MCUP3052 ATTACHMENT B REFERRAL GUIDELINES FOR ADULTS Nutrition Criteria/ Recommended Number ICD-10 Codes Definition of Adult Criteria of Visits Cardiovascular disease/or risk of E78.0 E78.3, E78.5 – I70.0 I70.249 Hypertension, hyperlipidemia and/or 3 visits over – I70.261 I70.299 coronary artery disease 3 months – I70.401 I70.419 – I70.501 I70.519 – I70.8 I70.92, I10 I11.9 – – Decubitus ulcer L89.90 L89.95 Increased nutritional need due to 1 visit – L89.000 L89.029 – L89.110 L89.149 L89.200 – – L89.329 L89.500 L89.819 – Impaired fasting glucose of > 100 mg/dl, but Pre-diabetes (impaired glucose <125 mg/dl. and/or impaired glucose 2 visits over tolerance) tolerance (IGT), defined as oral glucose 6 months R73.01 R73.09 tolerance test value of – > 140 mg/dl, but less than 200 mg/dl Diabetes 4 visits over 6 months Type 1 & Type 2 E10.10 E11.9 – Eating disorder Anorexia nervosa or bulimia and being 4 visits over F50.00 F50.02 – treated by a mental health clinician 2 months F50.02 Gastrointestinal disease: Need for dietary manipulation due to 2 visits over · Crohn’s Disease K50.00, gastrointestinal condition 2 months K50.010, K50.80, K50.90 · ulcerative colitis K51.00, K52.9, K51.20, K51.30, K51.40, K51.50, K51.80, K51.90 · irritable syndrome K58.9 ·malabsorption, s/p GI surgery K90.0 K90.3 – K90.81 K90.9 – HIV/AIDS 4 visits over Nutritional problems related to HIV/AIDS B20 3 months
MCUP3052 ATTACHMENT B REFERRAL GUIDELINES FOR ADULTS Nutrition Criteria/ ICD-10 Codes Definition of Adult Criteria Recommended Number of Visits Cardiovascular disease/or risk of E78.0 – E78.3, E78.5 I70.0 – I70.249 I70.261 – I70.299 I70.401 – I70.419 I70.501 – I70.519 I70.8 – I70.92, I10 – I11.9 Hypertension, hyperlipidemia and/or coronary artery disease 3 visits over 3 months Decubitus ulcer L89.90 – L89.95 L89.000 – L89.029 L89.110 – L89.149 L89.200 – L89.329 L89.500 – L89.819 Increased nutritional need due to 1 visit Pre-diabetes (impaired glucose tolerance) R73.01 – R73.09 Impaired fasting glucose of > 100 mg/dl, but <125 mg/dl. and/or impaired glucose tolerance (IGT), defined as oral glucose tolerance test value of > 140 mg/dl, but less than 200 mg/dl 2 visits over 6 months Diabetes E10.10 – E11.9 Type 1 & Type 2 4 visits over 6 months Eating disorder F50.00 – F50.02 F50.02 Anorexia nervosa or bulimia and being treated by a mental health clinician 4 visits over 2 months Gastrointestinal disease: · Crohn’s Disease K50.00, K50.010, K50.80, K50.90 · ulcerative colitis K51.00, K52.9, K51.20, K51.30, K51.40, K51.50, K51.80, K51.90 · irritable syndrome K58.9 ·malabsorption, s/p GI surgery K90.0 – K90.3 K90.81 – K90.9 Need for dietary manipulation due to gastrointestinal condition 2 visits over 2 months HIV/AIDS B20 Nutritional problems related to HIV/AIDS 4 visits over 3 months