Escolar Documentos
Profissional Documentos
Cultura Documentos
A
Ablation........................................................................................................ CARD-2.9
Abscess, Anorectal....................................................................................... GI-15
Achalasia...................................................................................................... GI-1
Acne.............................................................................................................. DERM-1
Acromegaly................................................................................................... ENDO-7
Actinic Keratosis........................................................................................... DERM-2
Adenoidectomy........................................................................................... .ENT-18
Adenomas.................................................................................................... GI-17
Addison’s disease........................................................................................ ENDO-6
Adjustment Disorder..................................................................................... MH-1.1
Alopecia........................................................................................................ DERM-7
Alcohol Related Disorders............................................................................ MH-7.1
Allergy, Drug................................................................................................. ALL-1
Allergy, Food................................................................................................. ALL-2
Allergy, Insect Sting ..................................................................................... ALL-3
Allergy, Other................................................................................................ ALL-4
Amblyopia..................................................................................................... OPHTH-1
Amyotrophic Lateral Sclerosis...................................................................... NEURO-1
Amenorrhea.................................................................................................. GYN-3.2
Anal Fissures................................................................................................ GI-15
Anaphylaxis................................................................................................... ALL-5
Anemia: Auto-immune hemolytic.................................................................. HEME-1
Anemia: B-12 Deficiency……………………………………………………….. HEME-3
Anemia: Folate Deficiency……………………………………………………… HEME-3
Anemia: Megaloblastic………………………………………………………….. HEME-3
Anemia: Pernicious……………………………………………………………… HEME-3
Angina Pectoris…………………………………………………………………... CARD-8.1
Angioedema.................................................................................................. ALL-5
Ankylosis Spondylitis..................................................................................... RHEUM-3
Anorexia Nervosa......................................................................................... .MH-4.1
Anterior Cruciate Ligament (ACL), Injury and Repair................................... ORTHO-11
Anxiety Disorder, Generalized....................................................................... MH-2.1
Anxiety Disorder, Other................................................................................ MH-2.6
Aortic Aneurysm............................................................................................ CARD-1.1
Aortic Coarctation.......................................................................................... CARD-1.2
Aortic Regurgitation....................................................................................... CARD-1.3
Aortic Stenosis............................................................................................... CARD-1.4
Appendectomy.............................................................................................. GI-14
Arrhythmias: Ventricular................................................................................ CARD-2.7
Arthritis: Juvenile Rheumatoid, Rheumatoid................................................. RHEUM-4
Arthritis: General........................................................................................... RHEUM-7
Ascites.......................................................................................................... GI-18
Asthma.......................................................................................................... RESP-1
Atrial Arrhythmias, Benign............................................................................ CARD-2.1
Atrial Fibrillation............................................................................................ CARD-2.2
Atrial Tachycardia, Other............................................................................ CARD- 2.3
Atrial Septal Defect (ASD)............................................................................ CARD-5.1
Attention-Deficit/Hyperactivity Disorder........................................................ MH-3.1
Atrioventricular Blocks.................................................................................. CARD-4.1
Revised 2/2009
INDEX
B
Back Pain...................................................................................................... ORTHO-15
Back Sprain................................................................................................... ORTHO-15
Back Strain.................................................................................................... ORTHO-15
Balanitis......................................................................................................... ID-5
Balanoposthitis.............................................................................................. ID-5
Bariatric Surgery............................................................................................ GI-24
Barrett’s Esophagus...................................................................................... GI-1
Bartholin Gland Infections............................................................................. GYN-7.1
Basal Cell Carcinoma.................................................................................... DERM-3
Bell’s palsy..................................................................................................... NEURO-2
Benign Paroxysmal Positional Vertigo (BPPV).............................................. ENT-9
Benign Prostatic Hypertrophy (BPH)............................................................. GU-4
Bipolar Disorder............................................................................................. MH-5.1
Blepharitis...................................................................................................... OPHTH-2
Breast: Implants, Reconstructive Surgery..................................................... GYN-1.3
Breast Mass, Solid........................................................................................ GYN-1.5
Bone Marrow Transplant............................................................................... HEME-6
Bowel Anastomosis....................................................................................... GI-14
Bowel Obstruction......................................................................................... GI-7
Bradycardia, Sinus........................................................................................ CARD-2.6
Bronchiectasis............................................................................................... RESP-2
Bronchitis....................................................................................................... RESP-2
Bruxism.......................................................................................................... DENT-2.1
Bulimia Nervosa............................................................................................ MH-4.2
Bundle Branch Blocks................................................................................... CARD-4.2
Bunions/Bunionectomy................................................................................. ORTHO-4
Bursitis......................................................................................................... ORTHO-1
C
Carcinoma, Bladder...................................................................................... GU-17
Carcinoma, Bone………………………………………………………………… ORTHO-19
Carcinoma, Breast……………………………………………………………….. GYN-1.1
Carcinoma, Bronchus.................................................................................... RESP-6
Carcinoma, Colorectal................................................................................... GI-28
Carcinoma, Ear.............................................................................................. ENT-4
Carcinoma, Endometrial................................................................................ GYN-6.2
Carcinoma, Kidney........................................................................................ GU-9
Carcinoma, Lung........................................................................................... RESP-6
Carcinoma, Neurologic.................................................................................. NEURO-4
Carcinoma, Ovary......................................................................................... GYN-4.1
Carcinoma, Prostrate..................................................................................... GU-6
Carcinoma, Testicle....................................................................................... GU-1
Carcinoma, Squamous Cell……………………………………………………... DERM-4
Carcinoma, Thyroid………………………………………………………………. ENDO-8
Carcinoma, Uterine……………………………………………………………….. GYN-6.5
Carcinoma, Vagina, Vulva.............................................................................. GYN-7.2
Cardiac Disorders, other................................................................................ CARD-14.7
Cardiomyopathy............................................................................................. CARD-14.1
Carotid Artery Occlusive Disease................................................................... CARD-10.3
Carpal Tunnel Syndrome............................................................................... ORTHO-5
Cataract: Repair, Implant………………………………………………………... OPHTH-3
Celiac Sprue………………………………………………………………………. GI-27
Cerebral Palsy............................................................................................... NEURO-13
Revised 2/2009
INDEX
D
Degenerative Disk Disease........................................................................... ORTHO-16
Dental Problems: Congenital, Developmental............................................... DENT- 1.1
Dental Decay................................................................................................. DENT- 3.2
Dental Procedures......................................................................................... DENT- 6.1
Dentures........................................................................................................ DENT- 5.1
Depression: Major......................................................................................... MH-5.4
Dermatitis...................................................................................................... DERM-10
Dermatomysitis............................................................................................. RHEUM-1
Deviated Nasal Septum................................................................................. ENT-10
Diabetes Insipidus.......................................................................................... ENDO-1
Diabetes Mellitus (insulin pump).................................................................... ENDO-3
Diethylstilbestrol Exposure............................................................................. GYN-2.1
Dislocation, Shoulder..................................................................................... ORTHO-13
Dissociative Disorders.................................................................................... MH-9.1
Diverticulitis.................................................................................................... GI-10
Diverticulosis.................................................................................................. GI-10
Dysfunctional Uterine Bleeding...................................................................... GYN-6.1
Revised 2/2009
INDEX
Dysmenorrhea................................................................................................ GYN-3.3
Dysphoric Disorder, Premenstrual................................................................. MH-5.5
Dysthymic Disorder........................................................................................ MH-5.3
E
Eating Disorder, not otherwise specified....................................................... MH 4.3
Elliptocytosis.................................................................................................. HEME-1
Emphysema................................................................................................... RESP-3
Endometriosis................................................................................................ GYN-6.4
Epididymitis................................................................................................... GU-2
Epididymectomy............................................................................................ GU-3
Erythroplasia.................................................................................................. ENT-15
Enucleation.................................................................................................... OPHTH-6
Endocarditis................................................................................................... CARD-14.2
Endometrial Hyperplasia............................................................................... GYN-6.3
Esophageal Obstruction................................................................................ GI-1
Esophageal Stricture..................................................................................... GI-1
Esophageal Tear........................................................................................... GI-2
Esophageal Varicies...................................................................................... GI-18
Esophagitis.................................................................................................... GI-3
Ethmoidectomy.............................................................................................. ENT-13
F
Factitious Disorders....................................................................................... MH-9.2
Fibrocystic Breast Changes........................................................................... GYN-1.4
Fibromyalgia.................................................................................................. RHEUM-6
Fibrous Dysplasia.......................................................................................... ORTHO-20
Fistulas.......................................................................................................... GI-15
Flashers......................................................................................................... OPHTH-7
Floaters.......................................................................................................... OPHTH-7
Fracture, Nose............................................................................................... ENT-11
Fractures....................................................................................................... ORTHO-2
Fungal Infections............................................................................................ ID-2
G
G6PD.............................................................................................................. HEME-11
Ganglion......................................................................................................... ORTHO-6
Gastrectomy................................................................................................... GI-5
Gastritis.......................................................................................................... GI-4
Gastroesophageal Reflux Disease (GERD)................................................... GI-3
Genital Herpes............................................................................................... ID-9
Glaucoma...................................................................................................... OPHTH-8
Glomerulonephritis: Acute, Chronic............................................................... GU-11
Gout............................................................................................................... ENDO-4
Gonorrhea..................................................................................................... ID-10
Gynecology Disorders, Other........................................................................ GYN-8.5
Gynecology, Surgery..................................................................................... GYN-8.4
H
Hashimoto’s Disease...................................................................................... ENDO-11
Headache....................................................................................................... NEURO-3
Hearing Impairment........................................................................................ ENT-3
Hemochromotatosis....................................................................................... HEME-10
Hemoglobin C: Disease, Trait........................................................................ HEME-4
Revised 2/2009
INDEX
I
Ileostomy........................................................................................................ GI-14
Immune Thrombocytopenia Purpura (ITP)..................................................... HEME-5
Impacted Third Molars (Wisdom Teeth)......................................................... DENT-3.4
Impaired Vision............................................................................................... OPHTH-1
Impetigo.......................................................................................................... DERM-14
Impingement Syndrome and Repair............................................................... ORTHO-14
Impulse Control Disorder................................................................................ MH-9.3
Insulinomas.................................................................................................... ENDO-5
Intraocular Hypertension................................................................................ OPHTH-8
Intussusception.............................................................................................. GI-7
Irritable Bowel Syndrome (IBS)...................................................................... GI-11
Iritis/Iridocyclitis.............................................................................................. OPHTH-13
Iron Deficiency............................................................................................... HEME-2
J
Joint Replacement, Prosthesis...................................................................... ORTHO-7
K
Keratinous (Sebaceous) Cyst........................................................................ DERM-12
Keratitis.......................................................................................................... OPHTH-5
Kyphosis........................................................................................................ ORTHO-17
L
Labyrinthitis.................................................................................................... ENT-9
Lactose Intolerance........................................................................................ GI-12
Revised 2/2009
INDEX
M
Macular Degeneration................................................................................... OPHTH-12
Mallory-Weiss Syndrome.............................................................................. GI-2
Marfan’s Syndrome....................................................................................... CARD-14.4
Mammography............................................................................................... GYN-8.3
Mastoiditis...................................................................................................... ENT-5
Mastoidectomy............................................................................................... ENT-5
Melanoma...................................................................................................... DERM-5
Meniere Disease............................................................................................ ENT-6
Meniscus Tears............................................................................................. ORTHO-12
Menstrual Disorders: Abnormal bleeding....................................................... GYN-3.1
Mitral Valve Prolapse..................................................................................... CARD-9.1
Mitral Valve Regurgitation.............................................................................. CARD-9.2
Mitral Valve Stenosis...................................................................................... CARD-9.3
Molluscum Contagiosum................................................................................ DERM-18
Mononucleosis............................................................................................... ID-4
Mood Disorders, Other................................................................................... MH-5.7
Multiple Myeloma........................................................................................... HEME-7
Multiple Sclerosis........................................................................................... NEURO-1
Murmurs, Heart…………………………………………………………………… CARD-2.4
Muscular Dystrophy....................................................................................... NEURO-5
Myasthenia Gravis......................................................................................... NEURO-1
Myelodysplastic Syndromes…………………………………………………….. HEME-6
Myeloid Metaplasia (Agnogenic).................................................................... HEME-8
Myelofibrosis.................................................................................................. HEME-8
Myocardial Infarction, post............................................................................. CARD-8.4
Myopathies………………………………………………………………………... NEURO-6
Myringotomy.................................................................................................. ENT-7
N
Narcolepsy..................................................................................................... NEURO-7
Neck Pain....................................................................................................... ORTHO-15
Nephrectomy.................................................................................................. GU-9
Nephrolithiasis (kidney stones)...................................................................... GU-14
Nephrotic Syndrome...................................................................................... GU-15
Nephritis......................................................................................................... GU-12
Nevi: Benign, Dysplastic................................................................................ DERM-6
Non-Hodgkin Lymphomas............................................................................. HEME-7
O
Obesity, Overweight...................................................................................... CARD-14.5
Revised 2/2009
INDEX
P
Paget’s disease............................................................................................. ORTHO-22
Palpitations..................................................................................................... CARD-2.5
Pancreatitis: Acute, Chronic........................................................................... GI-21
Panic Disorder................................................................................................ MH 2.3
Pap smear: Abnormal.................................................................................... GYN-2.2
Papilledema................................................................................................... OPHTH-10
Parkinson’s disease...................................................................................... NEURO-1
Patent Ductus Arteriosis (PDA)..................................................................... CARD-5.2
Pelvic Inflammatory Disease (PID)................................................................ GYN-5.1
Peptic Ulcer Disease...................................................................................... GI-5
Peridontal Disease (Gingivitis)...................................................................... DENT-3.5
Perioral Dermatitis......................................................................................... DERM-8
Peripheral Vascular Disease (PVD).............................................................. CARD-10.1
Perforated Tympanic Membrane................................................................... ENT-7
Personality Disorders.................................................................................... MH-6.1
Phobias......................................................................................................... MH-2.4
Pilonidal Cyst................................................................................................. DERM-9
Pituitary Adenomas....................................................................................... ENDO-7
Pneumonectomy............................................................................................ RESP-6
Pneumonia (recurrent)................................................................................... RESP-2
Pneumothorax: Spontaneous, Traumatic...................................................... RESP-4
Polio, Post Syndrome.................................................................................... NEURO-8
Polycythemia Vera........................................................................................ HEME-8
Polycystic Ovarian Syndrome (Stein-Leventhal Syndrome)......................... GYN-4.3
Polyps, Colonic............................................................................................. GI-13
Polyps, Nasal................................................................................................ ENT-12
Polymyositis.................................................................................................. RHEUM-1
Polypectomy, Nasal...................................................................................... ENT-12
Polypectomy, Colon...................................................................................... GI-13
Posttraumatic Stress Disorder (PTSD)......................................................... MH- 2.5
Pregnancy, Termination................................................................................ GYN-8.2
Premenstrual Syndrome............................................................................... GYN-3.4
Proctitis......................................................................................................... GI-8
Proctocolectomy........................................................................................... GI-14
Prostatectomy............................................................................................... GU-4, 6
Prostatitis: Acute, Chronic............................................................................. GU-5
Psoriasis........................................................................................................ DERM-11
Psychiatric V Codes...................................................................................... MH-11.1
Psychotic Disorder, Brief............................................................................... MH-8.1
Pterygium...................................................................................................... OPHTH-11
Pulmonary Embolism.................................................................................... CARD-13.2
Revised 2/2009
INDEX
R
Raynaud’s Disease....................................................................................... CARD-10.2
Reactive Airway Disease............................................................................... RESP-1
Reactive Arthritis........................................................................................... RHEUM-2
Renal Failure: Acute, Chronic....................................................................... GU-12
Reiter’s Syndrome........................................................................................ RHEUM-2
Respiratory Surgery...................................................................................... RESP-6
Retinal Detachment/Repair.......................................................................... OPHTH-12
Retinitis Pigmentosa..................................................................................... OPHTH-12
Rhinitis, Allergic............................................................................................ ALL-7
Rhinitis, Non Allergic..................................................................................... ALL-7
Rhinoplasty................................................................................................... ENT-10
Rosacea........................................................................................................ DERM-8
Rotator Cuff, Injury and Repair.................................................................... ORTHO-14
S
Salivary Gland Disorders............................................................................. .ENT-17
Sarcoidosis................................................................................................... RESP-5
Schizophrenia.............................................................................................. MH-8.2
Scoliosis....................................................................................................... ORTHO-17
Seasonal Affective Disorder......................................................................... MH 5.6
Seborrheic Keratosis.................................................................................... DERM-13
Sedatives-Hypnotics……………………………………………………………. MH-2.7
Seizure Disorder........................................................................................... NEURO-9
Septoplasty................................................................................................... ENT-10
Sialolithiasis: Current, Acute......................................................................... ENT-17
Sialoadenectomy.......................................................................................... ENT-17
Sialosis......................................................................................................... ENT-17
Sickle Cell: Disease, Trait............................................................................ HEME-4
Sinusitis, Acute............................................................................................. ENT-13
Sinusitis, Chronic.......................................................................................... ENT-13
Sleep Apnea................................................................................................. RESP-7
Sinusotomy................................................................................................... ENT-13
Solitary Kidney............................................................................................. GU-9
Somatization Disorder.................................................................................. MH-9.4
Spermatocele............................................................................................... GU-3
Spherocytosis............................................................................................... HEME-1
Spleen: Cyst................................................................................................. HEME-9
Splenectomy................................................................................................. HEME-9
Splenomegaly............................................................................................... HEME-9
Sprains......................................................................................................... ORTHO-3
Spondylitis.................................................................................................... RHEUM-2
Spondylosis.................................................................................................. ORTHO-18
Spondylolisthesis (subluxation).................................................................... ORTHO-18
Strains.......................................................................................................... ORTHO-3
Strabismus................................................................................................... OPHTH-1
Stress Incontinence...................................................................................... GU-22
Sty................................................................................................................ OPHTH-4
Stroke........................................................................................................... NEURO-12
Subluxation, Patella.................................................................................... ORTHO-10
Revised 2/2009
INDEX
T
Teeth: Missing............................................................................................... DENT 2.2
Temporal Mandibular Joint Dysfunction (TMJ).............................................. DENT.2.3
Tendinitis...................................................................................................... ORTHO-3
Testicular Torsion......................................................................................... GU-7
Thalassemia: Disease, Trait......................................................................... HEME-4
Thrombocythemia: Essential (Primary)......................................................... HEME-8
Thrombocytopenia........................................................................................ HEME-5
Thrombosis, deep vein (DVT)....................................................................... CARD-13.1
Thrombosis, superficial vein......................................................................... CARD-13.3
Thrombophlebitis.......................................................................................... CARD-13.4
Thought Disorder, Other............................................................................... MH-8.3
Thyroiditis..................................................................................................... ENDO-11
Tinea Cruris.................................................................................................. DERM-15
Tinea Pedis................................................................................................... DERM-15
Tinea Versicolor………………………………………………………………….. DERM-15
Tinnitus.......................................................................................................... ENT-8
Tonsillectomy................................................................................................ ENT-18
Tooth, Abscessed......................................................................................... DENT-3.1
Tooth, Fractured........................................................................................... DENT-3.3
Tonsillectomy: Acute, Chronic.................................................................... . ENT-18
Tornwaldt’s Cyst........................................................................................... ENT-14
Tourette syndrome....................................................................................... NEURO-11
Tricuspid Regurgitation (insufficiency)......................................................... CARD-12.1
Tricuspid Stenosis........................................................................................ CARD-12.2
Tuberculosis................................................................................................. ID-13
TURP............................................................................................................ GU-4
Tympanoplasty............................................................................................. ENT-7
U
Ulcerative Colitis........................................................................................... GI-8
Underweight................................................................................................. GI-26
Undescended Testicle.................................................................................. GU-8
Ureterolithiasis (Urethral Stones)................................................................. GU-14
Urethral Obstruction..................................................................................... GU-20
Urethral Stricture.......................................................................................... GU-20
Urethritis....................................................................................................... GU-21
Urinary Fistula.............................................................................................. GU-22
Urticaria........................................................................................................ ALL-5
Uterine Leiomyomas (Fibroids)………………………………………………... GYN-6.6
Uveitis…………………………………………………………………………….. OPHTH-13
V
Vaginitis........................................................................................................ D-12, GYN-7.3
Varicella........................................................................................................ DERM-16
Variococele................................................................................................... GU-3
Ventricular Septal Defect (VSD)................................................................... CARD-5.1
Ventricular Shunt.......................................................................................... NEURO-10
Vertigo.......................................................................................................... ENT-9
Revised 2/2009
INDEX
Revised 2/2009
ANXIETY DISORDER NOT OTHERWISE SPECIFIED (NOS) MH 2.7
Does not meet clearance criteria due to one or more of the following: MHA DEFER
• History of moderate or severe symptoms of this condition within the past Deferral period consistent
one year. with clearance criteria.
• Ineffective management of mild symptoms of this condition within the past
1 year.
• Some impairment of functioning, socially or occupationally, during the past
1 year (corresponds to a GAF below 75)
• Active phase of psychotherapy or counseling not complete.
• Not stable for at least the past one year on psychotropic medication.
• Change in medication regime within the last year.
• Current substance-induced anxiety or anxiety due to a medical condition
(continued on next page)
Does not meet clearance criteria due to one or more of the following: MHA RISK VARIES
• History of suicide attempt, gesture, or ideation with plan within last 5 years
• History of distinct coexisting psychiatric disorders (Axis I and Axis II)
Does not meet clearance criteria due to one or more of the following: MHA TO MNQ
• History of psychosis. MED ADVISOR
• History of repeated, severe, episodes of anxiety.
• History of repeated suicide attempts or gestures.
DIAGNOSTIC CODES
300.00 Anxiety Disorder Not Otherwise Specified
Cross Reference DSM - IV
NOTES AND INSTRUCTIONS FOR REVIEWERS
Reviewers to Consider:
• Current mental health evaluation, i.e., Mental Health Evaluation Form.
• Telephone interview with applicant.
• Telephone interview with applicant’s mental health provider or treating physician.
COMMENTS
Anxiety Disorder Not Otherwise Specified: The patient presents with symptoms of prominent anxiety or phobic avoidance that do not
meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and
Depressed Mood. Examples include: (1) a mixed anxiety-depressive disorder where the patient has both anxiety symptoms and
depression, but the criteria are not met for either a Mood Disorder or and Anxiety Disorder; (2) the patient has significant social phobic
symptoms that are related to the social impact of having a general medical condition or mental disorder, e.g., stuttering, Body
Dysmorphic Disorder; (3) situations in which the clinician has concluded that an Anxiety Disorder is present, but is not certain whether it
is a primary disorder, due to a medical condition, or is substance induced.
A. Bronchospasm
CLEARANCE CRITERIA REVIEWER GUIDANCE
1. No history of chronic airway disease or asthma.
2. Isolated airway bronchospasm; May be defined as one or more of the following:
• Shortness of breath secondary to allergic trigger or upper respiratory infection.
• Wheezing secondary to allergic trigger or upper respiratory infection.
3. One or two episodes per year.
4. Symptoms do not significantly interfere with activities of daily living, e.g., activity level or work.
5. No history of urgent care or emergency room visits during the past 5 years.
6. No history of life-threatening shortness of breath or intubation.
7. No history of inhaled, oral, or injectable steroid use.
8. No coexisting irreversible respiratory or cardiac disease.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR ______
• More than two episodes per year. Risk varies - assess based on
• Symptoms significantly interfere with activities of daily living, e.g., activity detailed history.
level or work.
• If treated, symptoms poorly controlled with short-acting- beta2- agonists, e.g.,
albuterol, and/or antibiotics, expectorants, or OTC bronchodilators, e.g.,
Primatine mist.
• Treatment includes long-acting beta2-agonists, cromolyn, nedocromil,
leukotriene inhibitors, theophylline, or corticosteroids.
• Use of inhaled, oral, or injectable steroids.
• History of urgent care or emergency room visits within the past 5 years.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER/MNQ
• History of life-threatening shortness of breath or intubation.
• Coexisting irreversible respiratory or cardiac disease.
Does not meet clearance criteria due to one or more of the following: RN ______
• History of chronic airway disease or asthma. See Tables B, C, D, or E
below.
B. Mild Intermittent
CLEARANCE CRITERIA REVIEWER GUIDANCE
1. Mild intermittent asthma as determined by evaluating physician and confirmed by reviewer.
2. Symptoms do not significantly interfere with activities of daily living, e.g., activity level or work.
3. If management requires steroids:
- inhaled steroids required intermittently and for short-term use only, i.e., frequency of use does not exceed approximately 5
episodes per year, 3-4 weeks per episode, or several days per month every month.
- oral or injectable steroids required for <2 exacerbations per year.
4. No history of urgent care or emergency room visits within the past 5 years.
5. No history of life-threatening asthma exacerbations or intubation.
6. No coexisting irreversible respiratory or cardiac disease.
7. No history of mild persistent, moderate persistent or severe persistent RAD.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR ______
• Medication management of symptoms requires Step 3 or Step 4 treatment
Risk varies – assess based
(see comments). on detailed history.
• Symptoms significantly interfere with activities of daily living, e.g., activity
level or work.
• If management requires steroids:
- frequency of inhaled steroid use exceeds 5 episodes per year, 3-4
weeks per episode, or several days per month every month.
- oral or injectable steroids required for >2 exacerbations per year.
• History of urgent care or emergency room visits within the past 5 years.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER/MNQ
• History of life-threatening asthma exacerbations or intubation.
• Coexisting irreversible respiratory or cardiac disease.
Does not meet clearance criteria due to one or more of the following: RN ______
• History, or frequent exacerbations, of mild, moderate, or severe persistent
See Tables C,D, or E below
asthma.
C. Mild Persistent
CLEARANCE CRITERIA REVIEWER GUIDANCE
1. Mild persistent asthma as determined by evaluating physician and confirmed by reviewer.
2. Symptoms do not significantly interfere with activities of daily living, e.g., activity level or work.
3. Symptoms well-controlled on asthma medications for at least the past 3 months.
4. Symptom management requires use of short-acting beta2-agonists < 2 times per week.
5. If management requires oral or injectable steroids, total use < 30 days per year.
6. No history of urgent care or emergency room visits within the past 5 years.
7. No history of life-threatening asthma exacerbations or intubation.
8. No, or rare, exacerbations of moderate or severe persistent asthma.
9. No coexisting irreversible respiratory or cardiac disease.
PCMO FOLLOW-UP
Monitor symptom patterns and medication compliance
q 4-6 months.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER
• Symptoms not well-controlled on asthma medications for at least the past 3
months.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR ______
• Symptoms interfere significantly with activities of daily living, e.g., activity Risk varies – assess based
level or work. on detailed history
• Symptom management requires use of short-acting beta2-agonist > 2 times
If cleared: Asthma
per week. Accommodation with MAC
• Total use of oral or injectable steroids > 30 days per year.
• Medication management of symptoms requires Step 4 treatment (see
comments).
• History of urgent care or emergency room visits within the past 5 years.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER/MNQ
• History of life-threatening asthma exacerbations or intubation.
• Coexisting irreversible respiratory or cardiac disease.
Does not meet clearance criteria due to one or more of the following: RN ______
• History, or frequent exacerbations, of moderate or severe persistent asthma. See Tables D or E below.
D. Moderate Persistent
CLEARANCE CRITERIA REVIEWER GUIDANCE
1. Moderate persistent asthma as determined by evaluating physician and confirmed by reviewer.
2. Symptoms do not significantly interfere with activities of daily living, e.g., activity level or work.
3. Symptoms well-controlled on asthma medications for at least the past 3 months.
4. Symptom management does not require daily use of short-acting beta2-agonists or use > 3-4 times per day.
5. If management requires oral or injectable steroids, use < 30 days per year [question required on asthma form].
6. No history of urgent care or emergency room visits within the past 5 years.
7. No history of life-threatening asthma exacerbations or intubation.
8. No, or rare, exacerbations of severe persistent asthma.
9. No coexisting irreversible respiratory or cardiac disease.
PCMO FOLLOW-UP
Monitor symptom patterns and medication compliance
q 4-6 months.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER
• Symptoms not well-controlled on asthma medications for at least the past 3
months.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR ______
• Symptoms significantly interfere with activities of daily living, e.g., activity Risk varies – assess based
level or work. on detailed history.
• Symptom management requires daily use of short-acting beta2-agonists or
requires use > 3-4 times a day.
• Use of oral or injectable steroids > 30 days per year.
• History of urgent care or emergency room visits within the past 5 years.
Does not meet clearance criteria due to one or more of the following: MED ADVISOR DEFER/MNQ
• History of life-threatening asthma exacerbations or intubation.
• History, or frequent exacerbations, of severe persistent asthma.
• Coexisting irreversible respiratory or cardiac disease.
E. Severe Persistent
CLEARANCE CRITERIA REVIEWER GUIDANCE
1. Severe persistent asthma (see NIH criteria in comments) as determined by evaluating physician and confirmed by reviewer.
DIAGNOSTIC CODES
493.0 Asthma
Cross Reference ICD.9.CM
NOTES AND INSTRUCTIONS FOR REVIEWERS
Reviewers to Consider:
• Triggers
• Accuracy of diagnosis
COMMENTS
Background: Asthma is a chronic inflammatory disorder of the small airways which results in reversible airflow obstruction, and is
characterized by fluctuations in lung function due to acute triggers of bronchospasm and variations in the severity of the inflammation
itself.
Approximate Values for Spirometry and Peak Flow for Various Degrees of Obstruction in Adults
• Prevent chronic asthma symptoms and asthma exacerbations during the day and night.
• Maintain normal activity levels.
• Have normal or near-normal lung function.
• Have no or minimal side effects while receiving optimal medications.
Stepwise Approach for Managing Asthma in Adults and Children Over 5 Years Old
- Minimize use of short-acting inhaled beta2-agonist. Overreliance indicates inadequate control of asthma and the need to initiate or intensify long-term control therapy
- Provide education on self-management and controlling environmental factors that make asthma worse (e.g., allergens and irritants).
- Refer to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if step 3 care is required.
Common Asthma Medications:
Long-Term-Control Medications Quick-Relief Medications
(Long-Acting Beta2-Agonist)
• salmeterol - inhaled (Serevent)
• salmeterol - extented release (Volmax, Proventil Repetabs)
(Theophylline - Oral)
• (Theo-Dur, Slo-bid, Theo-24)
Steroids:
Follow-Up: Increases and decreases in medications may be needed as asthma severity and control vary over time. The “Expert Panel
Report” recommends follow-up visits every 1-6 months.
References:
Quick Reference: The National Education and Prevention Program (NAEPP). NAEPP Expert Panel Report: Guidelines for the Diagnosis
and Management of Asthma-Update on Selected Topics. 2002. National Institutes of Health. National Heart, Lung, and Blood Institute.
http://www.nhlbi.nih.gov.