Notification Issue Date:

Policy Attachment

Attachment to Policy # 00.01.18d


Policy #:00.01.18d

Description:Diagnosis Codes

Title:Reimbursement for Associated Services Performed in Conjunction with Dental Care

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Diagnosis Codes

F70Mild intellectual disabilities
F71Moderate intellectual disabilities
F72Severe intellectual disabilities
F73Profound intellectual disabilities
F78Other intellectual disabilities
F79Unspecified intellectual disabilities
F84.0Autistic disorder
F84.2Rett's syndrome
F84.3Other childhood disintegrative disorder
F84.5Asperger's syndrome
F84.8Other pervasive developmental disorders
F84.9Pervasive developmental disorder, unspecified
F90.0Attention-deficit hyperactivity disorder, predominantly inattentive type
F90.1Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2Attention-deficit hyperactivity disorder, combined type
F90.8Attention-deficit hyperactivity disorder, other type
F90.9Attention-deficit hyperactivity disorder, unspecified type
G30.0Alzheimer's disease with early onset
G30.1Alzheimer's disease with late onset
G30.8Other Alzheimer's disease
G30.9Alzheimer's disease, unspecified
G31.81Alpers disease
G31.82Leigh's disease
G31.84Mild cognitive impairment, so stated
G31.85Corticobasal degeneration
G31.89Other specified degenerative diseases of nervous system
G31.9Degenerative disease of nervous system, unspecified
I50.1Left ventricular failure, unspecified
I50.20Unspecified systolic (congestive) heart failure
I50.21Acute systolic (congestive) heart failure
I50.22Chronic systolic (congestive) heart failure
I50.23Acute on chronic systolic (congestive) heart failure
I50.30Unspecified diastolic (congestive) heart failure
I50.31Acute diastolic (congestive) heart failure
I50.32Chronic diastolic (congestive) heart failure
I50.33Acute on chronic diastolic (congestive) heart failure
I50.40Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810Right heart failure, unspecified
I50.811Acute right heart failure
I50.812Chronic right heart failure
I50.813Acute on chronic right heart failure
I50.814Right heart failure due to left heart failure
I50.82Biventricular heart failure
I50.83High output heart failure
I50.84End stage heart failure
I50.89Other heart failure
I50.9Heart failure, unspecified
J44.0Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9Chronic obstructive pulmonary disease, unspecified
Q90.0Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2Trisomy 21, translocation
Q90.9Down syndrome, unspecified
Q91.0Trisomy 18, nonmosaicism (meiotic nondisjunction)
Q91.1Trisomy 18, mosaicism (mitotic nondisjunction)
Q91.2Trisomy 18, translocation
Q91.3Trisomy 18, unspecified
Q91.4Trisomy 13, nonmosaicism (meiotic nondisjunction)
Q91.5Trisomy 13, mosaicism (mitotic nondisjunction)
Q91.6Trisomy 13, translocation
Q91.7Trisomy 13, unspecified
Q99.2Fragile X chromosome

Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A

2017 AmeriHealth.