1.0 POLICY
1.1 Any physiological
disorder or condition or anatomical loss affecting one or more body
systems which has lasted, or with reasonable certainty is expected
to last, for a minimum period of 12 contiguous months, and which
precludes the person with the disorder, condition or anatomical
loss from unaided performance of at least one of the following major
life activities is an Extended Health Care Option (ECHO) qualifying
condition: breathing, cognition, hearing, seeing, and age appropriate ability
essential to bathing, dressing, eating, grooming, speaking, stair
use, toilet use, transferring, and walking.
1.2 For a beneficiary less than
three years of age, a developmental delay qualifies as a serious physical
disability when the score on the standardized diagnostic psychometric
tests of motor function is two standard deviations below the mean.
1.3 Serious physical disabilities
include, but are not limited to 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) for the purpose
of establishing an ECHO qualifying condition:
1.3.1 Infantile
Cerebral Palsy: ICD-9-CM 343.0 - 343.9 / ICD-10-CM G80.0 - G80.9.
1.3.2 Spina Bifida: ICD-9-CM 741.0
- 741.93 / ICD-10-CM Q05.0 - Q05.9.
1.3.3 Vision:
ICD-9-CM 369.01 - 369.08 inclusive; 369.11 - 369.14 inclusive; 369.21;
369.22; 369.4 / ICD-10-CM H54.0 - H54.12 inclusive; H54.8.
1.3.4 Hearing-Testable Patients:
as determined by audiologic function tests:
• A pure
tone hearing threshold level of 45 decibels or greater in one ear;
or by
• A pure tone hearing threshold
level of 30 decibels or greater in both ears; or by
• Speech discrimination of 60%
or poorer with either ear.
1.3.5 Hearing-Non-Testable Patients:
Where pure tone audiometry or speech discrimination testing is not
available or reliable, the attending physician must submit documentation
which demonstrates the patient is unable to engage in basic productive
activities of daily living expected of unimpaired persons of the
same age group.
1.3.6 Breathing:
Total reliance upon a respirator.
1.3.7 Acquired
or congenital total loss, or loss of use, of an arm or leg.
1.3.8 Autism Spectrum Disorder (ASD):
ICD-10-CM F84.0, (Autistic Disorder).
1.3.9 Multiple
Sclerosis (MS): ICD-9-CM 340.