No. 30877 (Amendment): R539-1-8. Non-Waiver Services for People with Brain Injury

DAR File No.: 30877
Filed: 01/04/2008, 01:52
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to include as part of the rule the specific International Classification of Diseases diagnosis codes eligible for coverage under the division's brain injury programs. This should remove any ambiguity about the conditions eligible for coverage.

Summary of the rule or change:

The rule now references the specific diagnostic codes eligible for coverage under the division's brain injury program.

State statutory or constitutional authorization for this rule:

Section 62A-5-103

Anticipated cost or savings to:

the state budget:

The inclusion of specific diagnosis codes in this rule will be budget neutral to the division or any other state agency. The rule will provide administrative clarity to the eligibility process, but it will not increase or decrease the number of individuals receiving services or the amount of services provided.

local governments:

Local governments do not provided these services and will not be otherwise affected by this rule. It will not affect the budgets of local governments.

small businesses and persons other than businesses:

Small businesses and other persons will not be affected by this rule. Some small businesses under contract to the division provide services to those that are eligible. This rule will not affect the services provided by small business.

Compliance costs for affected persons:

The only potential compliance costs could be seeking more than one medical opinion to obtain the diagnosis to be considered for eligibility.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule should not have any fiscal impact on businesses. Individuals who apply for division brain injury services now have specific diagnostic codes to help determine eligibility. Businesses will not be affected by the eligibility determinations for these individuals. Lisa-Michele Church, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Human Services
Services for People with Disabilities
120 N 200 W
SALT LAKE CITY UT 84103-1500

Direct questions regarding this rule to:

Steven Bradford at the above address, by phone at 801-538-4197, by FAX at 801-538-4279, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

03/03/2008

This rule may become effective on:

03/10/2008

Authorized by:

George Kelner, Director

RULE TEXT

R539. Human Services, Services for People with Disabilities.

R539-1. Eligibility.

R539-1-8. Non-Waiver Services for People with Brain Injury.

(1) The Division will serve those Applicants who meet the eligibility requirements for brain injury services. To be determined eligible for non-waiver brain injury services the Applicant must:

(a) have a documented acquired neurological brain injury[;] (by a licensed physician) according to the International Classifications of Diseases, 9th Revision, (ICD 9 CM). The following codes listed below qualify for ABI services:

047.9--aseptic meningitis (unspecified viral meningitis)

290 - 294 Codes not accepted as stand alone diagnosis (needing additional diagnosis)

290.4--vascular dementia

290.10 Prehensile dementia, uncomplicated

293.9--psychotic, post traumatic brain injury syndrome

294.0--amnesia

294.9--unspecified persistent mental disorders due to conditions classified elsewhere

294.9--with psychotic reaction

294.10-294.11--dementia without and with behavior disturbance Aggression, combative violent behaviors and wandering off

310.0 - 310.9 nonpsychotic disorder, brain damage

310.0--frontal lobe syndrome

310.1--mild memory loss or lack following organic brain damage

310.1--personality change due to conditions classified elsewhere

310.2--post concussion syndrome

310.2--post contusion syndrome, includes encephalopathy

310.2--post contusion syndrome, includes TBI

310.2--post contusion syndrome, includes TBI

310.2--post traumatic brain injury

310.2--post traumatic brain injury syndrome

310.8 - 310.9--other nonpsychotic mental disorder, following organic brain damage

310.8--other specified mental disorder following organic brain damage

310.8--other specified nonpsychotic mental disorders following organic brain damage

310.9--organic brain syndrome

310.9--Organic brain syndrome

310.9--organic brain syndrome (chronic or acute)

310.9--unspecified nonpsychotic mental disorder following organic brain damage

320.9--meningitis, bacterial

322.0--meningitis, nonpyogenic

322.2--meningitis, chronic

322.9--meningitis

323.0 - 323.82--choose to pick cause of encephalitis, not 323.9

324.0 - 324.9--Intracranial and intraspinal abscess

325 Phlebitis and thrombophlebitis of intracranial venous sinuses

326 Late effects of intracranial abscess or pyogenic infection

348.0--arachnoid cyst, brain; not as stand alone diagnosis (needs additional diagnosis)

348.1--anoxic brain damage

349.82 Toxic encephalopathy

430--subarachnoid hemorrhage

431--intracerebral hemorrhage

432.0--hematoma, non-traumatic brain

432.1--subdural hematoma

432--other and unspecified intracranial hemorrhage

433 Occlusion and stenosis of precerebral arteries (only if 5th digit is 1)

434 Occlusion of cerebral arteries (only if 5th digit is 1)

436--brain or cerebral, acute seizure; need another diagnosis in combination

438 - 438.89 Late effects of cerebrovascular disease (excluding 438.9)

780.93--Memory loss amnesia -only in combination with an E Code - (excludes 310.1 Mild Memory Disturbance due to organic brain damage) need an E code secondary to cause

List codes from 800 - 804 then 5th digit list only those that are 2 - 9 exclude 0 to 1(excluding 802's)

800.0--closed skull fracture, vault (parietal, frontal, vertex)

800.1 Fracture skull vault (frontal parietal) closed with laceration and contusion

800.1--closed skull fracture, vault with cerebral contusion

800.2 closed head injury with subarachnoid, subdural, and extradural hemorrhage

800.2 Closed skull fracture, with subarachnoid, subdural, and extradural hemorrhage

800.2--closed skull fracture, vault with epidural, extradural hemorrhage

800.2--closed skull vault fracture with subdural hemorrhage

800.3--closed skull fracture, vault with intracranial hemorrhage

800.3--Closed skull fx with other and unspecified intracranial hemorrhage

800.4--closed skull fracture, vault with intracranial injury

800.4--closed skull fx with intracranial injury of other and unspecified nature

800.5 - 800.9--Open skull fracture, vault (parietal or frontal area)

800.6--open skull fx with cerebral laceration and contusion

800.7--open skull fx with subarachnoid, subdural, and extra dural hemorrhage

800.7--open skull vault fracture with subdural hemorrhage

800.8--open skull fx other and unspecified intracranial hemorrhage

800.9--Open skull fx with intracranial injury of other and unspecified nature

800.9--open vault fracture with intracranial injury of other and unspecified nature

801.0 - 801.9 Fracture of base of skull

801.0--closed skull fracture, base

801.1--closed skull fracture, with cerebral hemorrhage

801.2--closed skull base fracture with subdural hemorrhage

801.2--closed skull fracture with epidural hemorrhage

801.3 - 801.4--closed skull fracture, base with intracranial hemorrhage

801.5 - 801.9--open skull fracture, base of skull

801.7--open skull base fracture with subdural hemorrhage

803.0 - 804.9--Other and unqualified skull fractures (includes single or multiple fx)

803.0--closed skull fracture with facial injuries

803.1--closed skull fracture with cerebral contusion

803.2--closed skull fracture with epidural, extradural hemorrhage

803.2--closed skull fracture, with subachnoid, subdural, and extradural hemorrhage

803.2--other and unqualified skull fractures, closed, subdural hemorrhage

803.3--closed skull fracture with intracranial hemorrhage

803.4--closed skull fracture with intracranial injury

803.5 - 803.9--open skull fracture, other and unqualified

803.7--other and unqualified skull fractures, open, subdural hemorrhage

804.2--multiple fractures skull and face, closed, subdural hemorrhage

804.5 - 804.9--Open skull fracture, multiple fractures skull and face

804.7--multiple fractures skull and face, open, subdural hemorrhage

List codes from 850-854 then 5th digit list only those that are 2 - 9 exclude 0 to 1

850.1 - 850.5--concussion with loss of conscious

851.0 - 851.9--cerebral laceration and contusion, open or closed, specifies site

851.0--cerebral contusion without mention open wound

851.2--cerebral laceration without mention of open wound

851.4 or 851-6--cerebral or brain stem contusion s mention open wnd

851.4--contusion brain stem

851.8--cerebral contusion (851.0 - 851.9--specify site, open, closed)

851.8--contusion brain

851.8--other and unspecified cerebral contusion

851.8--other unspecified cerebral s mention open wound

852.0, 852.2, 854.4 hemorrhage s mention open wound

852.0 - 852.5--Subarachnoid, subdural, and extradural hemorrhage following injury

852.0--subarachnoid hemorrhage

852.2 - 852.3--subdural hemorrhage, injury, without mention open, open

852.2--subdural hemorrhage following injury, s mention open wound

852.2--traumatic brain injury, subdural

852.3--subdural hemorrhage following injury, with open wound

852.4 - 852.5--extradural hemorrhage injury, without mention open

853.0 other intracranial hemorrhage after injury s mention open wound

853.0 - 853.1--other and unspecified intracranial hemorrhage following injury

853.0--hematoma, traumatic brain

854.0 - 854.1--Intracranial injury of other and unspecified nature

854.0--injury intracranial

854.0--intracranial hemorrhage due to injury

854.1--intracranial injury of other and unspecified nature s mention open w

905.0 Late effects of fracture of skull and face bones (5th digit list only those that are 2 - 9 exclude 0 - 1)

906.0 Late effects of open wound of head, neck, and trunk (5th digit list only those that are 2 - 9 exclude 0 - 1)

907.0--late effect of intracranial injury (5th digit list only those that are 2 - 9 exclude 0 - 1);

(b) Be 18 years of age or older;

(c) score between 40 and 120 on the Comprehensive Brain Injury Assessment Form 4-1.

(d) meet at least three of the functional limitations listed under number (4).

(2) Applicants with functional limitations due solely to mental illness, substance abuse or deteriorating diseases like Multiple Sclerosis, Muscular Dystrophy, Huntington's Chorea, Ataxia or Cancer are ineligible for non-waiver services.

(3) Applicants with mental retardation or related conditions are ineligible for these non-waiver services.

(4) In addition to the definitions in Section 62A-5-101(3) and (5), eligibility for brain injury services will be evaluated according to the Applicant's functional limitations as described in the following definitions:

(a) Memory or Cognition means the Applicant's brain injury resulted in substantial problems with recall of information, concentration, attention, planning, sequencing, executive level skills, or orientation to time and place.

(b) Activities of Daily Life means the Applicant's brain injury resulted in substantial dependence on others to move, eat, bathe, toilet, shop, prepare meals, or pay bills.

(c) Judgment and Self-protection means the Applicant's brain injury resulted in substantial limitation of the ability to:

(i) provide personal protection;

(ii) provide necessities such as food, shelter, clothing, or mental or other health care;

(iii) obtain services necessary for health, safety, or welfare;

(iv) comprehend the nature and consequences of remaining in a situation of abuse, neglect, or exploitation.

(d) Control of Emotion means the Applicant's brain injury resulted in substantial limitation of the ability to regulate mood, anxiety, impulsivity, agitation, or socially appropriate conduct.

(e) Communication means the Applicant's brain injury resulted in substantial limitation in language fluency, reading, writing, comprehension, or auditory processing.

(f) Physical Health means the Applicant's brain injury resulted in substantial limitation of the normal processes and workings of the human body.

(g) Employment means the Applicant's brain injury resulted in substantial limitation in obtaining and maintaining a gainful occupation without ongoing supports.

(5) The Applicant shall be provided with information concerning service options available through the Division and a copy of the Division's Guide to Services.

(6) The Applicant or the Applicant's Guardian must be physically present in Utah and provide evidence of residency prior to the determination of eligibility.

(7) It is the Applicant's or Applicant's Representative's responsibility to provide the intake worker with documentation of brain injury, signed by a licensed physician;

(8) The intake worker will complete or compile the following documents as needed to make an eligibility determination:

(a) Comprehensive Brain Injury Assessment Form 4-1, Part I through Part VII; and

(b) Brain Injury Social History Summary Form 824L[BI], completed or updated within one year of eligibility determination;

(9) If eligibility documentation is not completed within 90 calendar days of initial contact, a written notification letter shall be sent to the Applicant or the Applicant's Representative indicating that the intake case will be placed in inactive status.

(a) The Applicant or Applicant's Representative may activate the application at anytime thereafter by providing the remaining required information.

(b) The Applicant or Applicant's Representative shall be required to update information.

(10) When all necessary eligibility documentation is received from the Applicant or Applicant's Representative, region staff shall determine the Applicant eligible or ineligible for funding for brain injury supports.

(11) A Notice of Agency Action, Form 522-I, and a Hearing Request, Form 490S, shall be mailed to each Applicant or Applicant's Representative upon completion of the determination of eligibility or ineligibility for funding. The Notice of Agency Action, Form 522, shall inform the Applicant or Applicant's Representative of eligibility determination and placement on the waiting list. The Applicant or Applicant's Representative may challenge the Notice of Agency Action by filing a written request for an administrative hearing before the Department of Human Services, Office of Administrative Hearings.

(12) Persons receiving Brain Injury services will have their eligibility re-determined on an annual basis. Persons who are determined to no longer be eligible for services will have a transition plan developed to discontinue services and ensure that health and safety needs are met.

 

KEY: human services, disabilities, social security numbers

Date of Enactment or Last Substantive Amendment: [November 14, 2007]2008

Notice of Continuation: November 29, 2007

Authorizing, and Implemented or Interpreted Law: 62A-5-103; 62A-5-105