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.