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
Below is a partial list 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 medical condition
- Acute or chronic medical condition associated with an unstable home environment or lack of a qualified caregiver
- End stage Disease Processes
- Cognitive rehabilitation
- Education on out-of-network utilization
- 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)
- Hospital readmission within 30 days, excluding planned admissions
- 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 plan or unstable disease process
- Multiple ER visits
- Neonatal intensive care unit (NICU)
- 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
- Cancer diagnosis
- 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
- Gender 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 may qualify for
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 |
| Other Malignancy Codes | |
| C00-C14 | Malignant neoplasm of lip, oral cavity and pharynx |
| C40-C41 | Malignant neoplasms of respiratory and intrathoracic organs |
| C73-C75 | Malignant neoplasms of eye, brain, and other parts of central nervous system |
| C81-C96 | Malignant neoplasms of thyroid and other endocrine glands |
| C81-C96 | Secondary neuroendocrine tumors |
| 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 |
Updated May 2020