Behavioral Health
Utilization Management Report
Guidelines
State Fiscal Year 2000
(Appendix E3 of MCO/HHSC CHIP Contract)
PURPOSE:
The purpose of the Utilization Management (UM) Report is to define a uniform system for measuring
access, quality of care, outcome and other aspects of services delivered to CHIP clients enrolled in
managed care organization (MCO) plans, including exclusive provider plans offered by insurers.
UM REPORT SPECIFICATIONS:
UM reports required by the State are to be reported quarterly. This Appendix, as may be modified or
amended by the State, controls the reporting criteria required in the Insurer/HHSC Contract. MCO
agrees to cooperate with the State in developing selected alternative reporting formats as identified by the
State. It is the MCO‟s responsibility to understand and fulfill the required reporting data elements in
accordance to the instructions. Failure to do so will result in a resubmission of data as required by the
State. The MCOs must submit the data utilizing UM Reports provided by the State.
MCOs should not extract data for the UM reports prior to 95 days after reporting period or the negotiated
provider submission deadline for encounter data / claims submission.
Reports should be submitted on the TexMedNet System on the specified due date. MCOs may inquire of
the State in writing for an extension of no more than 2 weeks. If an MCO submits any of the UM reports
after the 2 week extension period, they will be sanctioned. The MCO is required to review and validate
the entire report prior to submission. Incongruities found by the State will be identified to the MCO.
These issues must be addressed, either via explanation or correction within one week of notification.
Changes to the report are allowable within 2 weeks after due date.
The MCO is required to report requested data utilizing industry accepted coding systems. . If the MCO
collects data utilizing different codes, it is the MCO‟s responsibility to “map” or translate the codes. The
plan should explain, in an attachment or appendix, the methodology it used to accomplish the conversion.
MCOs must label each report table page with the following Criteria:
Name of the MCO
Name of the BHO (If Applicable)
State Fiscal Year and Quarter the report represents
Date of Submission
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Behavioral Health Utilization Management Report (Instructions)
Reporting Conventions:
Abbreviations:
The following abbreviations are utilized throughout this text and the corresponding tables:
Abbreviation: Definition:
# A measurable numerical value
Avg. Average
BH Behavioral Health
BHO Behavioral Health Care Organization
CD Chemical Dependency
Dx Diagnosis
CSA CHIP Service Area
ER Emergency Room/Department
LOS Length of Stay
MCO Managed Care Organization
MM Member Months
PH Physical Health
QTR Quarter
SFY State Fiscal Year
HHSC Health and Human Services Commission
UM Utilization Management
w/o Without
Age Of Member:
Table elements of the report require computations be stratified by age brackets relative to the reported
population. For the purposes of determining age of a member, the individual is quantified under the age
category he/she belongs to on the last day of the reporting period. All fractions are dropped when
determining this value.
Coding Systems:
Accepted Coding Systems utilized by this text are:
DRGs Diagnosis-Related Groups, Definitions Manual, 1997
ICD-9 (CM) International Classification of Diseases, Ninth Revision, Clinical Modification, 1999
CPT-4 Physicians Current Procedural Terminology, 1999
DSMIV Diagnostic and Statistical Manual IV 5th Printing, April 1996
UB-92 UB-92 Form Field Codes, 1999
HCFA 1500 HCFA 1500 Form Field Codes, 1999
Length of Stay (LOS):
The LOS is computed as the number of days from the Admission Date to the Discharge Date, the last day
of the stay not being counted. The formula below illustrates:
LOS = (Discharge Date) – (Admission Date);
If LOS = Ø, Then Report LOS as = 1
If the Date of Discharge and the Date of Admission are the same, the stay is considered to be one (1) day.
Length of stay is never to be reported as zero or a null value.
Relationship between MCO & BHO:
If a Behavioral Health Organization is completing this report in conjunction with an MCO, please note
that some of the report tables call for an examination of activities occurring on the physical health side of
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Behavioral Health Utilization Management Report (Instructions)
the plan. It is suggested that the MCO provide the BHO with data for encounters which occur on the
physical health side of the plan that are behavioral health in nature.
Suggested Work Flow:
The tables contained in this report have been ordered in such a fashion as to be completed in a
chronological fashion. One table‟s data requirements are usually fulfilled in part, by the results generated
in a previous table‟s work. It is suggested that the tables be completed in ascending order fashion,
according to their number. It is also recommended that a singular individual complete all the tables in
this report to better ensure follow-through, consistency and correlation between related tables. If this is
not possible, please be sure to provide each member of your team with a complete copy of these
instructions.
Zero and Null Values:
For data elements not available, the MCO should supply the descriptor “Null” for the requested value.
Elements left ‘Blank’ will be cause the related portion of the report to be regarded as incomplete. The Ø
or ‘zero’ character is only to be utilized in a data element to establish a verifiable count or computation.
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Behavioral Health Utilization Management Report (Instructions)
List of Behavioral Health Tables FY2000
Table Table Name Page:
No:
1.01 Count of Member Months of MCO CHIP Population By Age, and Gender 5
1.02 Unduplicated Count of MCO CHIP Population By Age, and Gender 6
1.03 Cultural Diversity of Unduplicated CHIP Members Receiving Behavioral 7
Health Services
1.04 Count of Member Months for MCO CHIP Population (Receiving Behavioral 8
Health Services), By Age, Gender and Disorder
1.05 Unduplicated Count of MCO CHIP Population (Receiving Behavioral Health 10
Services), By Age, Gender and Disorder
2.01 Utilization of Inpatient Hospital Behavioral Health Services 12
2.02 Utilization of Outpatient Behavioral Health Services 15
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Behavioral Health Utilization Management Report (Instructions)
Table 1.01
Count of Member Months for MCO CHIP Population By Age & Gender
Purpose of Table: To provide a count of the member months an MCO‟s CHIP population
represents. Member month computations allow plans of different sizes to be
compared with each other.
Population Criteria: The entire enrolled CHIP population of the MCO should be counted. This table
should reflect numbers equal to that of its counterpart in the Physical Health
Report (with the exception of different age stratification in the Physical Health
report). Discrepancies between this table‟s results and the Physical Health table
should be investigated by the MCO and addressed in a narrative accompanying
this report.
This value is equal to Both
A B the sum of Cells B2B4 on
Age/Sex Total this table and the related total
Category CHIP for Males on the Physical
1 Male Health Table 1.A
2 0-5
3 6-12
4 13-18
This value is equal to Both
5 Total
the sum of Cells B7B9 on
6 Female this table and the related total
7 0-5 for Females on the Physical
6-12 Health Table 1.A
8
9 13-18
10 Total
This value is equal to Both
11 Males & Females the sum of Cells B12B14 on
12 0-5 this table and B5 + B10 and
13 6-12 the related total for Males &
Females on the Physical
14 13-18
Health Table 1.A
15 Total
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Behavioral Health Utilization Management Report (Instructions)
Table 1.02
Unduplicated Count of MCO CHIP Population By Age & Gender
Purpose of Table: To provide an unduplicated count of the number of people an MCO‟s CHIP
population represents.
Population Criteria: The entire enrolled CHIP population of the MCO should be counted. This table
should reflect numbers equal to that of its counterpart in the Physical Health
Report (with the exception of different age stratification in the Physical Health
report). Discrepancies between this table‟s results and the Physical Health table
should be investigated by the MCO and addressed in a narrative accompanying
this report.
A B This value is equal to Both
the sum of Cells B2B4 on
Age/Sex Total
this table and the related total
Category CHIP
for Males on the Physical
1 Male Health Table 1.B
2 0-5
3 6-12
4 13-18
5 Total This value is equal to Both
Female the sum of Cells B7B9 on
6 this table and the related total
7 0-5 for Females on the Physical
8 6-12 Health Table 1.B
9 13-18
10 Total
This value is equal to Both
11 Males & Females the sum of Cells B12B14 on
12 0-5 this table and B5 + B10 and
6-12 the related total for Males &
13 Females on the Physical
14 13-18 Health Table 1.B
15 Total
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Behavioral Health Utilization Management Report (Instructions)
Table 1.03
Cultural Diversity of Unduplicated CHIP Members, Receiving Behavioral Health Services
Purpose of Table: To provide an unduplicated count of the number of people within an MCO‟s
CHIP population who have accessed Behavioral Health services within the
reporting period.
Population Criteria: The entire enrolled CHIP population of the MCO should be utilized. Count only
those individuals who received a Behavioral Health service during the reporting
period and stratify by the supplied ethnic designations.
Total Unduplicated CHIP membership
during reporting period (from Table 1.02) 0.000
Distribution of CHIP Membership by Ethnic Ethnicity Codes Number of Unique Percentage of
Heritage Members in this Total CHIP
Ethnic Distinction Population
White (Non-Hispanic) 1
African-American/Black 2
Hispanic 3
American Indian (Non-Hispanic) 4
Oriental / Asian 5
Unknown/Other 6
TOTAL 0
This value equals the sum of the values The sum of the above
above and also equals the total number of values should equal
unique members on table 1.05 of this report 100% in this box.
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Behavioral Health Utilization Management Report (Instructions)
Table 1.04
Count of Member Months for MCO CHIP Population (Receiving Behavioral Health
Services), By Age, Gender and Disorder
Purpose of Table: To provide a count of the member months an MCO‟s CHIP population who
access Behavioral Health services represents. Member month computation
allows plans of different sizes to be compared with each other as well as allows
for the sub population to be compared to the plan as a whole.
Population Criteria: The member months, represented by entire enrolled CHIP population of the
MCO, that have received Behavioral Health services, should be counted.
Utilize the Code sets, contained at the end of this text, to identify individuals receiving BH services
during this reporting period, as well as to stratify according to type of disorder. If within a single
encounter, a secondary diagnosis is identified, „recount‟ the individual‟s member months in the bottom
portion of the table.
Only PAID claims should be utilized for this table. Exclude all pending and denied claims.
Each Member is counted only once during the reporting period.
If multiple primary diagnoses exist within the reporting period for the same individual, stratify the
individual via the first diagnosis recorded.
The total value of member months of this table should NOT exceed that of table 1.01.
Remember that each age category and disorder stratification must be totaled for each area on the
table.
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Behavioral Health Utilization Management Report (Instructions)
Table 1.04
Count of Member Months for MCO CHIP Population (Receiving Behavioral Health Services), By Age, Gender and Disorder
DISORDER Males (By age Bracket) Females (By Age Bracket) Males & Females (By Age
Bracket)
00-05 06-12 13-18 Total 00-05 06-12 13-18 Total 00-05 06-12 13-18 Total
PRIMARY
DISORDERS
Mood / Affective
Disorders
Schizophrenia &
Other Psychoses
ADHD Disorders
Disruptive Behavior
/ Impulse Control
Adjustment
Disorders
Personality
Disorders
SA – Alcohol
SA – Inhalants
SA – Cocaine
SA – Opiates
Polysubstance Dep.
Other Disorders
Total
SECONDARY
DISORDERS
Mental Retardation
/ Autism
Substance Related
Disorders
Suicide
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Behavioral Health Utilization Management Report (Instructions)
Table 1.05
Unduplicated Count of MCO CHIP Population (Receiving Behavioral Health Services), By
Age, Gender and Disorder
Purpose of Table: To provide an unduplicated count of the unique members in an MCO‟s CHIP
population who accessed Behavioral Health services.
Population Criteria: The entire enrolled CHIP population of the MCO, that have received Behavioral
Health services during the reporting period, should be counted.
Utilize the Code sets, contained at the end of this text, to identify individuals receiving BH services
during this reporting period, as well as to stratify according to type of disorder. If a secondary diagnosis
is identified, within a single encounter, „recount‟ the individual in the bottom portion of the table.
Only PAID claims should be utilized for this table. Exclude all pending and denied claims.
Each Member is counted only once during the reporting period.
If multiple primary diagnoses exist within the reporting period for the same individual, stratify the
individual via the first diagnosis recorded.
Remember that each age category, and disorder stratification must be totaled in each area on the table.
The total value of unique members on this table should Equal table 1.03.
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Behavioral Health Utilization Management Report (Instructions)
Table 1.05
Unduplicated Count of MCO CHIP Population (Receiving Behavioral Health Services), By Age, Gender and Disorder
DISORDER Males (By age Bracket) Females (By Age Bracket) Males & Females (By Age
Bracket)
00-05 06-12 13-18 Total 00-05 06-12 13-18 Total 00-05 06-12 13-18 Total
PRIMARY
DISORDERS
Mood / Affective
Disorders
Schizophrenia &
Other Psychoses
ADHD Disorders
Disruptive Behavior
/ Impulse Control
Adjustment
Disorders
Personality
Disorders
SA – Alcohol
SA – Inhalants
SA – Cocaine
SA – Opiates
Polysubstance Dep.
Other Disorders
Total
SECONDARY
DISORDERS
Mental Retardation
/ Autism
Substance Related
Disorders
Suicide
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Behavioral Health Utilization Management Report (Instructions)
Table 2.01
Utilization of Inpatient Hospital Behavioral Health Services
Purpose of Table: To monitor access and track Hospital Inpatient Behavioral Health utilization by
age group and disorder.
Population Criteria: The entire enrolled CHIP population of the MCO, that have received Behavioral
Health services during the reporting period, should be counted.
Utilize the Code sets, contained at the end of this text, to identify individuals receiving BH services
during this reporting period, as well as to stratify according to type of disorder. If you are completing
these reports in numerical order, you should already have this subset identified.
Hospital Inpatient stays are identified as those Behavioral Health service encounters, which have a
discharge date different from the admit date.
If a secondary diagnosis is identified within a single encounter, „recount‟ the encounter/individual in
the bottom portion of the table.
Only PAID claims should be utilized for this table. Exclude all pending and denied claims.
Area #1 on the sample table, which follows, counts number of separate encounters.
Area #2 on the sample table, which follows, counts number of unique individuals, which represent
those encounters.
Area # 3 counts the number of days those unique members stayed in an inpatient facility.
Area #4 counts the number of discharges, which had an admission generated by a court order.
If multiple encounters, with different primary diagnoses exist within the reporting period for the same
individual, stratify the member via the last discharge diagnosis recorded.
Remember that each age category and each disorder stratification, must be totaled in each area on the
table.
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Behavioral Health Utilization Management Report (Instructions)
Table 2.01
Utilization of Inpatient Hospital Behavioral Health Services
DISORDER # of Inpatient Discharges # of Unique Members Total Days Stayed
Representing those
Discharges
00-05 06-12 13-18 Total 00-05 06-12 13-18 Total 00-05 06-12 13-18 Total
PRIMARY
DISORDERS
Mood / Affective
Disorders
Schizophrenia &
Other Psychoses
ADHD Disorders
Disruptive Behavior
/ Impulse Control Area #1 Area #2 Area #3
Adjustment
Disorders
Personality
Disorders
SA – Alcohol
SA – Inhalants
SA – Cocaine
SA – Opiates
Polysubstance Dep.
Other Disorders
Total
SECONDARY
DISORDERS
Mental Retardation
/ Autism
Substance Related
Disorders
Suicide
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Behavioral Health Utilization Management Report (Instructions)
Table 2.01 (Continued)
Utilization of Inpatient Hospital Behavioral Health Services
DISORDER # of Discharges From
Court Ordered Admissions
00-05 06-12 13-18 Total
PRIMARY
DISORDERS
Mood / Affective
Disorders
Schizophrenia &
Other Psychoses
ADHD Disorders
Disruptive Behavior
/ Impulse Control Area #4
Adjustment
Disorders
Personality
Disorders
SA – Alcohol
SA – Inhalants
SA – Cocaine
SA – Opiates
Polysubstance Dep.
Other Disorders
Total
SECONDARY
DISORDERS
Mental Retardation
/ Autism
Substance Related
Disorders
Suicide
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Behavioral Health Utilization Management Report (Instructions)
Table 2.02
Utilization of Outpatient Behavioral Health Services
Purpose of Table: To monitor and track the number of outpatient visits, per age group and
diagnostic category, for Behavioral Health Services.
Population Criteria: The entire enrolled CHIP population of the MCO, that have received Behavioral
Health services during the reporting period, should be counted.
Utilize the Code sets, contained at the end of this text, to identify individuals receiving BH services
during this reporting period as well as to stratify according to type of disorder. If you are completing
these reports in numerical order, you should already have a subset of Behavioral Health encounters
identified.
MCO Outpatient visits are identified, as those where the admit and discharge dates are the same, BUT do
have a procedural code listed on the “Outpatient Procedures” code set included at the end of this text.
If a secondary diagnosis is identified within a single encounter, „recount‟ the encounter/individual in
the bottom portion of the table.
Only PAID claims should be utilized for this table. Exclude all pending and denied claims.
Area #1 on the sample table, which follows, counts number of visits.
Area #2 on the sample table, which follows, counts number of unique members representing those
visits.
Remember that each age category and each disorder stratification, must be totaled in each area on the
table.
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Behavioral Health Utilization Management Report (Instructions)
Table 2.02
Utilization of Outpatient Behavioral Health Services
DISORDER # of Outpatient Visits # of Unique Members
Representing Those Visits
00-05 06-12 13-18 Total 00-05 06-12 13-18 Total
PRIMARY
DISORDERS
Mood / Affective
Disorders
Schizophrenia &
Other Psychoses
ADHD Disorders
Disruptive Behavior
/ Impulse Control
Adjustment
Area #1 Area #2
Disorders
Personality
Disorders
SA – Alcohol
SA – Inhalants
SA – Cocaine
SA – Opiates
Polysubstance Dep.
Other Disorders
Total
SECONDARY
DISORDERS
Mental Retardation
/ Autism
Substance Related
Disorders
Suicide
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Behavioral Health Utilization Management Report (Instructions)
Primary Diagnosis Codes:
Mood / Affective Disorders:
ICD-9 ICD-9
Description: Description:
Code: Code:
290 Senile and presenile organic psychotic conditions 296.4 Bipolar affective disorder, manic
Organic Affective Syndrome - Transient organic
293.83 psychotic condition, depressive type
296.40 Unspecified
296.0 Manic disorder, single episode 296.41 Mild
296.00 Unspecified 296.42 Moderate
296.01 Mild 296.43 Severe, w/o mention of psychotic behavior
296.02 Moderate 296.44 Severe, specified as with psychotic behavior
296.03 Severe, w/o mention of psychotic behavior 296.45 In partial or unspecified remission
296.04 Severe, specified as with psychotic behavior 296.46 In full remission
296.05 In partial or unspecified remission 296.5 Bipolar affective disorder, depressed
296.06 In full remission 296.50 Unspecified
296.1 Manic disorder, recurrent episode 296.51 Mild
296.10 Unspecified 296.52 Moderate
296.11 Mild 296.53 Severe, w/o mention of psychotic behavior
296.12 Moderate 296.54 Severe, specified as with psychotic behavior
296.13 Severe, w/o mention of psychotic behavior 296.55 In partial or unspecified remission
296.14 Severe, specified as with psychotic behavior 296.56 In full remission
296.15 In partial or unspecified remission 296.6 Bipolar affective disorder, mixed
296.16 In full remission 296.60 Unspecified
296.2 Major depressive disorder, single episode 296.61 Mild
296.20 Unspecified 296.62 Moderate
296.21 Mild 296.63 Severe, w/o mention of psychotic behavior
296.22 Moderate 296.64 Severe, specified as with psychotic behavior
296.23 Severe, w/o mention of psychotic behavior 296.65 In partial or unspecified remission
296.24 Severe, specified as with psychotic behavior 296.66 In full remission
296.25 In partial or unspecified remission 296.7 Bipolar affective disorder, unspecified
Manic-depressive psychosis, other and
296.26 In full remission 296.8 unspecified
296.3 Major depressive disorder, recurrent episode 296.80 Unspecified
296.30 Unspecified 296.81 Atypical manic disorder
296.31 Mild 296.82 Atypical depressive disorder
296.32 Moderate 296.9 Other and unspecified affective psychoses
296.33 Severe, w/o mention of psychotic behavior 296.90 Unspecified affective psychosis
296.34 Severe, specified as with psychotic behavior 296.99 Other specified affective psychoses
296.35 In partial or unspecified remission 300 Neurotic disorders
296.36 In full remission 300.4 Neurotic depression
V-Codes:
V11.10 Affective Disorders - Personal History of Manic- V79.00 Depression (screening)
Depressive Psychosis
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Behavioral Health Utilization Management Report (Instructions)
Anxiety / Stress/ Phobia Disorders:
ICD-9 ICD-9
Description: Description:
Code: Code:
293.84 Organic Anxiety Syndrome 306.4 Gastrointestinal (aerophagy)
300 Neurotic disorders 306.5 Genitourinary
300.0 Anxiety states 306.50 Psychogenic genitourinary malfunction
300.00 Anxiety state, unspecified 306.51 Psychogenic vaginismus
300.01 Panic disorder 306.52 Psychogenic dysmenorrhea
300.02 Generalized anxiety disorder 306.53 Psychogenic dysuria
300.09 Other 306.59 Other
300.1 Hysteria 306.6 Endocrine
300.10 Hysteria unspecified 306.7 Organs of special sense
Other specified psycho-physiological
300.11 Conversion disorder 306.8 malfunction
300.12 Psychogenic amnesia 306.9 Unspecified psycho-physiological malfunction
Special symptoms or syndromes, not elsewhere
300.13 Psychogenic fugue 307 classified,
300.14 Multiple personally 307.0 Stammering and stuttering
300.15 Dissociative disorder or reaction, unspecified 307.1 Anorexia nervosa
300.16 Factitious illness with psychological symptoms 307.2 Tics
300.19 Other and unspecified factitious illness 307.20 Tic, disorder; unspecified
300.2 Phobic disorders 307.21 Transient tic disorder of childhood
300.20 Phobia unspecified 307.22 Chronic motor tic disorder
Gilles de la tourette‟s disorder (motor-verbal tic
300.21 Agoraphobia with panic attacks 307.23 disorder)
300.22 Agoraphobia without mention of panic attacks 307.4 Specific disorders of sleep of non-organic origin
300.23 Social phobia 307.40 Non-organic sleep disorder, unspecified
Transient disorder of initiating or maintaining
300.29 Other isolated or simple phobia 307.41 sleep
Persistent disorder of initiating or maintaining
300.3 Obsessive compulsive disorders 307.42 sleep
Transient disorder of initiating or maintaining
300.5 Neurasthenia 307.43 wakefulness
Persistent disorder of initiating or maintaining
300.6 Depersonalization syndrome 307.44 wakefulness
Phase-shift disruption of 24-hour sleep-wake
300.7 Hypochondriasis 307.45 cycle
300.8 Other neurotic disorders 307.46 Somnambulism or night terrors
Other dysfunctions of sleep stages or arousal
300.81 Somatization disorder 307.47 from sleep (nightmares)
300.82 Undifferentiated somatoform disorder 307.48 Repetitive intrusions of sleep
300.89 Other 307.49 Other
300.9 Unspecified neurotic disorder 307.5 Other and unspecified disorders of eating
302 Sexual deviation and disorders 307.50 Eating disorder, unspecified
Physiological malfunction arising from mental
306 factors
307.51 Bulimia (overeating of non-organic origin)
306.0 Musculoskeletal (psychogenic paralysis) 307.52 Pica (perverted appetite of non-organic origin )
306.1 Respiratory (psychogenic) 307.53 Psychogenic rumination
306.2 Cardiovascular (cardiac neurosis) 307.54 Psychogenic vomiting
306.3 Skin (psychogenic pruitus) 307.59 Other
Continued on next page
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Behavioral Health Utilization Management Report (Instructions)
Anxiety / Stress/ Phobia Disorders:
(Continued)
ICD-9 ICD-9
Description: Description:
Code: Code:
307.6 Enuresis 315.8 Other specified delays in development
307.7 Encopresis 315.9 Unspecified delay in development
Psychic factors associated with diseases
307.8 Psychalgia 316 classified elsewhere
307.80 Psychogenic pain, site unspecified V Codes:
307.81 Tension headache V11.2 Neurosis
307.89 Other V61.0 Family disruption (divorce , estrangement)
Other and unspecified special symptoms or
307.9 syndromes, not elsewhere classified
V61.1 Counseling for marital and partner problems
Counseling for marital and partner problems,
308 Acute reaction to stress V61.10 unspecified
308.0 Predominant disturbance of emotions V61.11 Counseling for victim of spousal, partner abuse
308.1 Predominant disturbance of consciousness V61.12 Parent-child problems
308.2 Predominant psychomotor disturbance V61.20 Counseling for parent-child problem, unspecified
308.3 Other acute reactions to stress V61.21 Counseling for victim of child abuse
Counseling for perpetrator of parental child
308.4 Mixed disorders as reaction to stress V61.22 abuse
308.9 Unspecified acute reaction to stress V61.29 Other
309.81 Prolonged posttraumatic stress disorder V61.3 Problems with aged parents or in-laws
Specific non-psychotic mental disorders due to
310 organic brain damage
V61.4 Health problems within family
310.0 Frontal lobe syndrome V61.8 Other specific family disturbance
310.1 Organic personality syndrome V61.9 Unspecified family disturbance
310.2 Post-concussion syndrome V62.4 Social maladjustment
Other specified non-psychotic mental disorders
310.8 following organic brain damage
V62.81 Interpersonal problems, not elsewhere classified
Unspecified non-psychotic mental disorder
310.9 following organic brain damage V62.82 Bereavement, uncomplicated
311 Depressive disorder, not elsewhere classified V62.89 Other
315 Specific delays in development V62.9 Unspecified psychosocial circumstance
Person with feared compliant in whom no
315.0 Specific reading disorder V65.5 diagnosis was made
Observation following alleged rape or seduction,
315.00 Reading disorder, unspecified V71.5 (examination of victim or culprit)
Observation following other inflicted injury,
315.01 Alexia V71.6 (examination of victim or culprit)
315.02 Development dyslexia
315.09 Other
315.1 Specific arithmetical disorder
315.2 Other specific learning difficulties
315.3 Development speech or language disorder
315.31 Development language disorder
315.32 Receptive language disorder (mixed)
315.39 Other (development articulation disorder)
315.4 Coordination disorder
315.5 Mixed development disorder
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Behavioral Health Utilization Management Report (Instructions)
Schizophrenia / Other Psychoses:
ICD-9 ICD-9
Description: Description:
Code: Code:
295 Schizophrenic Disorders 295.6 Residual schizophrenia
295.0 Simple type 295.60 Unspecified
295.00 Unspecified 295.61 Sub-chronic
295.01 Sub-chronic 295.62 Chronic
295.02 Chronic 295.63 Sub-chronic with acute exacerbation
295.03 Sub-chronic with acute exacerbation 295.64 Chronic with acute exacerbation
295.04 Chronic with acute exacerbation 295.65 In remission
295.05 In remission 295.7 Schizo-Affective type
295.1 Disorganized type 295.70 Unspecified
295.10 Unspecified 295.71 Sub-chronic
295.11 Sub-chronic 295.72 Chronic
295.12 Chronic 295.73 Sub-chronic with acute exacerbation
295.13 Sub-chronic with acute exacerbation 295.74 Chronic with acute exacerbation
295.14 Chronic with acute exacerbation 295.75 In remission
295.15 In remission 295.8 Other specified types of schizophrenia
295.2 Catatonic type 295.80 Unspecified
295.20 Unspecified 295.81 Sub-chronic
295.21 Sub-chronic 295.82 Chronic
295.22 Chronic 295.83 Sub-chronic with acute exacerbation
295.23 Sub-chronic with acute exacerbation 295.84 Chronic with acute exacerbation
295.24 Chronic with acute exacerbation 295.85 In remission
295.25 In remission 295.9 Unspecified schizophrenia
295.3 Paranoid type 295.90 Unspecified
295.30 Unspecified 295.91 Sub-chronic
295.31 Sub-chronic 295.92 Chronic
295.32 Chronic 295.93 Sub-chronic with acute exacerbation
295.33 Sub-chronic with acute exacerbation 295.94 Chronic with acute exacerbation
295.34 Chronic with acute exacerbation 295.95 In remission
295.35 In remission 297.0 Paranoid state, simple
295.4 Acute schizophrenic episode 297.1 Paranoia
295.40 Unspecified 297.2 Paraphrenia
295.41 Sub-chronic 297.3 Shared paranoid disorder
295.42 Chronic 297.8 Other specified paranoid states
295.43 Sub-chronic with acute exacerbation 297.9 Unspecified paranoid state
295.44 Chronic with acute exacerbation 298 Other non-organic psychoses
295.45 In remission 298.0 Depressive type psychoses
295.5 Latent schizophrenia 298.1 Excitative type psychosis
295.50 Unspecified 298.2 Reactive confusion
295.51 Sub-chronic 298.3 Acute paranoid reaction
295.52 Chronic 298.4 Psychogenic paranoid psychosis
295.53 Sub-chronic with acute exacerbation 298.8 Other and unspecified reactive psychosis
295.54 Chronic with acute exacerbation 298.9 Unspecified psychosis
295.55 In remission Continued on Next Page
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Behavioral Health Utilization Management Report (Instructions)
Schizophrenia / Other Psychoses:
(Continued)
ICD-9 ICD-9
Description: Description:
Code: Code:
299 Psychoses 299.8 Other specified early childhood psychoses
299.0 Infantile autism 299.80 Current or active state
299.00 Current or active state 299.81 Residual state
299.01 Residual state 299.9 Unspecified
299.1 Disintegrative psychosis 299.90 Current or active state
299.10 Current or active state 299.91 Residual state
299.11 Residual state V Codes:
V110 Schizophrenia
ADHD Disorders:
ICD-9
Description:
Code:
314 Hyperkinetic syndrome of childhood
314.0 Attention deficit disorder
314.00 Without mention of hyperactivity
314.01 With hyperactivity
314.1 Hyperkinesis with development delay
314.2 Hyperkinetic conduct disorder
314.8 Other specified manifestations of hyperkinetic
314.9 Unspecified hyperkinetic syndrome
Page 21 of 28
Behavioral Health Utilization Management Report (Instructions)
Disruptive Behavior / Impulse Control:
ICD-9 ICD-9
Description: Description:
Code: Code:
Disturbance of conduct , not elsewhere Sensitivity, shyness, and social
312 313.2
classified withdrawal disorder
Undersocialized conduct disorder,
312.0 313.21 Shyness disorder of childhood
aggressive type
312.00 Unspecified 313.22 Introverted disorder of childhood
312.01 Mild 313.23 Relationship problems
Other or mixed emotional disturbance
312.02 Moderate 313.8
of childhood or adolescence
312.03 Severe 313.81 Oppositional disorder
Undersocialized conduct disorder,
312.1 313.82 Identity disorder
unaggressive type
312.10 Unspecified 313.83 Academic underachievement disorder
312.11 Mild 313.89 Other
Unspecified emotional disturbance of
312.12 Moderate 313.9
childhood or adolescence
312.13 Severe
312.2 Socialized conduct disorder
312.10 Unspecified
312.11 Mild
312.12 Moderate
312.13 Severe
Disorder of impulse control, not
312.3
elsewhere classified
312.30 Impulse control disorder, unspecified
312.31 Pathological gambling
312.32 Kleptomania
312.33 Pyromania
312.34 Intermittent explosive disorder
312.35 Isolated explosive disorder
312.39 Other
Mixed disturbance of conduct and
312.4
emotions
Other specified disturbance of conduct,
312.8
not elsewhere classified
312.81 Conduct disorder, childhood onset type
312.82 Conduct disorder, adolescent onset type
312.89 Other conduct disorder
312.9 Unspecified disturbance of conduct
Disturbance of emotions specific to
313
childhood and adolescence
313.0 Overanxious disorder
313.1 Misery and unhappiness disorder
Page 22 of 28
Behavioral Health Utilization Management Report (Instructions)
Adjustment Disorders: Personality Disorders:
ICD-9 ICD-9
Description: Description:
Code: Code:
309.0 Brief depressive reaction 301.0 Paranoid personality disorder
309.1 Prolonged depressive reaction 301.1 Affective personality disorder
With predominant disturbance of other Affective personality disorder,
309.2 301.10
emotions unspecified
309.21 Separation anxiety disorder 301.11 Chronic hypomanic personality disorder
Emancipation disorder of adolescence
309.22 301.12 Chronic depressive personality disorder
and early adult life
309.23 Specific academic or work inhibition 301.13 Cyclothymic disorder
309.24 Adjustment reaction with anxious mood 301.2 Schizoid personality disorder
Adjustment reaction with mixed Schizoid personality disorder,
309.28 301.20
emotional features unspecified
With predominant disturbance of
309.3 301.21 Introverted personality
conduct
With mixed disturbance of emotions and
309.4 301.22 Schizotypal personality
conduct
309.8 Other specified adjustment reactions 301.3 Explosive personality
Adjustment reaction with physical
309.82 301.4 Compulsive personality disorder
symptoms
309.83 Adjustment reaction with withdrawal 301.5 Histrionic personality disorder
Histrionic personality disorder,
309.89 Other 301.50
unspecified
Chronic factitious illness with physical
309.9 Unspecified adjustment reaction 301.51
symptoms
301.59 Other histrionic personality disorder
301.6 Dependent personality disorder
301.7 Antisocial personality disorder
301.8 Other personality disorder
301.81 Narcissistic personality
301.82 Avoidant personality
301.83 Borderline personality
301.84 Passive-aggressive personality
301.89 Other
301.9 Unspecified personality disorder
Page 23 of 28
Behavioral Health Utilization Management Report (Instructions)
Substance Abuse Disorders:
Alcohol: Cocaine:
ICD-9 ICD-9
Description: Description:
Code: Code:
291 Alcoholic psychoses 304.2 Cocaine Dependence
291.0 Alcohol withdrawal delirium 304.20 Unspecified
291.1 Alcohol amnestic syndrome 304.21 Continuous
291.2 Other alcholic dementia 304.22 Episodic
291.3 Alcohol withdrawal hallucinosis 304.23 In remission
291.4 Idiosyncratic alcohol intoxication 305.6 Cocaine Abuse
291.5 Alcoholic jealousy 305.60 Unspecified
291.8 Other specified alcoholic psychosis 304.61 Continuous
291.81 Alcohol withdrawal 304.62 Episodic
291.89 Other 304.63 In remission
Noxious influences affecting fetus via
291.9 Unspecified alcoholic psychosis 760.75
placenta or breast milk -Cocaine
303 Alcohol dependence syndrome Opiates:
303.0 Acute alcoholic intoxication 304.0 Opioid Type Dependence
303.00 Unspecified 304.00 Unspecified
303.01 Continuous 304.01 Continuous
303.02 Episodic 304.02 Episodic
303.03 In remission 304.03 In remission
Other and unspecified alcohol
303.9 305.5 Opioid abuse
dependence
303.90 Unspecified 304.50 Unspecified
303.91 Continuous 304.51 Continuous
303.92 Episodic 304.52 Episodic
303.93 In remission 304.53 In remission
305.0 Alcohol abuse Polysubstance Dependence:
Combination of Opioid drug with any
305.00 Unspecified 304.7
other
305.01 Continuous 304.70 Unspecified
305.02 Episodic 304.71 Continuous
305.03 In remission 304.72 Episodic
Inhalants: 304.73 In remission
Other specified drug dependence Combination of drug dependence
304.6 304.8
Absinthe Addiction, glue sniffing excluding Opioid type drug
304.60 Unspecified 304.80 Unspecified
304.61 Continuous 304.81 Continuous
304.62 Episodic 304.82 Episodic
304.63 In remission 304.83 In remission
Page 24 of 28
Behavioral Health Utilization Management Report (Instructions)
Other Disorders:
ICD-9 Code: Description:
290.xx – 319.xx All Behavioral Health Codes, excluding those previously listed
291.xx – 314.9x Miscellaneous Disorders
Noxious influences affecting fetus via placenta or breast milk
760.72 – 760.73 Narcotics
Hallucinogenic Agents
779.5 Drug withdrawal syndrome in newborn
Secondary Diagnosis Codes:
Mental Retardation / Autism:
ICD-9 Code: Description:
299.0 Mental Retardation / Autism (Infantile Autism)
317 Mild mental retardation
318 Other specified mental retardation
318.0 Moderate mental retardation
318.1 Severe mental retardation
318.2 Profound mental retardation
319 Mental retardation, severity unspecified
Page 25 of 28
Behavioral Health Utilization Management Report (Instructions)
Substance Related Disorders:
ICD-9 ICD-9
Description: Description:
Code: Code:
292 Drug psychoses 304.40 Unspecified
292.0 Drug withdrawal syndrome 304.41 Continuous
Paranoid and / or hallucinatory states
292.1 304.42 Episodic
induced by drugs
Drug-induced organic delusional
292.11 304.43 In remission
syndrome
292.12 Drug-induced hallucinosis 304.5 Hallucinogen dependence
292.2 Pathological drug intoxication 304.50 Unspecified
Other specified drug-induced mental
292.8 304.51 Continuous
disorders
292.81 Drug-induced delirium 304.52 Episodic
292.82 Drug-induced dementia 304.53 In remission
292.83 Drug-induced amnestic syndrome 304.6 Other specified drug dependence
Drug-induced organic affective
292.84 304.60 Unspecified
syndrome
292.89 Other 304.61 Continuous
Unspecified drug-induced mental
292.9 304.62 Episodic
disorder
304 Drug dependence 304.63 In remission
Combinations of opioid type drug
304.0 Opioid type dependence 304.7
with any other
304.00 Unspecified 304.70 Unspecified
304.01 Continuous 304.71 Continuous
304.02 Episodic 304.72 Episodic
304.03 In remission 304.73 In remission
Barbiturate and similarly acting sedative Combinations of drug dependence
304.1 304.8
or hypnotic dependence excluding opioid type drug
304.10 Unspecified 304.80 Unspecified
304.11 Continuous 304.81 Continuous
304.12 Episodic 304.82 Episodic
304.13 In remission 304.83 In remission
304.2 Cocaine dependence 304.9 Unspecified drug dependence
304.20 Unspecified 304.90 Unspecified
304.21 Continuous 304.91 Continuous
304.22 Episodic 304.92 Episodic
304.23 In remission 304.93 In remission
304.3 Cannabis dependence 305 Nondependent abuse of drugs
304.30 Unspecified 305.0 Alcohol abuse
304.31 Continuous 305.00 Unspecified
304.32 Episodic 305.01 Continuous
304.33 In remission 305.02 Episodic
Amphetamine and other psychostimulant
304.4 305.03 In remission
dependence
Continued on next page
Page 26 of 28
Behavioral Health Utilization Management Report (Instructions)
Substance Related Disorders:
(Continued)
ICD-9 ICD-9
Description: Description:
Code: Code:
305.2 Cannabis abuse 305.6 Cocaine abuse
305.20 Unspecified 305.60 Unspecified
305.21 Continuous 305.61 Continuous
305.22 Episodic 305.62 Episodic
305.23 In remission 305.63 In remission
Amphetamine or related acting
305.3 Hallucinogen abuse 305.7
sympathomimetic abuse
305.30 Unspecified 305.70 Unspecified
305.31 Continuous 305.71 Continuous
305.32 Episodic 305.72 Episodic
305.33 In remission 305.73 In remission
Barbiturate and similarly acting sedative
305.4 305.8 Antidepressant type abuse
or hypnotic abuse
305.40 Unspecified 305.80 Unspecified
305.41 Continuous 305.81 Continuous
305.42 Episodic 305.82 Episodic
305.43 In remission 305.83 In remission
Other, mixed, or unspecified drug
305.5 Opioid abuse 305.9
abuse
305.50 Unspecified 305.90 Unspecified
305.51 Continuous 305.91 Continuous
305.52 Episodic 305.92 Episodic
305.53 In remission 305.93 In remission
V Codes
V11.3 Alcoholism
Suicide:
ICD-9 Code: Description:
E 950.00 –
Suicide (& Self Inflicted Injury)
E 959.00
Page 27 of 28
Behavioral Health Utilization Management Report (Instructions)
Outpatient Service Codes
CPT-4 Codes:
Code: Description: Code: Description:
1050x Individual counseling-LMSW-ACP/LPC 90845 Medical psychoanalysis
1051x Group counseling-LMSW-ACP/LPC 90847 Family med psychotherapy by M.D.
1052x Family therapy LMSW-ACP/LPC 90853 Group med psych (not multi fam grp)
3002x Outpatient group counseling, per hour 90857 Interactive group med psychotherapy
Outpatient individual counseling, per
3003x 90862 Pharmacology management
hour
Narcosynthesis for psychiatric
5144x Neuro-psychological eval-compr-4hrs 90865
diagnostic and therapeutic purposes
5145x Neuro-psychological eval-interm-3hrs 90870 Electroconvulsive (ECT), one seizure
Electroconvulsive (ECT), multi
5146x Neuro-psychological eval-mini-2hrs 90871
sz/day
5375x Group counseling-LPC/LMSW (1hr.) 90899 Unlisted psych service or procedure
90801 Psychiatric diagnostic interview exam 96100 Psychological testing battery, per hr.
Interactive Psychiatric diagnostic
90802 96117 Neuro-psych test, per hr (outpt hosp)
interview exam
90804 90810
90805 90811
Individual psychotherapy, insight
90806 90812
oriented, behavior modifying and/or Individual psychotherapy, interactive
90807 90813
supportive
90808 90814
90809 90815
Page 28 of 28
Behavioral Health Utilization Management Report (Instructions)