Other Chronic Health, Mental Health, and Potentially Disabling Conditions
There are 41 other chronic health, mental health, substance abuse, and potentially disabling condition categories available for file years 2000 forward (except where noted). These conditions enhance research of the Medicare-Medicaid dual enrolled population; however, they are available for all non-dually enrolled Medicare and Medicaid beneficiaries as well.
All variables listed on this page are currently available in the Master Beneficiary Summary File (MBSF) in the MBSF_OTCC_YYYY file.
They are also available in Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) (2006–2012) and Medicaid Enrollee Supplemental File (MESF) (1999–2013) (except where noted).
The Applying Chronic Conditions to Medicaid Data (MAX) document provides guidance when applying Chronic Conditions or Other Chronic Health, Mental Health, and Potentially Disabling Conditions algorithms to Medicaid data.
The Comparing the Chronic Pain Algorithm and the Fibromyalgia, Chronic Pain, and Fatigue Algorithm document introduces the Chronic Pain algorithm developed in 2024, and explains the difference between the Chronic Pain Algorithm and the existing Fibromyalgia, Chronic Pain, and Fatigue Algorithm It also provides users with recommendations for the use of each algorithm.
CCW Other Chronic Conditions Algorithms and Change History
CCW Other Chronic Conditions Algorithms Reference List
| Algorithms | Reference Period1 | Valid ICD-9/MS DRG/HCPCS Codes2 | Valid ICD-10/CPT4/HCPCS Codes2 | Number/Type of Claims to Qualify3 |
|---|---|---|---|---|
| ADHD, Conduct Disorders, and Hyperkinetic Syndrome | 2 Years | DX 312.00, 312.01, 312.02, 312.03, 312.10, 312.11, 312.12, 312.13, 312.20, 312.21, 312.22, 312.23, 312.30, 312.31, 312.32, 312.33, 312.34, 312.35, 312.39, 312.4, 312.81, 312.82, 312.89, 312.9, 314.00, 314.01, 314.1, 314.2, 314.8, 314.9 (any DX on the claim) | DX F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Alcohol Use Disorders | 2 Years | DX 291.0, 291.1, 291.2, 291.3, 291.4, 291.5, 291.8, 291.81, 291.82, 291.89, 291.9, 303.00, 303.01, 303.02, 303.90, 303.91, 303.92, 305.00, 305.01, 305.02, 357.5, 425.5, 535.30, 535.31, 571.0, 571.1, 571.2, 571.3, 760.71, 980.0, V65.42, V79.1, E860.0 ICD-9 Procedure Codes: 94.6, 94.61, 94.62, 94.63, 94.67, 94.68, 94.69 (any DX or procedure on the claim) |
DX F10.10, F10.120, F10.121, F10.129, F10.130, F10.131, F10.132, F10.139, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F10.920, F10.921, F10.929, F10.930, F10.931, F10.932, F10.939, F10.94, F10.950, F10.951, F10.959, F10.96, F10.97, F10.980, F10.981, F10.982, F10.988, F10.99, G62.1, I42.6, K29.20, K29.21, K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, P04.3, Q86.0, T51.0X1A, T51.0X2A, T51.0X3A, T51.0X4A, Z71.41, Z71.42 ICD-10 Procedure Codes: HZ2ZZZZ, HZ30ZZZ, HZ31ZZZ, HZ32ZZZ, HZ33ZZZ, HZ34ZZZ, HZ35ZZZ, HZ36ZZZ, HZ37ZZZ, HZ38ZZZ, HZ39ZZZ, HZ3BZZZ, HZ40ZZZ, HZ93ZZZ, HZ96ZZZ (any DX or procedure on the claim) |
At least 1 inpatient claim OR 2 other non-drug claims of any service type Procedure codes require only one claim to qualify |
| Anxiety Disorders | 2 Years | DX 293.84, 300.00, 300.01, 300.02, 300.09, 300.10, 300.20, 300.21, 300.22, 300.23, 300.29, 300.3, 300.5, 300.89, 300.9, 308.0, 308.1, 308.2, 308.3, 308.4, 308.9, 309.81, 313.0, 313.1, 313.21, 313.22, 313.3, 313.82, 313.83 (any DX on the claim) | DX F06.4, F40.00, F40.01, F40.02, F40.10, F40.11, F40.210, F40.218, F40.220, F40.228, F40.230, F40.231, F40.232, F40.233, F40.240, F40.241, F40.242, F40.243, F40.248, F40.290, F40.291, F40.298, F40.8, F40.9, F41.0, F41.1, F41.3, F41.8, F41.9, F42, F42.2, F42.3, F42.4, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F44.9, F45.8, F48.8, F48.9, F93.8, F99, R45.2, R45.5, R45.6, R45.7 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Autism Spectrum Disorders | 2 Years | DX 299.0, 299.00, 299.01, 299.1, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, 299.91 (any DX on the claim) | DX F84.0, F84.3, F84.5, F84.8, F84.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Bipolar Disorder | 2 Years | DX 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89, 296.90, 296.99 (any DX on the claim) | DX F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9, F33.8, F34.81, F34.89, F34.9, F39 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Cerebral Palsy | 2 Years | DX 333.71, 343, 343.0, 343.1, 343.2, 343.3, 343.4, 343.8, 343.9 (any DX on the claim) | DX G80.0, G80.1, G80.2, G80.3, G80.4, G80.8, G80.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Chronic Pain4 | 3 Years | N/A | DX B02.22, B02.23, C34.10, C34.11, C34.12, C34.90, C34.91, C34.92, C44.01, C44.319, C44.41, C44.42, C82.00, C90.00, D04.39, D57.00, D57.03, D57.09, D57.211, D57.213, D57.218, D57.219, D57.413, D57.418, D57.419, D57.431, D57.432, D57.433, D57.438, D57.439, D57.451, D57.452, D57.453, D57.458, D57.459, D57.813, D57.818, D57.819, E10.610, E11.42, E11.44, E11.49, E11.610, E11.618, G43.011, G43.019, G43.109, G43.111, G43.119, G43.419, G43.709, G43.711, G43.719, G43.811, G43.819, G43.909, G43.911, G43.919, G43.B1, G43.E11, G43.E19, G44.001, G44.021, G44.201, G44.221, G44.301, G44.321, G44.51, G44.52, G50.0, G50.1, G56.01, G56.02, G56.03, G56.41, G56.42, G57.71, G57.72, G62.9, G89.18, G89.21, G89.28, G89.29, G89.4, G90.09, G90.50, G90.511, G90.512, G90.513, G90.519, G90.521, G90.522, G90.529, I20.0, I25.10, I25.110, I25.118, I25.119, I25.5, I25.84, I42.9, I70.213, I70.221, I70.222, I70.223, I70.228, I70.229, I70.321, I70.322, I70.521, I70.522, I70.523, I73.00, I73.9, K74.60, K76.0, K76.89, M05.79, M06.00, M06.0A, M06.9, M10.071, M10.072, M10.079, M10.9, M13.851, M13.852, M13.859, M13.871, M13.872, M13.879, M15.0, M15.9, M16.0, M16.10, M16.11, M16.12, M17.0, M17.10, M17.11, M17.12, M17.30, M17.31, M17.32, M17.9, M18.10, M18.11, M18.12, M19.011, M19.012, M19.019, M19.031, M19.032, M19.039, M19.041, M19.042, M19.049, M19.071, M19.072, M19.079, M19.90, M23.321, M23.322, M23.329, M25.361, M25.362, M25.369, M25.421, M25.422, M25.429, M25.461, M25.462, M25.469, M25.471, M25.472, M25.473, M25.50, M25.511, M25.512, M25.519, M25.521, M25.522, M25.529, M25.531, M25.532, M25.539, M25.541, M25.542, M25.549, M25.551, M25.552, M25.559, M25.561, M25.562, M25.569, M25.571, M25.572, M25.579, M25.59, M25.60, M25.611, M25.612, M25.619, M25.661, M25.662, M25.669, M25.69, M25.78, M32.9, M41.9, M43.16, M43.6, M45.0, M45.AB, M46.1, M47.26, M47.812, M47.814, M47.816, M47.817, M47.896, M48.00, M48.02, M48.06, M48.061, M48.062, M48.07, M48.56XA, M48.56XD, M48.56XG, M48.56XS, M50.32, M50.321, M50.322, M50.323, M51.16, M51.26, M51.36, M51.37, M53.2X7, M53.81, M54.12, M54.16, M54.17, M54.2, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.50, M54.51, M54.59, M54.6, M54.9, M62.49, M70.60, M70.61, M70.62, M71.20, M71.21, M71.22, M71.9, M75.100, M75.101, M75.102, M75.120, M75.121, M75.122, M75.50, M75.51, M75.52, M79.1, M79.10, M79.11, M79.12, M79.18, M79.601, M79.602, M79.604, M79.605, M79.609, M79.621, M79.622, M79.641, M79.642, M79.643, M79.644, M79.645, M79.646, M79.661, M79.662, M79.671, M79.672, M79.673, M79.674, M79.675, M79.676, M79.7, M79.89, M80.00XA, M80.00XD, M80.00XG, M80.00XK, M80.00XP, M80.00XS, M80.08XA, M80.08XD, M80.08XG, M80.08XK, M80.08XP, M80.08XS, M80.0AXA, M80.0AXD, M80.0AXG, M80.0AXK, M80.0AXP, M80.0AXS, M87.9, M96.1, M99.04, M99.05, N18.3, N18.30, N18.31, N18.32, N18.9, N23, N41.0, N41.1, R07.0, R07.2, R07.81, R07.89, R07.9, R10.11, R10.12, R10.13, R10.2, R10.30, R10.31, R10.32, R10.84, R10.9, R30.0, R30.9, R39.82, R51, R51.0, R51.9, R52, S22.41XA, S22.41XB, S22.41XD, S22.41XG, S22.41XK, S22.41XS, S22.42XA, S22.42XB, S22.42XD, S22.42XG, S22.42XK, S22.42XS, S22.49XA, S22.49XB, S22.49XD, S22.49XG, S22.49XK, S22.49XS, S32.010A, S32.010B, S32.010D, S32.010G, S32.010K, S32.010S, S32.020A, S32.020B, S32.020D, S32.020G, S32.020K, S32.020S, S32.030A, S32.030B, S32.030D, S32.030G, S32.030K, S32.030S, S32.040A, S32.040B, S32.040D, S32.040G, S32.040K, S32.040S, S32.050A, S32.050B, S32.050D, S32.050G, S32.050K, S32.050S, S32.10XA, S32.10XB, S32.10XD, S32.10XG, S32.10XK, S32.10XS, S32.591A, S32.591B, S32.591D, S32.591G, S32.591K, S32.591S, S32.592A, S32.592B, S32.592D, S32.592G, S32.592K, S32.592S, S32.599A, S32.599B, S32.599D, S32.599G, S32.599K, S32.599S, S32.810A, S32.810B, S32.810D, S32.810G, S32.810K, S32.810S, S32.82XA, S32.82XB, S32.82XD, S32.82XG, S32.82XK, S32.82XS, S32.89XA, S32.89XB, S32.89XD, S32.89XG, S32.89XK, S32.89XS (any DX on the claim) | At least 1 claim of any service type |
| Cystic Fibrosis and Other Metabolic Developmental Disorders | 2 Years | DX 243, 255.2, 269.2, 270.1, 270.2, 270.3, 270.4, 270.6, 270.7, 271.1, 277.0, 277.00, 277.01, 277.02, 277.03, 277.09, 277.6, 277.81, 277.85 (any DX on the claim) | DX D81.810, D84.1, E00.0, E00.1, E00.2, E00.9, E03.0, E03.1, E25.0, E25.8, E25.9, E56.9, E70.0, E70.1, E70.20, E70.21, E70.29, E70.30, E70.310, E70.311, E70.318, E70.319, E70.320, E70.321, E70.328, E70.329, E70.330, E70.331, E70.338, E70.339, E70.39, E70.5, E70.8, E70.81, E70.89, E70.9, E71.0, E71.110, E71.111, E71.118, E71.19, E71.2, E71.310, E71.311, E71.312, E71.313, E71.314, E71.318, E71.32, E71.41, E72.10, E72.11, E72.12, E72.19, E72.20, E72.21, E72.22, E72.23, E72.29, E72.3, E72.4, E72.50, E72.51, E72.59, E72.8, E74.20, E74.21, E74.29, E74.810, E74.818, E74.819, E74.89, E84.0, E84.11, E84.19, E84.8, E84.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Depressive Disorders | 2 Years | DX 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 300.4, 311 (any DX on the claim) | DX F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.89, F32.9, F32.A, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.1 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Drug Use Disorders | 2 Years | DX 292.0, 292.11, 292.12, 292.2, 292.81, 292.82, 292.83, 292.84, 292.85, 292.89, 292.9, 304.00, 304.01, 304.02, 304.10, 304.11, 304.12, 304.2, 304.20, 304.21, 304.22, 304.3, 304.30, 304.31, 304.32, 304.4, 304.40, 304.41, 304.42, 304.5, 304.50, 304.51, 304.52, 304.6, 304.60, 304.61, 304.62, 304.7, 304.70, 304.71, 304.72, 304.8, 304.80, 304.81, 304.82, 304.9, 304.90, 304.91, 304.92, 305.2, 305.20, 305.21, 305.22, 305.3, 305.30, 305.31, 305.32, 305.4, 305.40, 305.41, 305.42, 305.5, 305.50, 305.51, 305.52, 305.6, 305.60, 305.61, 305.62, 305.7, 305.70, 305.71, 305.72, 305.8, 305.80, 305.81, 305.82, 305.9, 305.90, 305.91, 305.92, 648.3, 648.30, 648.31, 648.32, 648.33, 648.34, 655.5, 655.50, 655.51, 655.53, 760.72, 760.73, 760.75, 779.5, 965.0, 965.00, 965.01, 965.02, 965.09, V65.42, E850.0, E850.1, E850.2, E854.1, E935.0, E935.1 ICD-9 Procedure Codes: 94.6, 94.64, 94.65, 94.66, 94.67, 94.68, 94.69 (any DX on the claim) |
DX F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F12.10, F12.120, F12.121, F12.122, F12.129, F12.13, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F12.90, F12.920, F12.921, F12.922, F12.929, F12.950, F12.951, F12.959, F12.980, F12.988, F12.99, F13.10, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.920, F14.921, F14.922, F14.929, F14.93, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.10, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.90, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F17.203, F17.208, F17.209, F17.213, F17.218, F17.219, F17.223, F17.228, F17.229, F17.293, F17.298, F17.299, F18.10, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.10, F19.120, F19.121, F19.122, F19.129, F19.130, F19.131, F19.132, F19.139, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, F55.0, F55.1, F55.2, F55.3, F55.4, F55.8, O35.5XX0, O35.5XX1, O35.5XX2, O35.5XX3, O35.5XX4, O35.5XX5, O35.5XX9, O99.320, O99.321, O99.322, O99.323, O99.324, O99.325, P04.41, P04.49, P96.1, P96.2, T40.0X1A, T40.0X2A, T40.0X3A, T40.0X4A, T40.0X5A, T40.0X5S, T40.1X1A, T40.1X2A, T40.1X3A, T40.1X4A, T40.2X1A, T40.2X2A, T40.2X3A, T40.2X4A, T40.3X1A, T40.3X2A, T40.3X3A, T40.3X4A, T40.3X5A, T40.3X5S, T40.411A, T40.412A, T40.413A, T40.414A, T40.415A, T40.421A, T40.422A, T40.423A, T40.424A, T40.425A, T40.491A, T40.492A, T40.493A, T40.494A, T40.495A, T40.4X1A, T40.4X2A, T40.4X3A, T40.4X4A, T40.601A, T40.602A, T40.603A, T40.604A, T40.691A, T40.692A, T40.693A, T40.694A, T40.711A, T40.721A, T40.7X1A, T40.8X1A, T40.901A, T40.991A, Z71.41, Z71.42, Z71.51, Z71.52, Z71.6 ICD-10 Procedure Codes: HZ2ZZZZ, HZ30ZZZ, HZ31ZZZ, HZ32ZZZ, HZ33ZZZ, HZ34ZZZ, HZ35ZZZ, HZ36ZZZ, HZ37ZZZ, HZ38ZZZ, HZ39ZZZ, HZ3BZZZ, HZ40ZZZ, HZ93ZZZ, HZ96ZZZ (any DX on the claim) |
At least 1 inpatient claim OR 2 other non-drug claims of any service type Procedure codes require only one claim to qualify |
| Epilepsy | 2 Years | DX 345, 345.0, 345.00, 345.01, 345.1, 345.10, 345.11, 345.2, 345.3, 345.4, 345.40, 345.41, 345.5, 345.50, 345.51, 345.6, 345.60, 345.61, 345.7, 345.70, 345.71, 345.8, 345.80, 345.81, 345.9, 345.90, 345.91 (any DX on the claim) | DX G40.001, G40.009, G40.011, G40.019, G40.101, G40.109, G40.111, G40.119, G40.201, G40.209, G40.211, G40.219, G40.301, G40.309, G40.311, G40.319, G40.401, G40.409, G40.411, G40.419, G40.42, G40.501, G40.509, G40.801, G40.802, G40.803, G40.804, G40.811, G40.812, G40.813, G40.814, G40.821, G40.822, G40.823, G40.824, G40.833, G40.834, G40.89, G40.901, G40.909, G40.911, G40.919, G40.A01, G40.A09, G40.A11, G40.A19, G40.B01, G40.B09, G40.B11, G40.B19, G40.C01, G40.C09, G40.C11, G40.C19 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Fibromyalgia, Chronic Pain and Fatigue | 2 Years | DX 338.2, 338.21, 338.22, 338.28, 338.29, 338.3, 338.4, 780.7, 780.71, 729.1, 729.2 (any DX on the claim) | DX G89.21, G89.22, G89.28, G89.29, G89.3, G89.4, M54.10, M54.11, M54.12, M54.13, M54.14, M54.15, M54.16, M54.17, M54.18, M60.80, M60.811, M60.812, M60.819, M60.821, M60.822, M60.829, M60.831, M60.832, M60.839, M60.841, M60.842, M60.849, M60.851, M60.852, M60.859, M60.861, M60.862, M60.869, M60.871, M60.872, M60.879, M60.88, M60.89, M60.9, M79.1, M79.10, M79.11, M79.12, M79.18, M79.2, M79.7, R53.82 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Human Immunodeficiency Virus and/or Acquired Immunodeficiency Syndrome (HIV/AIDS)5 | 2 Years | DX 042, 042.0, 042.1, 042.2, 042.9, 043, 043.1, 043.2, 043.3, 043.9, 044, 044.0, 044.9, 079.53, 795.71, V08 (any DX on the claim) EXCEPTION: 795.71 requires a second qualifying claim that is not 795.71 (a screening code) Medicare DRG Codes (old codes used through 09/2007): 488, 489, 490 MS DRG Codes: 969, 970, 974, 975, 976, 977 HCC Code*: 1 (HIV/AIDS) *CMS Hierarchical Condition Category (HCC) data are obtained from the CMS Integrated Data Repository (IDR). Beneficiaries identified as having this condition due to HCC code will not have an associated "Ever" date. |
DX B20, B97.35, R75, Z21 (any DX on the claim) EXCEPTION: R75 requires a second qualifying claim that is not R75 (a screening code) MS DRG Codes: 969, 970, 974, 975, 976, 977 HCC Code*: 1 (HIV/AIDS) *CMS Hierarchical Condition Category (HCC) data is obtained from the CMS Integrated Data Repository (IDR). Beneficiaries identified as having this condition due to HCC code will not have an associated "Ever" date. |
At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Intellectual Disabilities and Related Conditions | 2 Years | DX 317, 318, 318.0, 318.1, 318.2, 319, 758, 758.0, 758.1, 758.2, 758.3, 758.31, 758.32, 758.33, 758.39, 758.5, 759.7, 759.81, 759.83, 759.89, 760.71 (any DX on the claim) | DX E78.71, E78.72, F70, F71, F72, F73, F78, F78.A1, F78.A9, F79, P04.3, Q86.0, Q87.1, Q87.11, Q87.19, Q87.2, Q87.3, Q87.5, Q87.81, Q87.83, Q87.84, Q87.85, Q87.89, Q89.7, Q89.8, Q90.0, Q90.1, Q90.2, Q90.9, Q91.0, Q91.1, Q91.2, Q91.3, Q91.4, Q91.5, Q91.6, Q91.7, Q92.0, Q92.1, Q92.2, Q92.5, Q92.61, Q92.62, Q92.7, Q92.8, Q92.9, Q93.0, Q93.1, Q93.2, Q93.3, Q93.4, Q93.5, Q93.51, Q93.52, Q93.59, Q93.7, Q93.81, Q93.88, Q93.89, Q93.9, Q95.2, Q95.3, Q99.2 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Learning Disabilities | 2 Years | DX 315, 315.00, 315.01, 315.02, 315.09, 315.1, 315.2, 315.31, 315.32, 315.34, 315.35, 315.39, 315.4 (any DX on the claim) | DX F80.0, F80.1, F80.2, F80.4, F80.81, F80.82, F80.89, F80.9, F81.0, F81.2, F81.81, F81.89, F81.9, F82, H93.25, R48.0 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Leukemias and Lymphomas | 2 Years | DX 200.0, 200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08, 200.1, 200.10, 200.11, 200.12, 200.13, 200.14, 200.15, 200.16, 200.17, 200.18, 200.2, 200.20, 200.21, 200.22, 200.23, 200.24, 200.25, 200.26, 200.27, 200.28, 200.3, 200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37, 200.38, 200.4, 200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, 200.48, 200.5, 200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58, 200.6, 200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68, 200.7, 200.70, 200.71, 200.72, 200.73, 200.74, 200.75, 200.76, 200.77, 200.78, 200.8, 200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86, 200.87, 200.88, 201.0, 201.00, 201.01, 201.02, 201.03, 201.04, 201.05, 201.06, 201.07, 201.08, 201.1, 201.10, 201.11, 201.12, 201.13, 201.14, 201.15, 201.16, 201.17, 201.18, 201.2, 201.20, 201.21, 201.22, 201.23, 201.24, 201.25, 201.26, 201.27, 201.28, 201.4, 201.40, 201.41, 201.42, 201.43, 201.44, 201.45, 201.46, 201.47, 201.48, 201.5, 201.50, 201.51, 201.52, 201.53, 201.54, 201.55, 201.56, 201.57, 201.58, 201.6, 201.60, 201.61, 201.62, 201.63, 201.64, 201.65, 201.66, 201.67, 201.68, 201.7, 201.70, 201.71, 201.72, 201.73, 201.74, 201.75, 201.76, 201.77, 201.78, 201.9, 201.90, 201.91, 201.92, 201.93, 201.94, 201.95, 201.96, 201.97, 201.98, 202.0, 202.00, 202.01, 202.02, 202.03, 202.04, 202.05, 202.06, 202.07, 202.08, 202.1, 202.10, 202.11, 202.12, 202.13, 202.14, 202.15, 202.16, 202.17, 202.18, 202.2, 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 202.4, 202.40, 202.41, 202.42, 202.43, 202.44, 202.45, 202.46, 202.47, 202.48, 202.7, 202.70, 202.71, 202.72, 202.73, 202.74, 202.75, 202.76, 202.77, 202.78, 202.8, 202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87, 202.88, 202.9, 202.90, 202.91, 202.92, 202.93, 202.94, 202.95, 202.96, 202.97, 202.98, 203.1, 203.10, 203.11, 203.12, 204.0, 204.00, 204.01, 204.02, 204.1, 204.10, 204.11, 204.12, 204.2, 204.20, 204.21, 204.22, 204.8, 204.80, 204.81, 204.82, 204.9, 204.90, 204.91, 204.92, 205.0, 205.00, 205.01, 205.02, 205.1, 205.10, 205.11, 205.12, 205.2, 205.20, 205.21, 205.22, 205.3, 205.30, 205.31, 205.32, 205.8, 205.80, 205.81, 205.82, 205.9, 205.90, 205.91, 205.92, 206.0, 206.00, 206.01, 206.02, 206.1, 206.10, 206.11, 206.12, 206.2, 206.20, 206.21, 206.22, 206.2, 206.20, 206.21, 206.22, 206.8, 206.80, 206.81, 206.82, 206.9, 206.90, 206.91, 206.92, 207.0, 207.00, 207.01, 207.02, 207.1, 207.10, 207.11, 207.12, 207.2, 207.20, 207.21, 207.22, 207.8, 207.80, 207.81, 207.82, 208.0, 208.00, 208.01, 208.02, 208.1, 208.10, 208.11, 208.12, 208.2, 208.20, 208.21, 208.22, 208.8, 208.80, 208.81, 208.82, 208.9, 208.90, 208.91, 208.92, V10.6, V10.60, V10.61, V10.62, V10.63, V10.69, V10.7, V10.71, V10.72, V10.79 (any DX on the claim) | DX C81.00, C81.01, C81.02, C81.03, C81.04, C81.05, C81.06, C81.07, C81.08, C81.09, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, C81.90, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C82.00, C82.01, C82.02, C82.03, C82.04, C82.05, C82.06, C82.07, C82.08, C82.09, C82.10, C82.11, C82.12, C82.13, C82.14, C82.15, C82.16, C82.17, C82.18, C82.19, C82.20, C82.21, C82.22, C82.23, C82.24, C82.25, C82.26, C82.27, C82.28, C82.29, C82.30, C82.31, C82.32, C82.33, C82.34, C82.35, C82.36, C82.37, C82.38, C82.39, C82.40, C82.41, C82.42, C82.43, C82.44, C82.45, C82.46, C82.47, C82.48, C82.49, C82.50, C82.51, C82.52, C82.53, C82.54, C82.55, C82.56, C82.57, C82.58, C82.59, C82.60, C82.61, C82.62, C82.63, C82.64, C82.65, C82.66, C82.67, C82.68, C82.69, C82.80, C82.81, C82.82, C82.83, C82.84, C82.85, C82.86, C82.87, C82.88, C82.89, C82.90, C82.91, C82.92, C82.93, C82.94, C82.95, C82.96, C82.97, C82.98, C82.99, C83.00, C83.01, C83.02, C83.03, C83.04, C83.05, C83.06, C83.07, C83.08, C83.09, C83.10, C83.11, C83.12, C83.13, C83.14, C83.15, C83.16, C83.17, C83.18, C83.19, C83.30, C83.31, C83.32, C83.33, C83.34, C83.35, C83.36, C83.37, C83.38, C83.39, C83.50, C83.51, C83.52, C83.53, C83.54, C83.55, C83.56, C83.57, C83.58, C83.59, C83.70, C83.71, C83.72, C83.73, C83.74, C83.75, C83.76, C83.77, C83.78, C83.79, C83.80, C83.81, C83.82, C83.83, C83.84, C83.85, C83.86, C83.87, C83.88, C83.89, C83.90, C83.91, C83.92, C83.93, C83.94, C83.95, C83.96, C83.97, C83.98, C83.99, C84.00, C84.01, C84.02, C84.03, C84.04, C84.05, C84.06, C84.07, C84.08, C84.09, C84.10, C84.11, C84.12, C84.13, C84.14, C84.15, C84.16, C84.17, C84.18, C84.19, C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48, C84.49, C84.60, C84.61, C84.62, C84.63, C84.64, C84.65, C84.66, C84.67, C84.68, C84.69, C84.70, C84.71, C84.72, C84.73, C84.74, C84.75, C84.76, C84.77, C84.78, C84.79, C84.7A, C84.90, C84.91, C84.92, C84.93, C84.94, C84.95, C84.96, C84.97, C84.98, C84.99, C84.A0, C84.A1, C84.A2, C84.A3, C84.A4, C84.A5, C84.A6, C84.A7, C84.A8, C84.A9, C84.Z0, C84.Z1, C84.Z2, C84.Z3, C84.Z4, C84.Z5, C84.Z6, C84.Z7, C84.Z8, C84.Z9, C85.10, C85.11, C85.12, C85.13, C85.14, C85.15, C85.16, C85.17, C85.18, C85.19, C85.20, C85.21, C85.22, C85.23, C85.24, C85.25, C85.26, C85.27, C85.28, C85.29, C85.80, C85.81, C85.82, C85.83, C85.84, C85.85, C85.86, C85.87, C85.88, C85.89, C85.90, C85.91, C85.92, C85.93, C85.94, C85.95, C85.96, C85.97, C85.98, C85.99, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.4, C90.10, C90.11, C90.12, C91.00, C91.01, C91.02, C91.10, C91.11, C91.12, C91.30, C91.31, C91.32, C91.40, C91.41, C91.42, C91.50, C91.51, C91.52, C91.60, C91.61, C91.62, C91.A0, C91.A1, C91.A2, C91.Z0, C91.Z1, C91.Z2, C91.90, C91.91, C91.92, C92.00, C92.01, C92.02, C92.10, C92.11, C92.12, C92.20, C92.21, C92.22, C92.30, C92.31, C92.32, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.90, C92.91, C92.92, C92.A0, C92.A1, C92.A2, C92.Z0, C92.Z1, C92.Z2, C93.00, C93.01, C93.02, C93.10, C93.11, C93.12, C93.30, C93.31, C93.32, C93.Z0, C93.Z1, C93.Z2, C93.90, C93.91, C93.92, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92, C96.4, C96.9, C96.Z, D45, Z85.6, Z85.71, Z85.72, Z85.79 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Liver Disease, Cirrhosis and Other Liver Conditions (except Viral Hepatitis) | 2 Years | DX 570, 571, 571.0, 571.1, 571.2, 571.3, 571.5, 571.6, 571.8, 571.9, 572, 572.0, 572.1, 572.2, 572.3, 572.4, 572.8, 573, 573.0, 573.4, 573.5, 573.8, 573.9, 576.1, 789.1, V42.7 (any DX on the claim) ICD-9-CM Procedure Codes: 42.91, 44.91, 54.91, 96.06 |
DX K70.0, K70.10, K70.11, K70.2, K70.30, K70.31, K70.40, K70.41, K70.9, K71.0, K71.11, K71.7, K71.8, K71.9, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K74.0, K74.00, K74.01, K74.02, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.0, K75.1, K75.81, K75.89, K75.9, K76.0, K76.1, K76.2, K76.3, K76.5, K76.6, K76.7, K76.81, K76.82, K76.89, K76.9, K77, K80.30, K80.31, K80.32, K80.33, K80.34, K80.35, K80.36, K80.37, K83.0, R16.0, R16.2, Z48.23, Z94.4 (any DX on the claim) ICD-10 Procedure Codes: 06L20ZZ, 06L23ZZ, 06L24ZZ, 06L30ZZ, 06L33ZZ, 06L34ZZ, 0DL57DZ, 0DL58DZ, 0D9S30Z, 0D9S3ZZ, 0D9S40Z, 0D9S4ZZ, 0D9T30Z, 0D9T3ZZ, 0D9T40Z, 0D9T4ZZ, 0D9V30Z, 0D9V3ZZ, 0D9V40Z, 0D9V4ZZ, 0D9W30Z, 0D9W3ZZ, 0D9W40Z, 0D9W4ZZ, 0W9F30Z, 0W9F3ZZ, 0W9F40Z, 0W9F4ZZ, 0W9G30Z, 0W9G3ZZ, 0W9G40Z, 0W9G4ZZ, 0W9J30Z, 0W9J3ZZ |
At least 1 inpatient claim OR 2 other non-drug claims of any service type Procedures must have at least one associated liver disease diagnosis on claim |
| Migraine and Other Chronic Headache | 2 Years | DX 339, 339.0, 339.00, 339.01, 339.02, 339.03, 339.04, 339.05, 339.09, 339.1, 339.10, 339.11, 339.12, 339.2, 339.20, 339.21, 339.22, 339.3, 339.4, 339.41, 339.42, 339.43, 339.44, 339.8, 339.81, 339.82, 339.83, 339.84, 339.85, 339.89, 346, 346.0, 346.00, 346.01, 346.02, 346.03, 346.1, 346.10, 346.11, 346.12, 346.13, 346.2, 346.20, 346.21, 346.22, 346.23, 346.3, 346.30, 346.31, 346.32, 346.33, 346.4, 346.40, 346.41, 346.42, 346.43, 346.5, 346.50, 346.51, 346.52, 346.53, 346.6, 346.60, 346.61, 346.62, 346.63, 346.7, 346.70, 346.71, 346.72, 346.73, 346.8, 346.80, 346.81, 346.82, 346.83, 346.9, 346.90, 346.91, 346.92, 346.93 (any DX on the claim) | DX G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G43.A0, G43.A1, G43.B0, G43.B1, G43.C0, G43.C1, G43.D0, G43.D1, G43.E01, G43.E09, G43.E11, G43.E19, G44.001, G44.009, G44.011, G44.019, G44.021, G44.029, G44.031, G44.039, G44.041, G44.049, G44.051, G44.059, G44.091, G44.099, G44.1, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, G44.301, G44.309, G44.311, G44.319, G44.321, G44.329, G44.40, G44.41, G44.51, G44.52, G44.53, G44.59, G44.81, G44.82, G44.83, G44.84, G44.85, G44.86, G44.89 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Mobility Impairments | 2 Years | DX 334.1, 342.00, 342.01, 342.02, 342.10, 342.11, 342.12, 342.80, 342.81, 342.82, 342.90, 342.91, 342.92, 344, 344.0, 344.00, 344.01, 344.02, 344.03, 344.04, 344.09, 344.1, 344.2, 344.3, 344.30, 344.31, 344.32, 344.4, 344.40, 344.41, 344.42, 344.5, 344.6, 344.60, 344.61, 344.8, 344.81, 344.89, 344.9, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50, 438.51, 438.52, 438.53 (any DX on the claim) | DX G04.1, G11.4, G81.00, G81.01, G81.02, G81.03, G81.04, G81.10, G81.11, G81.12, G81.13, G81.14, G81.90, G81.91, G81.92, G81.93, G81.94, G82.20, G82.21, G82.22, G82.50, G82.51, G82.52, G82.53, G82.54, G83.0, G83.10, G83.11, G83.12, G83.13, G83.14, G83.20, G83.21, G83.22, G83.23, G83.24, G83.30, G83.31, G83.32, G83.33, G83.34, G83.4, G83.5, G83.81, G83.82, G83.83, G83.84, G83.89, G83.9, I69.031, I69.032, I69.033, I69.034, I69.039, I69.041, I69.042, I69.043, I69.044, I69.049, I69.051, I69.052, I69.053, I69.054, I69.059, I69.061, I69.062, I69.063, I69.064, I69.065, I69.069, I69.131, I69.132, I69.133, I69.134, I69.139, I69.141, I69.142, I69.143, I69.144, I69.149, I69.151, I69.152, I69.153, I69.154, I69.159, I69.161, I69.162, I69.163, I69.164, I69.165, I69.169, I69.231, I69.232, I69.233, I69.234, I69.239, I69.241, I69.242, I69.243, I69.244, I69.249, I69.251, I69.252, I69.253, I69.254, I69.259, I69.261, I69.262, I69.263, I69.264, I69.265, I69.269, I69.331, I69.332, I69.333, I69.334, I69.339, I69.341, I69.342, I69.343, I69.344, I69.349, I69.351, I69.352, I69.353, I69.354, I69.359, I69.361, I69.362, I69.363, I69.364, I69.365, I69.369, I69.831, I69.832, I69.833, I69.834, I69.839, I69.841, I69.842, I69.843, I69.844, I69.849, I69.851, I69.852, I69.853, I69.854, I69.859, I69.861, I69.862, I69.863, I69.864, I69.865, I69.869, I69.931, I69.932, I69.933, I69.934, I69.939, I69.941, I69.942, I69.943, I69.944, I69.949, I69.951, I69.952, I69.953, I69.954, I69.959, I69.961, I69.962, I69.963, I69.964, I69.965, I69.969 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Multiple Sclerosis and Transverse Myelitis | 2 Years | DX 340, 341, 341.0, 341.2, 341.20, 341.21, 341.22, 341.8, 341.9 (any DX on the claim) | DX G35, G36.0, G36.1, G36.8, G36.9, G37.1, G37.2, G37.3, G37.4, G37.8, G37.81, G37.89, G37.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Muscular Dystrophy | 2 Years | DX 359, 359.0, 359.1 (any DX on the claim) | DX G71.0, G71.00, G71.01, G71.02, G71.031, G71.032, G71.033, G71.0340, G71.0341, G71.0342, G71.0349, G71.035, G71.038, G71.039, G71.09, G71.11, G71.2, G71.20, G71.21, G71.220, G71.228, G71.29 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Obesity | 2 Years | DX 278.0, 278.00, 278.01, 278.03, V85.3, V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.4, V85.41, V85.42, V85.43, V85.44, V85.45 (any DX on the claim) | DX E66.01, E66.09, E66.1, E66.2, E66.8, E66.9, Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Opioid Use Disorder (OUD) #1: Overarching Opioid Use Disorder6 | 2 Years | Any positive result from indicators OUD#2, OUD#3, or OUD#4, below. | Any positive result from indicators OUD#2, OUD#3, or OUD#4, below. | |
| OUD #2: Diagnosis- and Procedure-code basis for OUD6 | 2 Years | DX 304.0, 304.00, 304.01, 304.02, 304.7, 304.70, 304.71, 304.72, 305.5, 305.50, 305.51, 305.52, 760.72, 965.0, 965.00, 965.01, 965.02, 965.09, E85.00, E85.01, E85.02, E93.50, E93.51 (any DX on the claim) | DX F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, T40.0X1A, T40.0X2A, T40.0X3A, T40.0X4A, T40.1X1A, T40.1X2A, T40.1X3A, T40.1X4A, T40.2X1A, T40.2X2A, T40.2X3A, T40.2X4A, T40.3X1A, T40.3X2A, T40.3X3A, T40.3X4A, T40.3X5A, T40.4X1A, T40.4X2A, T40.4X3A, T40.4X4A, T40.411A, T40.412A, T40.413A, T40.414A, T40.415A, T40.421A, T40.422A, T40.423A, T40.424A, T40.425A, T40.491A, T40.492A, T40.493A, T40.494A, T40.495A, T40.601A, T40.602A, T40.603A, T40.604A, T40.691A, T40.692A, T40.693A, T40.694A ICD-10 Procedure Codes: HZ81ZZZ, HZ84ZZZ, HZ85ZZZ, HZ86ZZZ, HZ91ZZZ, HZ94ZZZ, HZ95ZZZ, HZ96ZZZ (any position on the claim) |
At least 1 inpatient claim OR 2 other non-drug claims of any service type with DX (or ICD-10-PCS procedure) codes |
| OUD #3: Opioid-related Hospitalizations/ED Visits6 | 2 Years | DX 304.00, 304.01, 304.02, 304.70, 304.71, 304.72, 305.50, 305.51, 305.52, 965.00, 965.01, 965.02, 965.09, 970.1, E85.00, E85.01, E85.02, E93.50, E93.51, E93.52, E94.01 (any DX on the claim) | DX F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, T40.0X1A, T40.0X1D, T40.0X1S, T40.0X2A, T40.0X2D, T40.0X2S, T40.0X3A, T40.0X3D, T40.0X3S, T40.0X4A, T40.0X4D, T40.0X4S, T40.0X5A, T40.0X5D, T40.0X5S, T40.1X1A, T40.1X1D, T40.1X1S, T40.1X2A, T40.1X2D, T40.1X2S, T40.1X3A, T40.1X3D, T40.1X3S, T40.1X4A, T40.1X4D, T40.1X4S, T40.2X1A, T40.2X1D, T40.2X1S, T40.2X2A, T40.2X2D, T40.2X2S, T40.2X3A, T40.2X3D, T40.2X3S, T40.2X4A, T40.2X4D, T40.2X4S, T40.2X5A, T40.2X5D, T40.2X5S, T40.3X1A, T40.3X1D, T40.3X1S, T40.3X2A, T40.3X2D, T40.3X2S, T40.3X3A, T40.3X3D, T40.3X3S, T40.3X4A, T40.3X4D, T40.3X4S, T40.3X5A, T40.3X5D, T40.3X5S, T40.4X1A, T40.4X1D, T40.4X1S, T40.4X2A, T40.4X2D, T40.4X2S, T40.4X3A, T40.4X3D, T40.4X3S, T40.4X4A, T40.4X4D, T40.4X4S, T40.4X5A, T40.4X5D, T40.4X5S, T40.411A, T40.411D, T40.411S, T40.412A, T40.412D, T40.412S, T40.413A, T40.413D, T40.413S, T40.414A, T40.414D, T40.414S, T40.415A, T40.415D, T40.415S, T40.421A, T40.421D, T40.421S, T40.422A, T40.422D, T40.422S, T40.423A, T40.423D, T40.423S, T40.424A, T40.424D, T40.424S, T40.425A, T40.425D, T40.425S, T40.491A, T40.491D, T40.491S, T40.492A, T40.492D, T40.492S, T40.493A, T40.493D, T40.493S, T40.494A, T40.494D, T40.494S, T40.495A, T40.495D, T40.495S, T40.601A, T40.601D, T40.601S, T40.602A, T40.602D, T40.602S, T40.603A, T40.603D, T40.603S, T40.604A, T40.604D, T40.604S, T40.605A, T40.605D, T40.605S, T40.691A, T40.691D, T40.691S, T40.692A, T40.692D, T40.692S, T40.693A, T40.693D, T40.693S, T40.694A, T40.694D, T40.694S, T40.695A, T40.695D, T40.695S (any position on the claim) | One inpatient claim OR one emergency department (ED) claim |
| OUD #4: Utilization of Medication-Assisted Therapy (MAT)6 | 2 Years | Same as ICD-10 | HCPCS codes for MAT: G2067, G2068, G2069, G2070, G2071, G2072, G2073, G2078, G2079, H0020, J0571, J0572, J0573, J0574, J0575, J0577, J0578, J0592, J1230, J2315, Q9991, Q9992, S0109 NDCs for Buprenorphine: 00054017613, 00054017713, 00054018813, 00054018913, 00093537856, 00093537956, 00093572056, 00093572156, 00121101830, 00121101930, 00121203630, 00121203830, 00228315303, 00228315403, 00228315473, 00228315503, 00228315567, 00228315573, 00228315603, 00378092393, 00378092493, 00378876516, 00378876593, 00378876616, 00378876693, 00378876716, 00378876793, 00378876816, 00378876893, 00406192303, 00406192403, 00406800503, 00406802003, 00490005100, 00490005130, 00490005160, 00490005190, 00781721606, 00781721664, 00781722706, 00781722764, 00781723806, 00781723864, 00781724906, 00781724964, 00904700906, 00904701006, 00904715404, 00904715504, 12496010001, 12496010002, 12496010005, 12496030001, 12496030002, 12496030005, 12496120201, 12496120203, 12496120401, 12496120403, 12496120801, 12496120803, 12496121201, 12496121203, 12496127802, 12496128302, 12496130602, 12496131002, 16590066605, 16590066630, 16590066705, 16590066730, 16590066790, 16729054910, 16729055010, 23490927003, 23490927006, 23490927009, 35356000407, 35356000430, 35356055530, 35356055630, 42291017430, 42291017530, 42858050103, 42858050203, 42858060103, 42858060203, 43063018407, 43063018430, 43063066706, 43063075306, 43598057901, 43598057930, 43598058001, 43598058030, 43598058101, 43598058130, 43598058201, 43598058230, 47781035503, 47781035511, 47781035603, 47781035611, 47781035703, 47781035711, 47781035803, 47781035811, 49999039507, 49999039515, 49999039530, 49999063830, 49999063930, 50090157100, 50090292400, 50268014411, 50268014415, 50268014511, 50268014515, 50383028793, 50383029493, 50383092493, 50383093093, 50742036401, 50742036430, 50742036501, 50742036530, 50742037201, 50742037204, 50742037301, 50742037304, 50742037401, 50742037404, 50742037501, 50742037504, 50742037601, 50742037604, 51862060830, 52427069203, 52427069211, 52427069403, 52427069411, 52427069803, 52427069811, 52427071203, 52427071211, 52440010014, 52959030430, 52959074930, 53217013830, 53217024630, 54123011430, 54123090730, 54123091430, 54123092930, 54123095730, 54123098630, 54569549600, 54569573900, 54569573901, 54569573902, 54569639900, 54569640800, 54569657800, 54868570700, 54868570701, 54868570702, 54868570703, 54868570704, 54868575000, 55045378403, 55700014730, 55700018430, 55700030230, 55700030330, 55700090130, 58284010014, 58284020801, 58284020891, 58284021601, 58284021691, 58284022401, 58284022491, 58284022801, 58284022891, 58284023201, 58284023291, 58284026401, 58284026491, 58284029601, 58284029691, 59385001201, 59385001230, 59385001401, 59385001430, 59385001601, 59385001630, 60429058611, 60429058630, 60429058633, 60429058711, 60429058730, 60429058733, 60687048111, 60687048121, 60687049211, 60687049221, 60687062611, 60687062665, 60687063711, 60687063765, 62175045232, 62175045832, 62756045983, 62756046083, 62756096983, 62756097083, 63629402801, 63629403401, 63629403402, 63629403403, 63629409201, 63629947501, 63629948201, 63629948301, 63874108403, 63874108503, 63874117303, 65162041503, 65162041603, 66336001630, 68071138003, 68071151003, 68258299103, 68258299903, 68308020230, 68308020830, 70518100700, 70518201400, 70518201401, 70518221700, 70518222600, 70518222602, 70518222603, 70518312900, 70518338900, 71335095001, 71335095002, 71335095003, 71335115401, 71335115402, 71335115403, 71335116301, 71335116302, 71335116303, 71335129601, 71335137801, 71335172501, 71335172502, 71335185801, 71335185802 NDCs for Naltrexone (see exclusion criteria, below): 00056001122, 00056001130, 00056001170, 00056007950, 00056008050, 00185003901, 00185003930, 00406009201, 00406009203, 00406117001, 00406117003, 00555090201, 00555090202, 00904703604, 16729008101, 16729008110, 23155088601, 23155088603, 42291063230, 43063059115, 47335032683, 47335032688, 50090286600, 50090492500, 50090682000, 50436010501, 51224020630, 51224020650, 51285027501, 51285027502, 52152010502, 52152010504, 52152010530, 54868557400, 62135024230, 62135024290, 63459030042, 63629104601, 63629104701, 65694010003, 65694010010, 65757030001, 65757030202, 68084029111, 68084029121, 68094085362, 68115068030, 71300660003, 71300661003, 71300664603, 71300664606, 71300664703, 71300664706, 71300664709, 72162156601, 72162156603, 72162215403 Exclude beneficiaries with NDC for Naltrexone, if the CCW alcohol use disorder indicator = Yes and opioid use disorder DX indicator (from measure #2 OUD using diagnoses) = No; or CCW drug use disorder indicator = Yes and opioid use DX disorder = No |
One or more drug claim with an NDC for opioid-MAT OR one or more non-drug claim with a HCPCS code. (NOTE: Naltrexone NDCs are excluded if there is evidence of an alcohol or other drug use disorder where opioid DX [OUD #2] is not present.) |
| Other Developmental Delays | 2 Years | DX 315.5, 315.8, 315.9 (any DX on the claim) | DX F81.9, F82, F88, F89 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Peripheral Vascular Disease (PVD) | 2 Years | DX 440.0, 440.1, 440.2, 440.20, 440.21, 440.22, 440.23, 440.29, 440.4, 443.8, 443.81, 443.82, 443.89, 443.9 (any DX on the claim) | DX E08.51, E08.52, E09.51, E09.52, E10.51, E10.52, E11.51, E11.52, E13.51, E13.52, I70.0, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.291, I70.292, I70.293, I70.298, I70.299, I70.92, I73.81, I73.89, I73.9, I79.1, I79.8 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Personality Disorders | 2 Years | DX 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9 (any DX on the claim) | DX F21, F34.0, F34.1, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F68.10, F68.11, F68.12, F68.13, F69 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Post-Traumatic Stress Disorder (PTSD) | 2 Years | DX 309.81 (any DX on the claim) | DX F43.10, F43.11, F43.12 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Pressure Ulcers and Chronic Ulcers | 2 Years | DX 707.00, 707.01, 707.02, 707.03, 707.04, 707.05, 707.06, 707.07, 707.09, 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, 707.19, 707.20, 707.22, 707.23, 707.24, 707.25, 707.8, 707.9 (any DX on the claim) EXCEPTION: Codes 707.20, 707.22, 707.23, 707.24, 707.25, 707.8, and 707.9 require a qualifying claim from 707.00, 707.01, 707.02, 707.03, 707.04, 707.05, 707.06, 707.07, 707.09 |
DX I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.45, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65, I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739, I70.741, I70.742, I70.743, I70.744, I70.745, I70.748, I70.749, I70.75, L89.000, L89.001, L89.002, L89.003, L89.004, L89.006, L89.009, L89.010, L89.011, L89.012, L89.013, L89.014, L89.016, L89.019, L89.020, L89.021, L89.022, L89.023, L89.024, L89.026, L89.029, L89.100, L89.101, L89.102, L89.103, L89.104, L89.106, L89.109, L89.110, L89.111, L89.112, L89.113, L89.114, L89.116, L89.119, L89.120, L89.121, L89.122, L89.123, L89.124, L89.126, L89.129, L89.130, L89.131, L89.132, L89.133, L89.134, L89.136, L89.139, L89.140, L89.141, L89.142, L89.143, L89.144, L89.146, L89.149, L89.150, L89.151, L89.152, L89.153, L89.154, L89.156, L89.159, L89.200, L89.201, L89.202, L89.203, L89.204, L89.206, L89.209, L89.210, L89.211, L89.212, L89.213, L89.214, L89.216, L89.219, L89.220, L89.221, L89.222, L89.223, L89.224, L89.226, L89.229, L89.300, L89.301, L89.302, L89.303, L89.304, L89.306, L89.309, L89.310, L89.311, L89.312, L89.313, L89.314, L89.316, L89.319, L89.320, L89.321, L89.322, L89.323, L89.324, L89.326, L89.329, L89.40, L89.41, L89.42, L89.43, L89.44, L89.45, L89.46, L89.500, L89.501, L89.502, L89.503, L89.504, L89.506, L89.509, L89.510, L89.511, L89.512, L89.513, L89.514, L89.516, L89.519, L89.520, L89.521, L89.522, L89.523, L89.524, L89.526, L89.529, L89.600, L89.601, L89.602, L89.603, L89.604, L89.606, L89.609, L89.610, L89.611, L89.612, L89.613, L89.614, L89.616, L89.619, L89.620, L89.621, L89.622, L89.623, L89.624, L89.626, L89.629, L89.810, L89.811, L89.812, L89.813, L89.814, L89.816, L89.819, L89.890, L89.891, L89.892, L89.893, L89.894, L89.896, L89.899, L89.90, L89.91, L89.92, L89.93, L89.94, L89.95, L89.96, L97.101, L97.102, L97.103, L97.104, L97.105, L97.106, L97.108, L97.109, L97.111, L97.112, L97.113, L97.114, L97.115, L97.116, L97.118, L97.119, L97.121, L97.122, L97.123, L97.124, L97.125, L97.126, L97.128, L97.129, L97.201, L97.202, L97.203, L97.204, L97.205, L97.206, L97.208, L97.209, L97.211, L97.212, L97.213, L97.214, L97.215, L97.216, L97.218, L97.219, L97.221, L97.222, L97.223, L97.224, L97.225, L97.226, L97.228, L97.229, L97.301, L97.302, L97.303, L97.304, L97.305, L97.306, L97.308, L97.309, L97.311, L97.312, L97.313, L97.314, L97.315, L97.316, L97.318, L97.319, L97.321, L97.322, L97.323, L97.324, L97.325, L97.326, L97.328, L97.329, L97.401, L97.402, L97.403, L97.404, L97.405, L97.406, L97.408, L97.409, L97.411, L97.412, L97.413, L97.414, L97.415, L97.416, L97.418, L97.419, L97.421, L97.422, L97.423, L97.424, L97.425, L97.426, L97.428, L97.429, L97.501, L97.502, L97.503, L97.504, L97.505, L97.506, L97.508, L97.509, L97.511, L97.512, L97.513, L97.514, L97.515, L97.516, L97.518, L97.519, L97.521, L97.522, L97.523, L97.524, L97.525, L97.526, L97.528, L97.529, L97.801, L97.802, L97.803, L97.804, L97.805, L97.806, L97.808, L97.809, L97.811, L97.812, L97.813, L97.814, L97.815, L97.816, L97.818, L97.819, L97.821, L97.822, L97.823, L97.824, L97.825, L97.826, L97.828, L97.829, L97.901, L97.902, L97.903, L97.904, L97.905, L97.906, L97.908, L97.909, L97.911, L97.912, L97.913, L97.914, L97.915, L97.916, L97.918, L97.919, L97.921, L97.922, L97.923, L97.924, L97.925, L97.926, L97.928, L97.929, L98.411, L98.412, L98.413, L98.414, L98.415, L98.416, L98.418, L98.419, L98.421, L98.422, L98.423, L98.424, L98.425, L98.426, L98.428, L98.429, L98.491, L98.492, L98.493, L98.494, L98.495, L98.496, L98.498, L98.499 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Schizophrenia | 2 Years | DX 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 295.53, 295.54, 295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 295.72, 295.73, 295.74, 295.75, 295.80, 295.81, 295.82, 295.83, 295.84, 295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95 (any DX on the claim) | DX F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Schizophrenia and Other Psychotic Disorders | 2 Years | DX 293.81, 293.82, 295.00, 295.01, 295.02, 295.03, 295.04, 295.05, 295.10, 295.11, 295.12, 295.13, 295.14, 295.15, 295.20, 295.21, 295.22, 295.23, 295.24, 295.25, 295.30, 295.31, 295.32, 295.33, 295.34, 295.35, 295.40, 295.41, 295.42, 295.43, 295.44, 295.45, 295.50, 295.51, 295.52, 295.53, 295.54, 295.55, 295.60, 295.61, 295.62, 295.63, 295.64, 295.65, 295.70, 295.71, 295.72, 295.73, 295.74, 295.75, 295.80, 295.81, 295.82, 295.83, 295.84, 295.85, 295.90, 295.91, 295.92, 295.93, 295.94, 295.95, 297.0, 297.1, 297.2, 297.3, 297.8, 297.9, 298.0, 298.1, 298.2, 298.3, 298.4, 298.8, 298.9 (any DX on the claim) | DX F06.0, F06.2, F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F32.3, F33.3, F44.89 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Sensory – Blindness and Visual Impairment | 2 Years | DX 369, 369.0, 369.00, 369.01, 369.02, 369.03, 369.04, 369.05, 369.06, 369.07, 369.08, 369.1, 369.10, 369.11, 369.12, 369.13, 369.14, 369.15, 369.16, 369.17, 369.18, 369.2, 369.20, 369.21, 369.22, 369.23, 369.24, 369.25, 369.3, 369.4 (any DX on the claim) | DX H54.0, H54.0X33, H54.0X34, H54.0X35, H54.0X43, H54.0X44, H54.0X45, H54.0X53, H54.0X54, H54.0X55, H54.10, H54.11, H54.1131, H54.1132, H54.1141, H54.1142, H54.1151, H54.1152, H54.12, H54.1213, H54.1214, H54.1215, H54.1223, H54.1224, H54.1225, H54.2, H54.2X11, H54.2X12, H54.2X21, H54.2X22, H54.3, H54.8 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Sensory – Deafness and Hearing Impairment | 2 Years | DX 389, 389.1, 389.10, 389.11, 389.12, 389.13, 389.14, 389.15, 389.16, 389.17, 389.18, 389.2, 389.20, 389.21, 389.22, 389.7, 389.8, 389.9 (any DX on the claim) | DX H90.3, H90.41, H90.42, H90.5, H90.6, H90.71, H90.72, H90.8, H90.A21, H90.A22, H90.A31, H90.A32, H91.01, H91.02, H91.03, H91.09, H91.3, H91.8X1, H91.8X2, H91.8X3, H91.8X9, H91.90, H91.91, H91.92, H91.93 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Sickle Cell Disease6 | 5 Years | 282.41, 282.42, 282.60, 282.61, 282.62, 282.63, 282.64, 282.68, 282.69 | DX D57.00, D57.01, D57.02, D57.03, D57.04, D57.09, D57.1, D57.20, D57.211, D57.212, D57.213, D57.214, D57.218, D57.219, D57.40, D57.411, D57.412, D57.413, D57.414, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.434, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.454, D57.458, D57.459, D57.80, D57.811, D57.812, D57.813, D57.814, D57.818, D57.819 | 3 or more non-drug claims of any service type |
| Spina Bifida and Other Congenital Anomalies of the Nervous System | 2 Years | DX 740.0, 740.1, 740.2, 741, 741.0, 741.00, 741.01, 741.02, 741.03, 741.9, 741.90, 741.91, 741.92, 741.93, 742.0, 742.1, 742.2, 742.3, 742.4, 742.5, 742.51, 742.53, 742.59, 742.8, 742.9 (any DX on the claim) | DX G90.1, Q00.0, Q00.1, Q00.2, Q01.0, Q01.1, Q01.2, Q01.8, Q01.9, Q02, Q03.0, Q03.1, Q03.8, Q03.9, Q04.0, Q04.1, Q04.2, Q04.3, Q04.4, Q04.5, Q04.6, Q04.8, Q04.9, Q05.0, Q05.1, Q05.2, Q05.3, Q05.4, Q05.5, Q05.6, Q05.7, Q05.8, Q05.9, Q06.0, Q06.1, Q06.2, Q06.3, Q06.4, Q06.8, Q06.9, Q07.00, Q07.01, Q07.02, Q07.03, Q07.8, Q07.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Spinal Cord Injury | 2 Years | DX 349.39, 806.00, 806.01, 806.02, 806.03, 806.04, 806.05, 806.06, 806.07, 806.08, 806.09, 806.10, 806.11, 806.12, 806.13, 806.14, 806.15, 806.16, 806.17, 806.18, 806.19, 806.20, 806.21, 806.22, 806.23, 806.24, 806.25, 806.26, 806.27, 806.28, 806.29, 806.30, 806.31, 806.32, 806.33, 806.34, 806.35, 806.36, 806.37, 806.38, 806.39, 806.4, 806.5, 806.60, 806.61, 806.62, 806.69, 806.70, 806.71, 806.72, 806.79, 806.8, 806.9, 907.2, 952.00, 952.01, 952.02, 952.03, 952.04, 952.05, 952.06, 952.07, 952.08, 952.09, 952.10, 952.11, 952.12, 952.13, 952.14, 952.15, 952.16, 952.17, 952.18, 952.19, 952.2, 952.3, 952.4, 952.8, 952.9 (any DX on the claim) | DX G96.11, S12.000A, S12.001A, S12.100A, S12.101A, S12.200A, S12.201A, S12.300A, S12.301A, S12.400A, S12.401A, S12.500A, S12.501A, S12.600A, S12.601A, S12.9XXA, S12.000B, S12.001B, S12.100B, S12.101B, S12.200B, S12.201B, S12.300B, S12.301B, S12.400B, S12.401B, S12.500B, S12.501B, S12.600B, S12.601B, S14.0XXA, S14.0XXS, S14.101A, S14.102A, S14.103A, S14.104A, S14.105A, S14.106A, S14.107A, S14.108A, S14.109A, S14.111A, S14.112A, S13.113A, S14.114A, S14.115A, S14.116A, S14.117A, S14.118A, S14.119A, S14.121A, S14.122A, S14.123A, S14.124A, S14.125A, S14.126A, S14.127A, S14.128A, S14.129A, S14.131A, S14.132A, S14.133A, S14.134A, S14.135A, S14.136A, S14.137A, S14.138A, S14.139A, S14.141A, S14.142A, S14.143A, S14.144A, S14.145A, S14.146A, S14.147A, S14.148A, S14.149A, S14.151A, S14.152A, S14.153A, S14.154A, S14.155A, S14.156A, S14.157A, S14.158A, S14.159A, S14.101S, S14.102S, S14.103S, S14.104S, S14.105S, S14.106S, S14.107S, S14.108S, S14.109S, S14.111S, S14.112S, S14.113S, S14.114S, S14.115S, S14.116S, S14.117S, S14.118S, S14.119S, S14.121S, S14.122S, S14.123S, S14.124S, S14.125S, S14.126S, S14.127S, S14.128S, S14.129S, S14.131S, S14.132S, S14.133S, S14.134S, S14.135S, S14.136S, S14.137S, S14.138S, S14.139S, S14.141S, S14.142S, S14.143S, S14.144S, S14.145S, S14.146S, S14.147S, S14.148S, S14.149S, S14.151S, S14.152S, S14.153S, S14.154S, S14.155S, S14.156S, S14.157S, S14.158S, S14.159S, S22.009A, S22.019A, S22.029A, S22.039A, S22.049A, S22.059A, S22.069A, S22.079A, S22.089A, S22.009B, S22.019B, S22.029B, S22.039B, S22.049B, S22.059B, S22.069B, S22.079B, S22.089B, S24.0XXA, S24.101A, S24.102A, S24.103A, S24.104A, S24.109A, S24.111A, S24.112A, S24.113A, S24.114A, S24.119A, S24.131A, S24.132A, S24.133A, S24.134A, S24.139A, S24.141A, S24.142A, S24.143A, S24.144A, S24.149A, S24.151A, S24.152A, S24.153A, S24.154A, S24.159A, S24.0XXS, S24.101S, S24.102S, S24.103S, S24.104S, S24.109S, S24.111S, S24.112S, S24.113S, S24.114S, S24.119S, S24.131S, S24.132S, S24.133S, S24.134S, S24.139S, S24.141S, S24.142S, S24.143S, S24.144S, S24.149S, S24.151S, S24.152S, S24.153S, S24.154S, S24.159S, S32.009A, S32.019A, S32.029A, S32.039A, S32.049A, S32.059A, S32.009B, S32.019B, S32.029B, S32.039B, S32.049B, S32.059B, S32.10XA, S32.2XXA, S32.10XB, S32.2XXB, S34.01XA, S34.02XA, S34.101A, S34.102A, S34.103A, S34.104A, S34.105A, S34.109A, S34.111A, S34.112A, S34.113A, S34.114A, S34.115A, S34.119A, S34.121A, S34.122A, S34.123A, S34.124A, S34.125A, S34.129A, S34.131A, S34.132A, S34.139A, S34.3XXA, S34.01XS, S34.02XS, S34.101S, S34.102S, S34.103S, S34.104S, S34.105S, S34.109S, S34.111S, S34.112S, S34.113S, S34.114S, S34.115S, S34.119S, S34.121S, S34.122S, S34.123S, S34.124S, S34.125S, S34.129S, S34.131S, S34.132S, S34.139S (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Tobacco Use Disorders | 2 Years | DX 305.1, 649.00, 649.01, 649.02, 649.03, 649.04, 989.84 (any DX on the claim) HCPCS Codes: 99406, 99407 |
DX F17.200, F17.201, F17.203, F17.208, F17.209, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, O99.330, O99.331, O99.332, O99.333, O99.334, O99.335, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A, Z72.0 (any DX on the claim) HCPCS Codes: 99406, 99407, G9276, G9458 |
At least 1 inpatient claim OR 2 other non-drug claims of any service type Procedure codes require only one claim to qualify |
| Traumatic Brain Injury and Nonpsychotic Mental Disorders due to Brain Damage | 2 Years | DX 310, 310.0, 310.1, 310.2, 310.8, 310.81, 310.89, 907, 907.0, 907.1 (any DX on the claim) | DX F07.0, F07.81, F07.89, F48.2, S04.011S, S04.012S, S04.019S, S04.02XS, S04.031S, S04.032S, S04.039S, S04.041S, S04.042S, S04.049S, S04.10XS, S04.11XS, S04.12XS, S04.20XS, S04.21XS, S04.22XS, S04.30XS, S04.31XS, S04.32XS, S04.40XS, S04.41XS, S04.42XS, S04.50XS, S04.51XS, S04.52XS, S04.60XS, S04.61XS, S04.62XS, S04.70XS, S04.71XS, S04.72XS, S04.811S, S04.812S, S04.819S, S04.891S, S04.892S, S04.899S, S04.9XXS, S06.0X0S, S06.0X1S, S06.0X2S, S06.0X3S, S06.0X4S, S06.0X5S, S06.0X6S, S06.0X7S, S06.0X8S, S06.0XAS, S06.0X9S, S06.1X0S, S06.1X1S, S06.1X2S, S06.1X3S, S06.1X4S, S06.1X5S, S06.1X6S, S06.1X7S, S06.1X8S, S06.1XAS, S06.1X9S, S06.2X0S, S06.2X1S, S06.2X2S, S06.2X3S, S06.2X4S, S06.2X5S, S06.2X6S, S06.2X7S, S06.2X8S, S06.2XAS, S06.2X9S, S06.300S, S06.301S, S06.302S, S06.303S, S06.304S, S06.305S, S06.306S, S06.307S, S06.308S, S06.30AS, S06.309S, S06.310S, S06.311S, S06.312S, S06.313S, S06.314S, S06.315S, S06.316S, S06.317S, S06.318S, S06.31AS, S06.319S, S06.320S, S06.321S, S06.322S, S06.323S, S06.324S, S06.325S, S06.326S, S06.327S, S06.328S, S06.32AS, S06.329S, S06.330S, S06.331S, S06.332S, S06.333S, S06.334S, S06.335S, S06.336S, S06.337S, S06.338S, S06.33AS, S06.339S, S06.340S, S06.341S, S06.342S, S06.343S, S06.344S, S06.345S, S06.346S, S06.347S, S06.348S, S06.34AS, S06.349S, S06.350S, S06.351S, S06.352S, S06.353S, S06.354S, S06.355S, S06.356S, S06.357S, S06.358S, S06.35AS, S06.359S, S06.360S, S06.361S, S06.362S, S06.363S, S06.364S, S06.365S, S06.366S, S06.367S, S06.368S, S06.36AS, S06.369S, S06.370S, S06.371S, S06.372S, S06.373S, S06.374S, S06.375S, S06.376S, S06.377S, S06.378S, S06.37AS, S06.379S, S06.380S, S06.381S, S06.382S, S06.383S, S06.384S, S06.385S, S06.386S, S06.387S, S06.388S, S06.38AS, S06.389S, S06.4X0S, S06.4X1S, S06.4X2S, S06.4X3S, S06.4X4S, S06.4X5S, S06.4X6S, S06.4X7S, S06.4X8S, S06.4XAS, S06.4X9S, S06.5X0S, S06.5X1S, S06.5X2S, S06.5X3S, S06.5X4S, S06.5X5S, S06.5X6S, S06.5X7S, S06.5X8S, S06.5XAS, S06.5X9S, S06.6X0S, S06.6X1S, S06.6X2S, S06.6X3S, S06.6X4S, S06.6X5S, S06.6X6S, S06.6X7S, S06.6X8S, S06.6XAS, S06.6X9S, S06.810S, S06.811S, S06.812S, S06.813S, S06.814S, S06.815S, S06.816S, S06.817S, S06.818S, S06.81AS, S06.819S, S06.820S, S06.821S, S06.822S, S06.823S, S06.824S, S06.825S, S06.826S, S06.827S, S06.828S, S06.82AS, S06.829S, S06.8A0S, S06.8A1S, S06.8A2S, S06.8A3S, S06.8A4S, S06.8A5S, S06.8A6S, S06.8AAS, S06.8A9S, S06.890S, S06.891S, S06.892S, S06.893S, S06.894S, S06.895S, S06.896S, S06.897S, S06.898S, S06.89AS, S06.899S, S06.9X0S, S06.9X1S, S06.9X2S, S06.9X3S, S06.9X4S, S06.9X5S, S06.9X6S, S06.9X7S, S06.9X8S, S06.9XAS, S06.9X9S, S06.A0XS, S06.A1XS (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Viral Hepatitis (General)7, including: | 2 Years | DX 070.0, 070.1, 070.2, 070.20, 070.21, 070.22, 070.23, 070.3, 070.30, 070.31, 070.32, 070.33, 070.4, 070.41, 070.42, 070.43, 070.44, 070.49, 070.5, 070.51, 070.52, 070.53, 070.54, 070.59, 070.6, 070.7, 070.70, 070.71, 070.9, V02.6, V02.60, V02.61, V02.62, V02.69 (any DX on the claim) | DX B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B17.0, B17.10, B17.11, B17.2, B17.8, B17.9, B18.0, B18.1, B18.2, B18.8, B18.9, B19.0, B19.10, B19.11, B19.20, B19.21, B19.9, Z22.50, Z22.51, Z22.52, Z22.59 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis A7 | 2 Years | DX 070.0, 070.1 (any DX on the claim) | DX B15.0, B15.9 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis B (acute or unspecified)7 | 2 Years | DX 070.2, 070.20, 070.21, 070.3, 070.30, 070.31 (any DX on the claim) | DX B16.0, B16.1, B16.2, B16.9, B19.10, B19.11 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis B (chronic)7 | 2 Years | DX 070.22, 070.23, 070.32, 070.33, V02.61 (any DX on the claim) | DX B18.0, B18.1, Z22.51 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis C (acute)7 | 2 Years | DX 070.41, 070.51 (any DX on the claim) | DX B17.10, B17.11 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis C (chronic)7 | 2 Years | DX 070.44, 070.54, V02.62 (any DX on the claim) | DX B18.2, Z22.52 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis C (unspecified)7 | 2 Years | DX 070.7, 070.70, 070.71 (any DX on the claim) | DX B19.20, B19.21 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis D7 | 2 Years | DX 070.21, 070.23, 070.31, 070.33, 070.42, 070.52 (any DX on the claim) | DX B16.0, B16.1, B17.0, B18.0 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
| Hepatitis E7 | 2 Years | DX 070.43, 070.53 (any DX on the claim) | DX B17.2 (any DX on the claim) | At least 1 inpatient claim OR 2 other non-drug claims of any service type |
- CCW data begins in 1999. When working with condition files prior to 2003, conditions with a reference period of two to five years will not have a sufficient length of data to fully meet the condition criteria in some years.
- ICD-10 codes are effective 10/2015; effective dates for ICD-9 codes vary, but are valid through 09/2015. Researchers may be interested in confirming the code(s) of interest in the accompanying claims data files.
- Non-drug claims do not include Medicare Part D Event or Medicaid MAX RX claims. When two claims are required, they must occur at least one day apart (i.e., different claim through dates [CLM_THRU_DT]).
- Chronic Pain-related indicators are available for data years 2018 forward. These indicators are not included in MMLEADS or MESF.
- There are also variables that measure care (largely Medicaid services) provided to individuals with HIV/AIDS. The CCW team does not include these variables in the MBSF or MESF.
- Opioid-related indicators and Sickle Cell Disease-related indicators were added to the 2017 file and have been subsequently populated in the data file for all historical years going back to 2000.
- The Viral Hepatitis (General) condition includes all other types of hepatitis covered; the variables for each specific type of hepatitis are not included in the MBSF.