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Complex Case Management Trigger Events and Diagnosis Codes Adult/Pediatric/High-Risk Maternity

Horizon Blue Cross Blue Shield of New Jersey’s Complex Case Management Program is a free, voluntary service that offers care coordination and guidance to our members and their covered dependents when faced with a serious illness or condition. The member’s physician and a Horizon BCBSNJ Care Manager will work collaboratively with the member to develop a treatment plan. The treatment plan will consist of both short- and long-term goals for our members or their covered dependents to achieve self-management of the illness or condition.

Horizon BCBSNJ identifies members for the Complex Case Management Program from many sources, including:

  • Physician referrals
  • Member self-referrals
  • Predictive modeling
  • Daily discharge logs
  • Weekly re-admission reports

The following pages include a partial list1 of trigger events and diagnosis codes for Complex Case Management services for adult, pediatric and high-risk maternity members. Triggers can be a diagnosis, an event, a circumstance or a behavior that represents an opportunity for case management intervention.

Horizon BCBSNJ reserves the right to modify this list at any time

Trigger Events and Circumstances

  • Acute or chronic condition/unstable home environment or lack of a qualified caregiver
  • All hospice requests/end stage pre-hospice/terminal illness
  • Cognitive rehabilitation
  • Emergency Room (ER) readmission for same diagnosis within 30 days
  • Extended acute hospital stay of more than seven days
  • Extended (greater than six weeks) physical, occupational and/or speech therapy
  • Extended (greater than six weeks) home intravenous therapy
  • Extended (greater than six weeks) home health aide (HHA) and skilled nursing
  • High dollar claimant (greater than or equal to $100,000 threshold)
  • Maternity – referred at less than 36 weeks gestation:
    • 17P progesterone therapy
    • Complication in pregnancy
    • Infertility services with confirmed pregnancy
    • Inpatient admission not resulting in delivery/determination or fetal demise
    • Multiple gestations
    • Over 35 years of age
    • Under 18 years of age
  • Member or physician referral
  • Multiple comorbidities without a current treatment or unstable disease process
  • Multiple ER visits
  • Multiple hospital admissions within 90 days
  • Neonatal intensive care unit (NICU)
  • Nonparticipating claims greater than or equal to $5,000 or five or more nonparticipating services
  • Pediatric open heart surgery
  • Pharmacy needs of six or more medications
  • Private duty nursing
  • Severe trauma
  • Specialized durable medical equipment (DME)
  • Ventilator dependent
  • Wound vacuum-assisted closure (VAC) devices

Trigger Diagnosis

  • Anoxic encephalopathy
  • Asthma (inpatient admission greater than two ER visits within 30 days)
  • Autoimmune diseases or HIV/AIDS
  • Chronic kidney disease (CKD)/End-stage renal disease (ESRD)
  • Chronic obstructive pulmonary disease (COPD)
  • Cleft palate
  • Clinical trials – outpatient setting
  • Congestive heart failure (CHF)
  • Coronary insufficiency syndrome
  • Cerebrovascular accident (CVA) – stroke
  • Diabetes (newly diagnosed/one inpatient admission or less than two ER visits within 30 days)
  • Hemophilia
  • Hypertension – uncontrolled (blood pressure)
  • Hypogammaglobulinemia
  • Intracranial hemorrhage
  • Limb amputation
  • Lupus
  • Myocardial infraction (MI) – heart attack
  • Multiple traumas
  • Neuromuscular conditions:
    • Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease
    • Cerebral palsy
    • DiGeorge syndrome
    • Down syndrome
    • Guillain-Barré
    • Huntington’s disease (HD)
    • Muscular dystrophy
    • Multiple sclerosis (MS)
    • Spinal muscular atrophy
  • Parkinson’s disease
  • Pediatric gastrointestinal disorders:
    • Inflammatory bowel
    • Crohn’s disease
    • Hirschsprung’s disease
    • Malabsorption syndrome
  • Premature infant
  • Pulmonary hypertension
  • Rare diseases
  • Respiratory failure or distress
  • Sex reassignment
  • Sickle cell anemia
  • Spinal cord injury (SCI)
  • Systematic sclerosis
  • Transplant candidates
  • Traumatic brain injury (TBI)
  • Unstable angina
  • Wounds (non-healing/infected or open)

The ICD-10 codes below are referred to
Complex Case Management

Malignant Neoplasm of Female Breast and Male Breast
Female codes
ICD-10 Codes Description
C50.011, C50.012, C50.019 Nipple and areola
C50.111, C50.112, C50.119 Central portion
C50.211, C50.212, C50.219 Upper-inner quadrant
C50.311, C50.312, C50.319 Lower-inner quadrant
C50.411, C50.412, C50.419 Upper-outer quadrant
C50.511, C50.512, C50.519 Lower-outer quadrant
C50.611, C50.612, C50.619 Axillary tail
C50.811, C50.812, C50.819 Malignant neoplasm of contiguous or overlapping sites of breast where point of origin cannot be determined: contiguous sites; ectopic sites; inner; lower; outer; midline
C50.911, C50.912, C50.919 Malignant neoplasm of breast, unspecified
C79.81 Secondary malignant neoplasm of breast
C79.82 Mastectomy
D05.00, D05.01, D05.02,D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.90, D05.91, D05.92 Carcinoma in situ of breast
Male codes
C50.021, C50.022, C50.029 Nipple and areola
C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929 Other and unspecified sites of male breast
Pancreatic Cancer and Leukemia
C25.0 Head of pancreas
C25.1 Body of pancreas
C25.2 Tail of pancreas
C25.3 Pancreatic duct
C25.4 Islets of Langerhans
C25.7, C25.8 Other specified sites of pancreas
C25.9 Malignant neoplasm of head of pancreas
C26.9 Pancreas, part unspecified
C91.40, C91.41, C91.42 Hairy-cell leukemia
C90.00 Multiple myeloma without mention of remission
C90.10 Plasma cell leukemia without mention of remission
C88.2, C88.3, C88.8, C88.9, C90.20, C90.30 Other immunoproliferative neoplasms without mention of remission
C91.00 Acute lymphoid leukemia without mention of remission
C91.10, C91.90 Chronic lymphoid leukemia without mention of remission
C91.Z0 Subacute myeloid leukemia without mention of remission
C91.30, C91.50, C91.60, C91.A0, C91.Z0 Lymphoid leukemia without mention of remission, other
C91.90 Lymphoid leukemia without mention of remission, unspecified
C92.00, C92.40, C92.50, C92.60, C92.90, C92.A0 Acute myeloid leukemia without mention of remission
C92.10 Chronic myeloid leukemia without mention of remission
C84.10, C84.19 Subacute myeloid leukemia without mention of remission
C92.30 Myeloid sarcoma without mention of remission, other
C92.Z0 Myeloid leukemia without mention of remission
C92.90 Myeloid leukemia without mention of remission, unspecified
C93.00 Acute monocytic leukemia without mention of remission
C93.10 Chronic monocytic leukemia without mention of remission
C93.90 Subacute monocytic leukemia without mention of remission
C93.30, C93.Z0 Monocytic leukemia without mention of remission, other
C94.00 Acute erythremia and erythroleukemia without mention of remission
D45,L53.8 Chronic erythremia without mention of remission
C94.20 Megakaryocytic leukemia without mention of remission
C94.30, C94.80 Specified leukemia without mention of remission, other
C95.00 Acute leukemia unspecified cell type without mention of remission
C95.10 Chronic leukemia of unspecified cell type without mention of remission
C95.90 Subacute leukemia of unspecified cell type without mention of remission
C95.90 Leukemia of unspecified cell type without mention of remission, other
C95.90 Leukemia without mention of remission, unspecified
Bladder Cancer
C67.0 Malignant neoplasm of trigone of urinary bladder
C67.1 Malignant neoplasm of dome of urinary bladder
C67.2 Malignant neoplasm of lateral wall of urinary bladder
C67.3 Malignant neoplasm of anterior wall of urinary bladder
C67.4 Malignant neoplasm of posterior wall of urinary bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of other specified sites of bladder
C67.9 Malignant neoplasm of bladder, part unspecified
D09.0 Carcinoma in situ of bladder
Lung Cancer
C34.00, C34.01, C34.02 Malignant neoplasm of main bronchus
C34.10, C34.11, C34.12 Malignant neoplasm of upper lobe, bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30, C34.31, C34.32 Malignant neoplasm of lower lobe, bronchus or lung
C34.80, C34.81, C34.82 Malignant neoplasm of other parts of bronchus or lung
C34.90, C34.91, C34.92 Malignant neoplasm of bronchus and lung, unspecified
C78.00, C78.01, C78.02 Secondary malignant neoplasm of lung
D02.20, D02.21, D02.22 Carcinoma in situ of bronchus and lung
Brain Cancer
ICD-10 Codes Description
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.9 Malignant neoplasm of brain, unspecified
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of ventricles
C71.6 Malignant neoplasm of cerebellum nitric oxide synthase (NOS)
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of other parts of brain
C70.0, C70.9 Malignant neoplasm of cerebral meninges
C79.31, C79.49 Secondary malignant neoplasm of brain and spinal cord
Prostate Cancer
C61 Malignant neoplasm of prostate
D07.5 Carcinoma in situ of prostate
Traumatic Brain Injury
S09.10XA, S09.11XA, S09.19XA, S09.8XXA, S09.90XA Head injury, unspecified
Intracranial Injury
S06.5X0A Subdural hemorrhage following injury without open intracranial wound without loss of consciousness
S06.5X1A, S06.5X2A Subdural hemorrhage following injury without open intracranial wound with brief (<1 hour) loss of consciousness
S06.5X3A, S06.5X4A Subdural hemorrhage following injury without open intracranial wound with moderate (1 to 24 hours) loss of consciousness
S06.5X5A Subdural hemorrhage following injury without open intracranial wound with prolonged (>24 hours) loss of consciousness, returned consciousness
S06.5X6A, S06.5X7A, S06.5X8A Subdural hemorrhage following injury without open intracranial wound with prolonged (>24 hours) loss of consciousness, without return of consciousness
S06.5X9A Subdural hemorrhage following injury without open intracranial wound with loss of consciousness, unspecified duration
S06.5X0A, S06.5X9A Subdural hemorrhage following injury without open intracranial wound with concussion, unspecified
S06.90A Other or unspecified intracranial injury without open intracranial wound unspecified utate consciousness
Sickle Cell Disease
ICD-10 Codes Description
D57, D57.0, D57.00, D57.01, D57.02 Sickle cell with crisis
D57.219 Sickle cell, unspecified
D57.3 Sickle cell trait
Pulmonary Hypertension
I27.0 Primary pulmonary hypertension
Heart Failure
I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 Congestive heart failure (CHF), unspecified
I50.1 Left heart failure
I50.20 Systolic heart failure
I50.20 Systolic heart failure, unspecified
I50.21 Acute systolic heart failure
I50.22 Chronic systolic heart failure
I50.23 Acute or chronic systolic heart failure
I50.30 Diastolic heart failure
I50.30 Diastolic heart failure, unspecified
I50.31 Acute diastolic heart failure
I50.32 Chronic diastolic heart failure
I50.33 Acute or chronic diastolic heart failure
I50.40 Combined systolic and diastolic heart failure
I50.40 Combined systolic and diastolic heart failure, unspecified
I50.41 Acute combined systolic and diastolic heart failure
I50.42 Chronic combined systolic and diastolic heart failure
I50.43 Acute or chronic combined systolic and diastolic heart failure
I50.9 Heart failure, unspecified
Transient Cerebral Ischemia
G45.0 Transient cerebral ischemia
G45.1, G45.2, G45.8, G46.0, G46.1, G46.2 Other specified transient cerebral ischemias
G45.9, I67.841, I67.848 Transient cerebral ischemia, unspecified
Cerebral Vascular Accident
I67.89 Acute but ill-defined cerebrovascular disease
I67.2 Other and ill-defined cerebrovascular disease
I69.01, I69.11, I69.21, I69.31, I69.81, I69.91 Late effects of cerebrovascular disease
S06.5X0A Subdural hemorrhage following injury without open intracranial wound with state of consciousness, unspecified
Chronic Obstructive Pulmonary Disease
ICD-10 Codes Description
J43.9 Emphysema
J43.0,J43.1,J43.2,J43.8,J43.9 Other emphysema
J44.9 Chronic obstructive asthma
J44.9 Chronic obstructive asthma, unspecified
J44.0 Chronic obstructive asthma with status asthmaticus
J44.1 Chronic obstructive asthma with (acute) exacerbation
J44.9 Chronic airway obstruction not elsewhere classified
Hip Fracture
M80.00XA, M80.80XA, M84.40XA, M84.50XA, M84.60XA Pathological fracture of neck of femur
M80.051A, M80.052A, M80.059A, M80.851A, M080.852A, M80.859A, M84.451A, M84.452A, M84.459A, M84.551A, M84.552A, M84.553A, M84.559A, M84.651A, M84.652A, M84.653A, M84.659A Pathological fracture of neck of femur
S72.001A, S72.002A, S72.009A Fracture of unspecified part of neck of femur,closed
S72.001B, S72.001C, S72.002B, S72.002C, S72.009B, S72.009C Fracture of unspecified part of neck of femur, open
Limb Amputation
Z89.201,Z89.202,Z89.209,Z89.9 Upper limb amputation status
Z89.201,Z89.202,Z89.209,Z89.9 Level upper limb amputation status, unspecified
Z89.011,Z89.012,Z89.019 Thumb amputation status
Z89.021,Z89.022,Z89.029 Other finger(s) amputation status
Z89.111,Z89.112,Z89.119 Hand amputation status
Z89.121,Z89.122,Z89.129 Wrist amputation status
Z89.211,Z89.212,Z89.219 Below elbow amputation status
Z89.221,Z89.222,Z89.229 Above elbow amputation status
Z89.231,Z89.232,Z89.239 Shoulder amputation status
Z89.9 Lower limb amputation status
Z89.9 Unspecified level lower limb amputation status
Z89.411,Z89.412,Z89.419 Great toe amputation status
Z89.421,Z89.422,Z89.429 Other toe(s) amputation status
Z89.431,Z89.432,Z89.439 Foot amputation status
Z89.441,Z89.442,Z89.449 Ankle amputation status
Z89.511,Z89.512,Z89.519 Below knee amputation status
Z89.611,Z89.612,Z89.619 Above knee amputation status
Z89.621,Z89.622,Z89.629 Hip amputation status
Spinal Cord Injury
ICD-10 Codes Description
S14.101A, S14.102A, S14.103A, S14.104A Spinal cord injury without evidence of spinal bone injury
S14.101A, S14.102A, S14.103A, S14.104A Cervical spinal cord injury without evidence of spinal bone injury
S14.101A, S14.102A, S14.103A, S14.104A C1-C4 level spinal cord injury, unspecified
S14.111A, S14.112A, S14.113A, S14.114A C1-C4 level with complete lesion of spinal cord
S14.113A, S14. S14.132A, S14.133A, S14.134A C1-C4 level with anterior cord syndrome
S14.121A, S14.122A, S14.123A, S14.124A C1-C4 level with central cord syndrome
S14.0XXA, S14.141A, S14.142A, S14.143A, S14.144A, S14.151A, S14.152A, S14.153A, S14.154A C1-C4 level with other specified spinal cord injury
S14.105A, S14.106A, S14.107A, S14.108A C5-C7 level spinal cord injury, unspecified
S14.115A, S14.116A, S14.117A, S14.118A C5-C7 level with complete lesion of spinal cord
S14.135A, S14.136A, S14.137A, S14.138A C5-C7 level with anterior cord syndrome
S14.125A, S14.126A, S14.127A, S14.128A C5-C7 level with central cord syndrome
S14.0XXA, S14.145A, S14.146A, S14.147A, S14.148A, S14.155A, S14.156A, S14.157A, S14.158A C5-C7 level with other specified spinal cord injury
S24.101A, S24.102A Dorsal (thoracic) spinal cord injury without evidence of spinal bone injury
S24.101A, S24.102A T1-T6 level spinal cord injury, unspecified
S24.111A, S24.112A T1-T6 level with complete lesion of spinal cord
S24.131A, S24.132A T1-T6 level with anterior cord syndrome
S24.151A, S24.152A T1-T6 level with central cord syndrome
S24.0XXA, S24.141A, S24.142A, S24.151A, S24.152A T1-T6 level with other specified spinal cord injury
S24.103A, S24.104A T7-T12 level spinal cord injury, unspecified
S24.113A, S24.114A T7-T12 level with complete lesion of spinal cord
S24.133A, S24.134A T7-T12 level with anterior cord syndrome
S24.153A, S24.154A T7-T12 level with central cord syndrome
S24.0XXA, S24.143A, S24.144A, S24.153A, S24.154A T7-T12 level with other specified spinal cord injury
S34.01XA, S34.101A, S34.102A, S34.103A, S34.104A, S34.105A, S34.109A, S34.111A, S34.112A, S34.113A, S34.114A, S34.115A, S34.119A, S34.121A, S34.122A, S34.23A, S34.124A, S34.125A, S34.129A Lumbar spinal cord injury without spinal bone injury
S34.02XA, S34.131A, S34.132A, S34.139A Sacral spinal cord injury without spinal bone injury
S34.3XXA Cauda equina spinal cord injury without spinal bone injury
S34.139A Multiple sites of spinal cord injury without spinal bone injury
S14.109A, S14.119A, S14.139A, S14.149A, S14.159A, S24.109A, S24.119A, S24.139A, S24.149A, S24.159A, S34.109A, S34.139A Site of spinal cord injury without spinal bone injury, unspecified