Extended Care Health Option (ECHO)
Chapter 9
Section 2.2
Eligibility - Qualifying Condition: Mental
Retardation
Issue Date: July
3, 1997
Revision:
1.0 POLICY
1.1 A diagnosis
of moderate or severe mental retardation in accordance with the
criteria in the current edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM), published by the American
Psychiatric Association, is an Extended Care Health Option (ECHO)
qualifying condition.
1.2 For a beneficiary less than three years
of age, the following conditions (International Classification of
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes cited
for services provided before the mandated date, as directed by Health
and Human Services (HHS), for International Classification of Diseases,
10th Revision (ICD-10) implementation, or ICD-10-CM codes cited
for services provided on or after the mandated date, as directed
by HHS, for ICD-10 implementation) may be presumed to precede a
diagnosis of moderate or severe mental retardation:
• Rett’s syndrome: ICD-9-CM 330.8 / ICD-10-CM
F84.2
• Down syndrome:
ICD-9-CM 758.0 / ICD-10-CM Q90.0-Q90.9
• Fragile X syndrome:
ICD-9-CM 759.83 / ICD-10-CM Q99.2
• Fetal alcohol
syndrome: ICD-9-CM 760.71 / ICD-10-CM Q86.0
1.3 For
a beneficiary less than three years of age, a developmental delay
qualifies as moderate or severe mental retardation when standardized
diagnostic psychometric tests demonstrate developmental delay equivalent
to two standard deviations below the mean in adaptive, cognitive,
or language function.
2.0 EXCLUSIONS
2.1 Unless the requirements
of
paragraph 1.3 are
met, the spectrum of Attention-Deficit and Disruptive Behavior Disorders
are not considered qualifying conditions for the ECHO.
2.2 Learning disorders,
individually and collectively, are not qualifying conditions for
eligibility under the ECHO.
3.0 EFFECTIVE
DATE
September 1, 2005.
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