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Blue Cross of Idaho
Serious Mental Illness (SMI) Determination Guidelines (State of Idaho membership only)

Subject Serious Mental Illness (SMI) Determination

Next Review 12/2010

Description

Serious Mental Illness = SMI. This group is defined as 18 & older. Once this determination is made, it is permanent and is not reviewed annually for changes. This allows the member to receive the extended mental health substance abuse benefit.

Policy

A designation of SMI is determined by the DSM IV diagnoses on Axis I, which are defined by the House Bill 615 as one of the 7 Biologics. The identified diagnoses are listed below as meeting the definition of the HB as a serious mental illness. The diagnosis must be made by one of the following methods and by one of the following providers:

 

  1. Diagnosis & documentation to be provided by a Board Certified Psychiatrist on the Prior Authorization form, the Additional Services Request form, consult notes or a psychiatric consultation during an inpatient admission.
  2. Diagnosis & documentation to be provided on a psychological consultation which includes related psychological or neuropsychological testing completed by a Licensed Psychologist.

In clinical situations where the member has received a Dual Diagnosis, a period of sobriety will be instituted prior to an SMI designation being made in order for the most appropriate diagnosis to be made psychiatrically. The following are the general determinants in determining the sobriety period, but the decision is not limited to these factors: substances used, current symptomology, prior history, length of use and type of use.

When the diagnostic record is received, the Case Manager will make the SMI designation. It may be necessary to consult with the Medical director or other providers to make this designation. When an SMI designation is made, the Case Manager will update or have the MMSS update the file in Facets & CCA as necessary. The member and provider(s) will be notified either verbally/in writing of the SMI designation.

DSM IV diagnoses included in SMI determination:

ICD9 Code Diagnosis
295 Schizophrenic Disorders
295.0 Simple Type Schizophrenia
295.00 Simple Type Schizophrenia, Unspecified Condition
295.01 Simple Type Schizophrenia, Subchronic Condition
295.02 Simple Type Schizophrenia, Chronic Condition
295.03 Simple Type Schizophrenia, Subchronic Condition With Acute Exacerbation
295.04 Simple Type Schizophrenia, Chronic Condition With Acute Exacerbation
295.05 Simple Type Schizophrenia, in Remission
295.1 Disorganized Type Schizophrenia
295.10 Disorganized Schizophrenia, Unspecified Condition
295.11 Disorganized Schizophrenia, Subchronic Condition
295.12 Disorganized Schizophrenia, Chronic Condition
295.13 Disorganized Schizophrenia, Subchronic Condition with Exacerbation
295.14 Disorganized Schizophrenia, Chronic Condition with Acute Exacerbation
295.15 Disorganized Schizophrenia, in Remission
295.2 Catatonic Schizophrenia
295.20 Catatonic Schizophrenia, Unspecified
295.21 Catatonic Schizophrenia, Subchronic Condition
295.22 Catatonic Schizophrenia, Chronic Condition
295.23 Catatonic Schizophrenia, Subchronic Condition with Acute Exacerbation
295.24 Catatonic Schizophrenia, Chronic Condition with Acute Exacerbation
295.25 Catatonic Schizophrenia, in Remission
295.3 Paranoid Schizophrenia
295.30 Paranoid Schizophrenia, Unspecified Condition
295.31 Paranoid Schizophrenia, Subchronic Condition
295.32 Paranoid Schizophrenia, Chronic Condition
295.33 Paranoid Schizophrenia, Subchronic Condition with Acute Exacerbation
295.34 Paranoid Schizophrenia, Chronic Condition with Acute Exacerbation
295.35 Paranoid Schizophrenia, in Remission
295.4 Schizophreniform Disorder
295.40 Schizophreniform Disorder, Unspecified
295.41 Schizophreniform Disorder, Subchronic
295.42 Schizophreniform Disorder, Chronic
295.43 Schizophreniform Disorder, Subchronic with Acute Exacerbation
295.44 Schizophreniform Disorder, Chronic with Acute Exacerbation
295.45 Schizophreniform Disorder, in Remission
295.5 Latent Schizophrenia
295.50 Latent Schizophrenia, Unspecified Condition
295.51 Latent Schizophrenia, Subchronic Condition
295.52 Latent Schizophrenia, Chronic Condition
295.53 Latent Schizophrenia, Subchronic Condition with Acute Exacerbation
295.54 Latent Schizophrenia, Chronic Condition with Acute Exacerbation
295.55 Latent Schizophrenia, in Remission
295.6 Residual Schizophrenia
295.60 Residual Schizophrenia, Residual Type, Unspecified
295.61 Residual Schizophrenia, Residual Type, Subchronic
295.62 Residual Schizophrenia, Residual Type, Chronic
295.63 Residual Schizophrenia, Residual Type, Subchronic with Acute Exacerbation
295.64 Residual Schizophrenia, Residual Type, Chronic with Acute Exacerbation
295.65 Residual Schizophrenia, Residual Type, in Remission
295.7 Schizo-Affective Disorder
295.70 Schizo-Affective Disorder, Unspecified Condition
295.71 Schizo-Affective Disorder, Subchronic Condition
295.72 Schizo-Affective Disorder, Chronic Condition
295.73 Schizo-Affective Disorder, Subchronic Condition with Acute Exacerbation
295.74 Schizo-Affective Disorder, Chronic Condition with Acute Exacerbation
295.75 Schizo-Affective Disorder, in Remission
295.8 Other Specified Types of Schizophrenia
295.80 Other Specified Types of Schizophrenia, Unspecified Condition
295.81 Other Specified Types of Schizophrenia, Subchronic Condition
295.82 Other Specified Types of Schizophrenia, Chronic Condition
295.83 Other Specified Types of Schizophrenia, Subchronic Condition with Acute Exacerbation
295.84 Other Specified Types of Schizophrenia, Chronic Condition with Acute Exacerbation
295.85 Other Specified Types of Schizophrenia, in Remission
295.9 Unspecified Schizophrenia
295.90 Unspecified Schizophrenia, Unspecified Condition
295.91 Unspecified Schizophrenia, Subchronic Condition
295.92 Unspecified Schizophrenia, Chronic Condition
295.93 Unspecified Schizophrenia, Subchronic Condition with Acute Exacerbation
295.94 Unspecified Schizophrenia, Chronic Condition with Acute Exacerbation
295.95 Unspecified Schizophrenia, in Remission
296 Episodic Mood Disorders
296.0 Bipolar I Disorder, Single Manic Episode
296.00 Bipolar I Disorder, Single Manic Episode, Unspecified
296.01 Bipolar I Disorder, Single Manic Episode, Mild Degree
296.02 Bipolar I Disorder, Single Manic Episode, Moderate Degree
296.03 Bipolar I Disorder, Single Manic Episode, Severe Degree, Without Mention of Psychotic Behavior
296.04 Bipolar I Disorder, Single Manic Episode, Severe Degree, Specified as with Psychotic Behavior
296.05 Bipolar I Disorder, Single Manic Episode, in Partial or Unspecified Remission
296.06 Bipolar I Disorder, Single Manic Episode, in Full Remission
296.1 Manic Disorder, Recurrent Episode
296.10 Manic Affective Disorder, Recurrent Episode, Unspecified Degree
296.11 Manic Affective Disorder, Recurrent Episode, Mild Degree
296.12 Manic Affective Disorder, Recurrent Episode, Moderate Degree
296.13 Manic Affective Disorder, Recurrent Episode, Severe Degree, Without Mention of Psychotic Behavior
296.14 Manic Affective Disorder, Recurrent Episode, Severe Degree, Specified as with Psychotic Behavior
296.15 Manic Affective Disorder, Recurrent Episode, in Partial or unspecified Remission
296.16 Manic Affective Disorder, Recurrent Episode, in Full Remission
296.2 Major Depressive Disorder, Episode, Single Episode
296.20 Major Depressive Affective Disorder, Episode, Single Episode, Unspecified Degree
296.21 Major Depressive Affective Disorder, Episode, Single Episode, Mild Degree
296.22 Major Depressive Affective Disorder, Episode, Single Episode, Moderate Degree
296.23 Major Depressive Affective Disorder, Episode, Single Episode, Severe Degree, Without Mention of Psychotic Behavior
296.24 Major Depressive Affective Disorder, Episode, Single Episode, Severe Degree, Specified as with Psychotic Behavior
296.25 Major Depressive Affective Disorder, Episode, Single Episode, in Partial or Unspecified Remission
296.26 Major Depressive Affective Disorder, Episode, Single Episode, in Full Remission
296.3 Major Depressive Disorder, Recurrent Episode
296.30 Major Depressive Affective Disorder, Recurrent Episode, Unspecified Degree
296.31 Major Depressive Affective Disorder, Recurrent Episode, Mild Degree
296.32 Major Depressive Affective Disorder, Recurrent Episode, Moderate Degree
296.33 Major Depressive Affective Disorder, Recurrent Episode, Severe Degree, Without Mention of Psychotic Behavior
296.34 Major Depressive Affective Disorder, Recurrent Episode, Severe Degree, Specified as with Psychotic Behavior
296.35 Major Depressive Affective Disorder, Recurrent Episode, in Partial or Unspecified Remission
296.36 Major Depressive Affective Disorder, Recurrent Episode, in Full Remission
296.4 Bipolar I Disorder, Most Recent Episode (or current) Manic
296.40 Bipolar I Disorder, Most Recent Episode (or current) Manic, Unspecified Degree
296.41 Bipolar I Disorder, Most Recent Episode (or current) Manic, Mild Degree
296.42 Bipolar I Disorder, Most Recent Episode (or current) Manic, Moderate Degree
296.43 Bipolar I Disorder, Most Recent Episode (or current) Manic, Severe Degree, Without Mention of Psychotic Behavior
296.44 Bipolar I Disorder, Most Recent Episode (or current) Manic, Severe Degree, Specified as with Psychotic Behavior
296.45 Bipolar I Disorder, Most Recent Episode (or current) Manic, in Partial or Unspecified Remission
296.46 Bipolar I Disorder, Most Recent Episode (or current) Manic, in Full Remission
296.5 Bipolar I Disorder, Most Recent Episode (or current) Depressed
296.50 Bipolar I Disorder, most recent episode (or current) Depressed, Unspecified Degree
296.51 Bipolar I Disorder, most recent episode (or current) Depressed, Mild Degree
296.52 Bipolar I Disorder, most recent episode (or current) Depressed, Moderate Degree
296.53 Bipolar I Disorder, most recent episode (or current) Depressed, Severe Degree, Without Mention of Psychotic Behavior
296.54 Bipolar I Disorder, most recent episode (or current) Depressed, Severe Degree, Specified as with Psychotic Behavior
296.55 Bipolar I Disorder, most recent episode (or current) Depressed, in Partial or Unspecified Remission
296.56 Bipolar I Disorder, most recent episode (or current) Depressed, in Remission
296.6 Bipolar I Disorder, most recent episode (or current) Mixed
296.60 Bipolar I Disorder, most recent episode (or current) Mixed, Unspecified Degree
296.61 Bipolar I Disorder, most recent episode (or current) Mixed, Mild Degree
296.62 Bipolar I Disorder, most recent episode (or current) Mixed, Moderate Degree
296.63 Bipolar I Disorder, most recent episode (or current) Mixed, Severe Degree, Without Mention of Psychotic Behavior
296.64 Bipolar I Disorder, most recent episode (or current) Mixed, Severe Degree, Specified as with Psychotic Behavior
296.65 Bipolar I Disorder, most recent episode (or current) Mixed, in Partial or Unspecified Remission
296.66 Bipolar I Disorder, most recent episode (or current) Mixed, in Full Remission
296.7 Bipolar Affective Disorder, Unspecified
296.8 Other and Unspecified Bipolar Disorders
296.80 Bipolar Disorder, Unspecified
296.81 Atypical manic disorder
296.82 Atypical depressive disorder
296.89 Bipolar disorder, other
269.9 Other and Unspecified Episodic Mood Disorder
296.90 Unspecified Episodic Mood Disorder
296.99 Other Specified Episodic Mood Disorder
297 Delusional Disorders
297.0 Paranoid State, Simple
297.1 Delusional Disorder
297.2 Paraphrenia
297.3 Shared Psychotic Disorder
297.8 Other Specified Paranoid States
297.9 Unspecified Paranoid State
298 Other Nonorganic Psychoses
298.0 Depressive Type Psychosis
298.1 Excitative Type Psychosis
298.2 Reactive Confusion
298.3 Acute Paranoid Reaction
298.4 Psychogenic Paranoid Psychosis
298.8 Other and Unspecified Reactive Psychosis
298.9 Unspecified Psychosis
299 Pervasive Developmental Disorders
299.0 Autistic Disorder
299.00 Autistic Disorder, current or active state
299.01 Autistic Disorder, residual state
299.1 Childhood Disintegrative Disorder
299.10 Childhood Disintegrative Disorder, current or active state
299.11 Childhood Disintegrative Disorder, residual state
299.8 Other Specified Pervasive Developmental Disorders
299.80 Other Specified Pervasive Developmental Disorders, current or active state
299.81 Other Specified Pervasive Developmental Disorders, residual state
299.9 Unspecified Pervasive Developmental Disorder
299.90 Unspecified Pervasive Developmental Disorder, current or active state
299.91 Unspecified Pervasive Developmental Disorder, residual state
300 Anxiety, Dissociative and Somatoform Disorders
300.0 Anxiety States
300.00 Anxiety state, Unspecified
300.01 Panic Disorder without Agoraphobia
300.02 Generalized Anxiety Disorder
300.09 Other
300.1 Dissociative, Conversion and Factitious Disorders
300.10 Hysteria, Unspecified
300.11 Conversion Disorder
300.12 Dissociative Amnesia
300.13 Dissociative Fugue
300.14 Dissociative Identity Disorder
300.15 Dissociative Disorder or Reaction, Unspecified
300.16 Factitious Disorder with Predominantly Psychological Signs and Symptoms
300.19 Other and Unspecified Factitious Illness
300.2 Panic Disorders
300.20 Phobia, Unspecified
300.21 Agoraphobia with Panic Disorder
300.22 Agoraphobia without mention of Panic Attacks
300.23 Social Phobia
300.29 Other Isolated or Specific Phobias
300.3 Obsessive-compulsive Disorders




References:

  1. Kenneth Minkoff, MD> 'CCISC MODEL- COMPREHENSIVE CONTINUOUS, INTEGRATED SYSTEM OF CARE MODEL'
  2. Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Rev (2005)
  3. CALCOCUS; Version 1.5

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