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.