From a payment perspective, Medical Assistance only pays for medically necessary services that are provided in the proper scope and amount, in accordance with professionally recognized standards. The case manager/service coordinator/service coordinator must justify care by presenting the appropriate facts. Medical records must substantiate diagnosis documentation.

The terminology used to describe people with developmental disabilities has changed over time. While DHS supports the use of “people first” language within its documents, certain outdated terms may be found within historical and official documents, such as statutes and reports.

The Disability Services Division is working with the Medicaid Management Information System (MMIS) to make changes and anticipates completion of changes and updates to this page in late 2011.

Before any services are provided to people with developmental disability or a related condition who need of social service and medical assistance, the county of financial responsibility must conduct or arrange for a diagnostic evaluation to determine whether the person has or may have developmental disability or related condition.

A comprehensive diagnostic evaluation must include:

1. A standardized test of intellectual functioning and an assessment of adaptive skills or for children under the age of five, standardized assessments of developmental functioning.

2. A social history report prepared no more than 12 months before the date of application for case management that contains:

Diagnostic information obtained by other providers including school information, may be used in whole or in part to meet the diagnostic requirements, when the final diagnosis contains all information required under Minn. R. 9525.0016.

Diagnostic assessments for children under the age of five years often result in an unspecified diagnosis of developmental disability, or a presumption that developmental disability or related condition may be present. Therefore, a review and re-evaluation of the diagnosis before or close to age five is essential in order to determine continued eligibility.

Diagnostic coding classifies data for health care programs and third-party reimbursement, as well as for basic health statistics. MMIS uses the ICD-9-CM coding system.

International Classification of Diseases, 9th Edition, Clinical Modification

The ICD-9-CM coding system contains three volumes of coding information:

The National Center for Health Statistics (NCHS) revises the ICD-9-CM diagnosis codes (Volumes 1 & 2) annually. CMS revises ICD-9-CM procedure codes (Volume 3) annually.

Diagnosis Code

Field 12 must contain the appropriate ICD-9-CM diagnosis code to record the person’s eligibility for DD case management services or the DD Waiver.

MMIS edits are in place in that affect what diagnosis codes may be entered into Fields 12, 13, 14 and 15.

Edit 203 (Change in Diagnosis Invalid) posts when the first diagnosis in Field 12 is changed more than one level of severity and the action type is not a full team screening. Counties have to do a full-team screening to change placement of diagnoses.

Edit 224 (Diagnosis 1 must be developmental disability or related condition) will post if Field 12 does not include the appropriate ICD-9-CMcode. This edit is not forcible.