Original Effective Date:
08/01/1994
Current Effective Date:
01/01/2015
The following examples are diagnoses and procedures that are potentially high-cost, high-utilization, complex, or result in the patient having special needs. Patients diagnosed with any of the following conditions or undergo one of the following procedures should be referred for health coordination services as soon as the condition is determined or the service is anticipated. Health coordinators will assist in coordinating community resources that are cost-effective and appropriate for the member’s care. See QUEST Integration (QI) Health Coordination Services (HCS).
Patients with Special Health Care Needs (SHCN), those at risk for institutionalization if left on their own, and those requiring or receiving long-term services and support (LTSS) may also benefit from the structured, specific patient education and support that health coordination provides them. Cases of substance abuse and child or spousal abuse should also be identified for referral to HMSA’s behavioral health services and DHS for social services.
The following conditions or patients that cannot perform either Instrumental Activities of Daily Living (IADL) or Activities of Daily Living (ADL) are examples of cases that should be referred:
| Diagnosis | ICD-9-CM (Codes) | ICD-10 (Codes) |
|---|---|---|
| AIDS/Human Immunodeficiency Virus (HIV) infection | 042 - 044.9 | B20 |
| Premature infants, neonatal period | 765.0 - 765.09, 765.10 - 765.19 | P07.00 - P07.18, P07.30 |
| Bronchopulmonary dysplasia | 770.7 | P27.0 - P27.9 |
| Hyaline membrane disease | 769 | P22.0 |
| Head injuries | 850.4, 851.05, 851.15, 851.25, 851.35, 851.45, 851.55, 851.65, 851.75, 851.85, 851.95, 852.05, 852.15, 852.25, 852.35, 852.45, 852.55, 853.05, 853.15, 854.05, 854.15 | S01.90x(A,D,S), S06.0x6(A,D,S), S06.1x6-S06.1x8(A,D,S), S06.2x6-S06.2x8(A,D,S), S06.306-S06.308(A,D,S), S06.316-S06.318(A,D,S), S06.326-S06.328(A,D,S), S06.336-S06.338(A,S,D), S06.346-S06.348(A,D,S), S06.356-S06.358(A,D,S), S06.366-S06.368(A,D,S), S06.376-S06.378(A,D,S), S06.386-S06.388(A,D,S), S06.4x6-S06.4x8(A,D,S), S06.5x6-S06.5x7(A,D,S), S06.6x6-S06.6x8(A,D,S), S06.816-S06.818(A,D,S), S06.826-S06.828(A,D,S), S06.896-S06.898(A,D,S), S06.9x6-S06.9x8(A,D,S) |
| Spinal cord injury | 952.0 - 952.9 | S14.0xx(A,D,S), S14.101-S14.159(A,D,S), S24.0xx(A,D,S), S24.101-S24.119(A,D,S), S24.131-S24.159(A,D,S), S34.01x-S34.139(A,D,S), S34.3xx(A,D,S) |
| Renal failure | 585 and 586 | N18.1-N18.9 |
| Hemophilia | 286.0 | D66 |
| Von Willebrand Disease | 286.4 | D68.00, D68.01, D68.020, D68.021, D68.022, D68.023, D68.029, D68.03, D68.04, D68.09 |
| Leukemia | 205.0 - 205.9 | C92.00-C92.62, C92.A0-C92.A2, C92.Z0-C92.Z2, C92.90 |
| Myeloid leukemia | 205.0 - 205.9 | C92.00-C92.62, C92.A0-C92.A2, C92.Z0-C92.Z2, C92.90 |
| Hodgkin’s disease | 201.0 - 201.9(0-8) | C871.00-C81.49, C81.70-C81.79, C81.90-C81.99 |
| Secondary malignant neoplasms | 196.0 - 198.89 | C77.0-C77.9, C78.00-C78.89, C79.00-C79.9 |
| Burns | 941.3(0-9), 941.40(0-9), 941.5(0-9), 942.3(0-9), 942.4(0-9), 942.5(0-9), 943.3(0-9), 943.4(0-9), 943.5(0-9), 944.3(4-8), 944.4(4-8), 944.5(4-8), 945.3(2-9), 945.4(2-9), 945.5(2-9), 946.3, 946.4, 946.5, 948.3 - 948.9 | T20.30x-T20.39x(A,D,S), T20.70x-T20.79x(A,D,S), T21.30x-T21.39x(A,D,S), T21.70x-T21.79x(A,D,S), T22.30x-T22.399(A,D,S), T22.70x-T22.799(A,D,S), T23.341-T23.399(A,D,S), T23.741-T23.799(A,D,S), T24.311-T24.399(A,D,S), T24.711-T24.799(A,D,S), T25.311-T25.329(A,D,S), T25.391-T25.399(A,D,S), T25.711-T25.729(A,D,S), T25.791-T25.799(A,D,S), T26.20x-T26.22x(A,D,S), T26.40x-T26.422x(A,D,S), T30.0, T30.4, T31.30-T31.90, T32.30-T32.90 |
| Congenital anomalies of the nervous system: | ||
| AV malformation | 747.6 | Q27.9 |
| Cerebra; AV malformation | 747.81 | Q28.2, Q28.3 |
| Hydrocephalus | 742.3 | Q03.0 - Q03.9 |
| Microcephalus | 742.1 | Q02 |
| Anencephalus and similar anomalies | 740.0, 740.1, 740.2 | Q00.0 - Q00.2 |
| Spina bifida | 741.0(0-3), 741.9(0-3) | Q05.0-Q05.9, Q07.00-Q07.03 |
| Complications of pregnancy: | ||
| Placenta previa/antepartum | 641.13, 641.23, 641.33 | O44.10-O44.13, O45.001-O45.93, O46.001-O46.099 |
| Hemorrhage | 641.83, 641.93 | O46.8x1-O46.93 |
| Severe pre-eclampsia | 642.53 | O14.10-O14.23 |
| Eclampsia | 642.63 | O15.0-O15.03 |
| Threatened premature labor | 644.03 | O60.00-O60.03 |
| Premature rupture of membranes | 658.23 | O42.111-O42.119 |
| Multiple fetus | 651.13, 651.23, 651.83 | O30.101-O30.899, O31.8x1-O31.8x3(0-5,9) |
| Cystic fibrosis | 277.0, 277.00, 277.01 | E84.9, E84.11 |
| Cerebral palsy | 343 - 343.9 | G80.0-G80.9 |
| Multiple sclerosis | 340 | G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D |
| Amyotrophic lateral sclerosis (ALS) | 335.20 | G12.21 |
| Lupus (SLE) | 710.0 | M32.0-M32.9 |
| Guillain-Barre disease or syndrome | 357.0 | G61.0 |
| Congenital anomalies of heart | 745.0 - 746.7, 747.1 - 747.49 | Q20.0-Q20.8, Q21.0-Q23.4, Q25.1-Q26.9 |
| Ventilator dependent >5 days | V46.1 | Z99.11 |
| Procedures | ICD-9-CM (Codes) | ICD-10 (Codes) |
|---|---|---|
| Dialysis: | ||
| Hemodialysis | 39.95 | 5A1D00Z, 5A1D60Z |
| Peritoneal dialysis | 54.98 | 3E1M39Z |
| CABG | 36.10 | 0210093, 02100A3, 02100J3, 02100K3, 02100Z3, 0210493, 02104A3, 02104J3, 02104K3, 02104Z3 |
| 36.11 | 021009W, 02100AW, 02100JW, 02100KW, 021049W, 02104AW, 02104JW, 02104KW | |
| 36.12 | 021109W, 02110AW, 02110JW, 02110KW, 021149W, 02114AW, 02114JW, 02114KW | |
| 36.13 | 021209W, 02120AW, 02120JW, 02120KW, 021249W, 02124AW, 02124JW, 02124KW | |
| 36.14 | 021309W, 02130AW, 02130JW, 02130KW, 021349W, 02134AW, 02134JW, 02134KW | |
| Transplant procedures: | ||
| Kidney | 55.6 | No corresponding ICD-10 codes |
| 55.61 | 0TS00ZZ, 0TS10ZZ | |
| 55.69 | 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 | |
| Liver | 50.5 | 0FT00ZZ, 0FT04ZZ |
| 50.59 | 0FY00Z0, 0FY00Z1 | |
| Heart | 37.5 | 02YA0Z0 |
| Bone marrow | 41.0 | 30230G0, 30230G1, 30233G0, 30233G1, 30240G0, 30240G1, 30243G0, 30243G1, 30250G0, 30250G1, 30253G0, 30253G1, 30260G0, 30260G1, 30263G0, 30263G1 |
| 41.01 | 30230G0, 30233G0, 30240G0, 30243G0, 30250G0, 30253G0, 30260G0, 30263G0 | |
| 41.02 | 30230G1, 30233G1, 30240G1, 30243G1, 30250G1, 30253G1, 30260G1, 30263G1, 3E03005, 3E03305, 3E04005, 3E04305, 3E05005, 3E05305, 3E06005, 3E06305 | |
| 41.03 | 30230G1, 30233G1, 30240G1, 30243G1, 30250G1, 30253G1, 30260G1, 30263G1 | |
| Lung | 33.5 | 0BYK0Z0, 0BYL0Z0 |
| TPN >10 days | 99.15 | 0E0336Z |
| Whipple procedure | 52.7 | 0D1607A, 0D160JA, 0D160KA, 0D160ZA, 0DT90ZZ, 0F190Z3, 0F1G0ZC, 0FTG0ZZ |
| Repair of congenital heart: | ||
| Atrial/ventricular septal defects | 35.5 | No corresponding ICD-10 codes |
| 35.73 | 02QB0ZZ, 02QB3ZZ, 02QB4ZZ, 02QC0ZZ, 02QC3ZZ, 02QC4ZZ | |
| Tetralogy of fallot | 35.81 | 02BK0ZZ, 02NH0ZZ, 02RM0JZ, 02RP0JZ, 02RQ0JZ, 02RR0JZ |
| Transposition of great vessels | 35.84 | 02SP0ZZ, 02SW0ZZ |
| Truncus arteriosus | 35.83 | 02LR0ZT, 02RM0JZ, 02RQ07Z, 02RQ0JZ, 02RR07Z, 02RR0JZ, 02VR0ZT |
| Total pulmonary venous connection | 35.82 | 02170ZP, 02170ZQ, 02170ZR, 02LS0ZZ, 02LT0ZZ, 02RM0JZ, 02U70JZ |
| Chemotherapy | 99.25 | XW03351 |
| Shunt-ventricular to abdomen | 02.34 | 0016075, 0016076, 00160J5, 00160J6, 00160K5, 00160K6, 0016375, 0016376, 00163J5, 00163J6, 00163K5, 00163K6, 0W110JG, 0W110JJ |
| Brain: | ||
| AV malformation | 38.31 | 03BG0ZZ, 03BG4ZZ, 05BL0ZZ, 05BL4ZZ |
| Aneurysm | 38.31 | 03BG0ZZ, 03BG4ZZ, 05BL0ZZ, 05BL4ZZ |
| Abscess | 01.59 | 00500ZZ, 00503ZZ, 00504ZZ, 00570ZZ, 00573ZZ, 00574ZZ, 005B0ZZ, 005B3ZZ, 005B4ZZ, 005C0ZZ, 005C3ZZ, 005C4ZZ, 005D0ZZ, 005D3ZZ, 005D4ZZ, 00B00ZZ, 00B03ZZ, 00B04ZZ, 00B60ZZ, 00B63ZZ, 00B64ZZ, 00B70ZZ, 00B73ZZ, 00B74ZZ, 00BB0ZZ, 00BB3ZZ, 00BB4ZZ, 00BC0ZZ, 00BC3ZZ, 00BC4ZZ, 00BD0ZZ, 00BD3ZZ, 00BD4ZZ |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|