MCUP3052 ATTACHMENT A REFERRAL GUIDELINES FOR CHILDREN / ADOLESCENTS Nutrition Criteria/ Recommended Number of ICD-10 Definition of Child/Adolescent Criteria Visits Diabetes Type 1 & Type 2 4 visits over 6 months E10.10 E11.9 – Eating disorders Anorexia nervosa or bulimia and being treated 4 visits over F50.00 - F50.02 by a mental health clinician 2 months F50.2 TAR Requires name of Mental Health Provider Lead poisoning 4 visits over Blood Lead Level T56.0X1A T56.OX4S 6 months – Ages 2 19 > 85th percentile by weight for – Obesity and Overweight 8 visits over height OR by BMI, using the appropriate growth E66.9, E66.3 1 year chart for age (NCHS) Impaired fasting glucose of > 100 mg/dl, but Pre-diabetes (impaired <125 mg/dl. and/or impaired glucose tolerance glucose tolerance) (IGT), defined as oral glucose tolerance test 2 visits over R73.01 R73.09 – value of 6 months > 140 mg/dl, but less than 200 mg/dl Has received a trial of iron therapy for 2 months Severe anemia and who still has a D50.0 D50.9 Hemoglobin less than or to 9.0gm/dl 3 visits over – D53.9 and a 6 months hemoglobin electrophoresis which does not indicate hemoglobinopathy Diagnosed food hypersensitivity to casein, Severe food gluten, or soy 2 visits over hypersensitivity L27.2 TAR Requires Type of Food Allergy 6 months Short Stature Measurement below the 5th percentile height for R62.0 3 visits over 6 months age using the appropriate growth chart for R62.50 R62.52 – age(NCHS) Measurement below the 5th percentile weight for Underweight, and/or height using the appropriate growth chart failure to thrive (NCHS) 3 visits over 6 months R62.0 or R62.50 R62.52 – Dramatic drop on the growth from previous visit by two percentiles
MCUP3052 ATTACHMENT A REFERRAL GUIDELINES FOR CHILDREN / ADOLESCENTS Nutrition Criteria/ ICD-10 Definition of Child/Adolescent Criteria Recommended Number of Visits Diabetes E10.10 – E11.9 Type 1 & Type 2 4 visits over 6 months Eating disorders F50.00 - F50.02 F50.2 Anorexia nervosa or bulimia and being treated by a mental health clinician TAR Requires name of Mental Health Provider 4 visits over 2 months Lead poisoning T56.0X1A – T56.OX4S Blood Lead Level 4 visits over 6 months Obesity and Overweight E66.9, E66.3 Ages 2 – 19 > 85th percentile by weight for height OR by BMI, using the appropriate growth chart for age (NCHS) 8 visits over 1 year 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 Severe anemia D50.0 – D50.9 D53.9 Has received a trial of iron therapy for 2 months and who still has a Hemoglobin less than or to 9.0gm/dl and a hemoglobin electrophoresis which does not indicate hemoglobinopathy 3 visits over 6 months Severe food hypersensitivity L27.2 Diagnosed food hypersensitivity to casein, gluten, or soy TAR Requires Type of Food Allergy 2 visits over 6 months Short Stature R62.0 R62.50 – R62.52 Measurement below the 5th percentile height for age using the appropriate growth chart for age(NCHS) 3 visits over 6 months Underweight, and/or failure to thrive R62.0 R62.50 – R62.52 Measurement below the 5th percentile weight for height using the appropriate growth chart (NCHS) or Dramatic drop on the growth from previous visit by two percentiles 3 visits over 6 months