Diagnostic Codes that will now be accepted for Medicare Part B in 13 States

(Changes to Local Coverage Determination L35101, effective retroactively to December 31, 2015)

Claims for the below diagnostic codes submitted by mental health practitioners participating in the Medicare Part B program in 13 states will no longer be denied. Moreover, claims submitted since December 31, 2015, when the policy was enacted, that have been denied will be retroactively approved and paid. These have been updated to reflect DSM-5, the standard manual used in the U.S. to diagnose mental health conditions.

The affected states are Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, and three jurisdictions in Virginia: Arlington and Fairfax Counties, and the City of Alexandria.

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Code Disorder Title in DSM-5 Disorder Title in ICD-10-CM
F10.239 Alcohol withdrawal, without perceptual disturbances Alcohol dependence with withdrawal, unspecified
F17.200 Tobacco Use Disorder, Moderate
Tobacco Use Disorder, Severe
Nicotine dependence, unspecified, uncomplicated
F20.9 Schizophrenia Schizophrenia unspecified
F31.9 Bipolar 1 Disorder, Current or most recent episode depressed, unspecified
Bipolar 1 Disorder, Current or most recent episode hypomanic, unspecified
Bipolar 1 Disorder, Current or most recent episode manic, unspecified
Bipolar 1 Disorder, Current or most recent episode, unspecified
Bipolar disorder, unspecified
F32.8 Other specified depressive disorder Other depressive episodes
F32.9 Major Depressive Disorder, single episode, unspecified Major depressive disorder, single episode, unspecified
F33.9 Major Depressive Disorder, Recurrent episode, unspecified Major depressive disorder, recurrent, unspecified
F40.00 Agoraphobia Agoraphobia, unspecified
F40.10 Social Anxiety Disorder (social phobia) Social phobia, unspecified
F41.9 Unspecified Anxiety Disorder Anxiety disorder, unspecified
F43.10 Posttraumatic Stress Disorder Post-traumatic stress disorder, unspecified
F43.20 Adjustment Disorder, Unspecified Adjustment disorder, unspecified
F43.9 Unspecified Trauma and Stressor Related Disorder Reaction to severe stress, unspecified
F60.9 Unspecified Personality Disorder Personality disorder, unspecified
F68.10 Factitious Disorder Factitious disorder, unspecified
F80.9 Language Disorder Developmental disorder of speech and language, unspecified
F90.9 Unspecified attention-deficit/hyperactivity disorder Attention-deficit hyperactivity disorder, unspecified type
F91.9 Conduct disorder, unspecified onset Conduct disorder, unspecified
G25.81 Restless Legs Syndrome Restless legs syndrome
G47.21 Circadian rhythm sleep-wake disorders, Delayed sleep phase type Circadian rhythm sleep disorder, delayed sleep phase type
G47.22 Circadian rhythm sleep-wake disorders, Advanced sleep phase type Circadian rhythm sleep disorder, advanced sleep phase type
G47.23 Circadian rhythm sleep-wake disorders, Irregular sleep-wake type Circadian rhythm sleep disorder, irregular sleep wake type
G47.24 Circadian rhythm sleep-wake disorders, Non-24-hour sleep-wake type Circadian rhythm sleep disorder, free running type
G47.26 Circadian rhythm sleep-wake disorders, Shift work type Circadian rhythm sleep disorder, shift work type
G47.31 Central sleep apnea, Idiopathic central sleep apnea Primary central sleep apnea
G47.33 Obstructive sleep apnea hypopnea Obstructive sleep apnea (adult) (pediatric)
G47.34 Sleep-related hypoventilation, Idiopathic hypoventilation Idiopathic sleep related nonobstructive alveolar hypoventilation
G47.35 Sleep-related hypoventilation, Congenital central alveolar hypoventilation Congenital central alveolar hypoventilation syndrome
G47.36 Sleep-related hypoventilation, Comorbid sleep-related hypoventilation Sleep related hypoventilation in conditions classified elsewhere
G47.37 Central sleep apnea comorbid with opioid use Central sleep apnea in conditions classified elsewhere
G47.411 Narcolepsy with cataplexy but without hypocretin deficiency Narcolepsy with cataplexy
G47.419 Autosomal dominant cerebellar ataxia, deafness, and narcolepsy
Autosomal dominant narcolepsy, obesity, and type 2 diabetes
Narcolepsy without cataplexy but with hypocretin deficiency
Narcolepsy without cataplexy
L98.1 Excoriation (skin-picking) Disorder Factitial dermatitis
N94.3 Premenstrual Dysphoric Disorder Premenstrual tension syndrome
R06.3 Central Sleep Apnea, Cheyne-Stokes Breathing Periodic breathing
R41.83 Borderline Intellectual Functioning Borderline intellectual functioning
T43.205A Antidepressant discontinuation syndrome, Initial encounter Adverse effect of unspecified antidepressants, initial encounter
T43.205D Antidepressant discontinuation syndrome, Subsequent encounter Adverse effect of unspecified antidepressants, subsequent encounter
T43.205S Antidepressant discontinuation syndrome, Sequelae Adverse effect of unspecified antidepressants, sequela
T50.905A Other adverse effect of medication, Initial encounter Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter
T50.905D Other adverse effect of a medication, Subsequent encounter Adverse effect of unspecified drugs, medicaments and biological substances, subsequent encounter
T50.905S Other adverse effect of a medication, Sequelae Adverse effect of unspecified drugs, medicaments and biological substances, sequela

These additions are reflected in Local Coverage Determination (LCD) L35101. The entire LCD can be found at cms.gov.

To view the full list of psychiatric codes covered, you will first be required to accept the terms and conditions of the website. Once you have accepted the conditions, and the LCD page appears, scroll down to the section titled: ICD-10 Codes that Support Medical Necessity. Next to “show entries”, choose “show entries 1-1500.”