: 04/29/2016 Reviewed: 4/2019 Mental Health Therapeutic Diversion Program Eligibility Diagnoses ------- Attachment B F33.9 MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED F34.1 PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) F39 MOOD DISORDER, UNSPECIFIED F40.00 AGORAPHOBIA F40.01 PANIC DISORDER W/ AGORAPHOBIA F40.02 AGORAPHOBIA W/O PANIC ATTACKS F41.0 PANIC DISORDER F41.1 GENERALIZED ANXIETY DISORDER F41.9 ANXIETY DISORDER, UNSPECIFIED F42 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (RUMINATION) F43.0 ACUTE STRESS DISORDER F43.10 POSTTRAUMATIC STRESS DISORDER F43.20 ADJUSTMENT DISORDER, UNSPECIFIED F43.21 ADJUSTMENT DISORDER W/ DEPPRESSED MOOD F43.22 ADJUSTMENT DISORDER W/ ANXIETY F43.23 ADJUSTMENT DISORDER, WITH MIXED ANXIETY AND DEPRESSED MOOD F43.24 ADJUSTMENT DISORDER, WITH DISTURBANCE OF CONDUCT F43.25 ADJUSTMENT DISORDER, WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT F43.29 ADJUSTMENT DISORDER UNSPECIFIED F44.0 DISSOCIATIVE AMNESIA F44.1 DISSOCIATIVE FUGUE (AMNESIA) F44.7 CONVERSION Disorder (FUNCTIONAL NEURO SX DISORDER) F44.81 DISSOCIATIVE IDENTITY DISORDER F44.9 DISSOCIATIVE DISORDER, UNSPECIFIED F50.01 ANOREXIA NERVOSA, RESTRICTING TYPE F50.02 ANOREXIA NERVOSA, BINGE-EATING/PURGING TYPE F50.2 BULIMIA NERVOSA F60.0 PARANOID PERSONALITY DISORDER F60.1 SCHIZOID PERSONALITY DISORDER F60.3 BORDERLINE PERSONALITY DISORDER F60.4 HISTRONIC PERSONALITY DISORDER F60.5 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER F60.6 AVOIDANT PERSONALITY DISORDER F60.7 DEPENDENT PERSONALITY F60.89 OTHER SPECIFIED PERSONALITY DISORDER F60.9 UNSPECIFIED PERSONALITY DISORDER F63.81 INTERMITTENT EXPLOSIVE DISORDER Page 3 G 52.3 Attachment B Effective: 04/29/2016 Reviewed: 4/2019 Mental Health Therapeutic Diversion Program Eligibility Diagnoses ------- Attachment B F84.5 ASPERGER'S/RHETT'S DISORDER F95.2 TOURETTE'S DISORDER R41.83 BORDERLINE INTELLECTUAL FUNCTIONING DMS-5 Diagnostic Categories ANXIETY DISORDERS BIPOLAR AND RELATED DISORDERS DEPRESSIVE DISORDERS DISRUPTIVE IMPULSE CONTROL AND CONDUCT DISORDERS PERSONALITY DISORDERS SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS TRAUMA AND STRESSOR RELATED DISORDERS Page 4 .