office of the assistant secretary of defense...

DEFENSE HEAL TH AG ENC

MB&RS

OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE HEALTH AFFAIRS

16401 EASTCENTRETECH PARKWAY AURORA, CO 80011-9066

CHANGE 139 6010.57-M AUGUST 20, 2015

PUBLICATIONS SYSTEM CHANGE TRANSMITTAL FOR

TRICARE POLICY MANUAL (TPM}, FEBRUARY 2008

The TRICARE Management Activity has authorized the following addition(s}/revision(s).

CHANGE TITLE: AMENDMENTS TO COMPREHENSIVE AUTISM DEMONSTRATION

CONREO: 17493

PAGE CHANGE(Sl: See page 2.

SUMMARY OF CHANGE(Sl: Updated to reflect Autism Spectrum Disorder (ASD) and the ICD-10 code.

EFFECTIVE DATE: September 1, 2015.

IMPLEMENTATION DATE: October 1, 2015.

This change is made in conjunction with Feb 2008 TOM, Change No. 148.

ATTACHMENT(S): DISTRIBUTION:

10 PAGE(S) 6010.57-M

Digitally signed by c 0 RN.GLENN COR~.GLEN_N . J . 1157445967 DN. c-US, o-U.S. Government,

J 1157445967 ou=DoD, ou=PKI , ou=DHA, • • cn=CORN.GLENN.J.1157445967

Date: 2015.08.18 10:55:38 -06'00'

Ann N. Fazzini Team Chief, Medical Benefits & Reimbursement Section (MB&RS) Defense Health Agency (DHA)

WHEN PRESCRIBED ACTION HAS BEEN TAKEN, FILE THIS TRANSMITTAL WITH BASIC DOCUMENT.

CHANGE 1396010.57-MAUGUST 20, 2015

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REMOVE PAGE(S) INSERT PAGE(S)

CHAPTER 9

Section 2.3, pages 1 and 2 Section 2.3, pages 1 and 2

APPENDIX A

pages 1 - 4, 25 - 28 pages 1 - 4, 25 - 28

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TRICARE Policy Manual 6010.57-M, February 1, 2008Extended Care Health Option (ECHO)

Chapter 9 Section 2.3

Eligibility - Qualifying Condition: Serious Physical Disability

Issue Date: July 3, 1997Authority: 32 CFR 199.5(b)(2)(ii), 10 USC 1079(d)(3)

1.0 POLICY

1.1 Any physiological disorder or condition or anatomical loss affecting one or more body systems which has lasted, or with reasonable certainty is expected to last, for a minimum period of 12 contiguous months, and which precludes the person with the disorder, condition or anatomical loss from unaided performance of at least one of the following major life activities is an Extended Health Care Option (ECHO) qualifying condition: breathing, cognition, hearing, seeing, and age appropriate ability essential to bathing, dressing, eating, grooming, speaking, stair use, toilet use, transferring, and walking.

1.2 For a beneficiary less than three years of age, a developmental delay qualifies as a serious physical disability when the score on the standardized diagnostic psychometric tests of motor function is 2 standard deviations below the mean.

1.3 Serious physical disabilities include, but are not limited to the following conditions (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes cited for services provided before the mandated date, as directed by Health and Human Services (HHS), for International Classification of Diseases, 10th Revision (ICD-10) implementation or ICD-10-CM codes cited for services provided on or after the mandated date, as directed by HHS, for ICD-10 implementation) for the purpose of establishing an ECHO qualifying condition:

1.3.1 Infantile Cerebral Palsy: ICD-9-CM 343.0 - 343.9 / ICD-10-CM G80.0 - G80.9.

1.3.2 Spina Bifida: ICD-9-CM 741.0 - 741.93 / ICD-10-CM Q05.0 - Q05.9.

1.3.3 Vision: ICD-9-CM 369.01 - 369.08 inclusive; 369.11 - 369.14 inclusive; 369.21; 369.22; 369.4 / ICD-10-CM H54.0 - H54.12 inclusive; H54.8.

1.3.4 Hearing-Testable Patients: as determined by audiologic function tests:

• A pure tone hearing threshold level of 45 decibels or greater in one ear; or by• A pure tone hearing threshold level of 30 decibels or greater in both ears; or by• Speech discrimination of 60% or poorer with either ear.

1.3.5 Hearing-Non-Testable Patients: Where pure tone audiometry or speech discrimination testing is not available or reliable, the attending physician must submit documentation which

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TRICARE Policy Manual 6010.57-M, February 1, 2008Chapter 9, Section 2.3

Eligibility - Qualifying Condition: Serious Physical Disability

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demonstrates the patient is unable to engage in basic productive activities of daily living expected of unimpaired persons of the same age group.

1.3.6 Breathing: Total reliance upon a respirator.

1.3.7 Acquired or congenital total loss, or loss of use, of an arm or leg.

1.3.8 Autism Spectrum Disorder (ASD): ICD-10-CM F84.0, (Autistic Disorder).

1.3.9 Multiple Sclerosis (MS): ICD-9-CM 340.

2.0 EFFECTIVE DATE

September 1, 2005.

- END -

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TRICARE Policy Manual 6010.57-M, February 1, 2008

Appendix A

Acronyms And Abbreviations

AA Anesthesiologist AssistantAA&E Arms, Ammunition and ExplosivesAAA Abdominal Aortic AneurysmAAAHC Accreditation Association for Ambulatory Health Care, Inc.AAFES Army/Air Force Exchange ServiceAAMFT American Association for Marriage and Family TherapyAAP American Academy of PediatricsAAPC American Association of Pastoral CounselorsAARF Account Authorization Request FormAATD Access and Authentication Technology DivisionABA American Banking Association

Applied Behavior AnalysisABAT Applied Behavior Analysis TechnicianABMT Autologous Bone Marrow TransplantABPM Ambulatory Blood Pressure MonitoringABR Auditory Brainstem ResponseAC Active ComponentACA Affordable Care ActACD Augmentative Communication DevicesACE Angiotensin-Converting EnzymeACH Automated Clearing HouseACI Autologous Chondrocyte ImplantationACIP Advisory Committee on Immunization PracticesACO Administrative Contracting OfficerACOG American College of Obstetricians and GynecologistsACOR Administrative Contracting Officer’s RepresentativeACP American College of PhysiciansACS American Cancer SocietyACSC Ambulatory Care Sensitive ConditionACSP Autism Demonstration Corporate Services ProviderACTUR Automated Central Tumor Registry2AD Active DutyADA American Dental Association

American Diabetes AssociationAmericans with Disabilities Act

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ADAMHA Alcohol, Drug Abuse, And Mental Health AdministrationADAMHRA Alcohol, Drug Abuse, And Mental Health Reorganization ActADCP Active Duty Claims ProgramADD Active Duty DependentADDP Active Duty Dental ProgramADFM Active Duty Family MemberADH Atypical Ductal HyperplasiaADL Activities of Daily LivingADP Automated Data ProcessingADSM Active Duty Service MemberAF Atrial FibrillationAFAP Attenuated Familial Adenomatous PolyposisAFB Air Force BaseAFOSI Air Force Office of Special InvestigationsAFS Ambulance Fee ScheduleAGR Active Guard/ReserveAHA American Hospital AssociationAHCB American Hippotherapy Certification BoardAHLTA Armed Forces Health Longitudinal Technology ApplicationAHRQ Agency for Healthcare Research and QualityAI Administrative InstructionAIDS Acquired Immune Deficiency SyndromeAIF Ambulance Inflation FactorAIIM Association for Information and Image ManagementAIS Ambulatory Infusion Suite

Automated Information SystemsAIX Advanced IBM UnixAJ Administrative JudgeALA Annual Letter of AssuranceALB All Lines BusyALH Atypical Lobular HyperplasiaALL Acute Lymphocytic LeukemiaALOS Average Length-of-StayALS Action Lead Sheet

Advanced Life SupportALT Autolymphocyte TherapyAM&S Acquisition Management and Support (Directorate)AMA Against Medical Advice

American Medical AssociationAMCB American Midwifery Certification BoardAMH Accreditation Manual for HospitalsAMHCA American Mental Health Counselor AssociationANCC American Nurses Credentialing Center

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AML Acute Myelogenous [Myeloid] LeukemiaANSI American National Standards InstituteAOA American Osteopathic AssociationAPA American Psychiatric Association

American Podiatry AssociationAPC Adenomatous Polyposis Coli

Ambulatory Payment ClassificationAPI Application Program InterfaceAPN Assigned Provider NumberAPO Army Post OfficeARB Angiotensin Receptor BlockerARCIS Archives and Records Centers Information SystemART Assisted Reproductive TechnologyARU Automated Response UnitARVC Arrhythmogenic Right Ventricular CardiomyopathyASA Adjusted Standardized Amount

American Society of AnesthesiologistsASAP Automated Standard Application for PaymentASC Accredited Standards Committee

Ambulatory Surgical CenterASCA Administrative Simplification Compliance ActASCUS Atypical Squamous Cells of Undetermind SignificanceASD Assistant Secretary of Defense

Atrial Septal DefectAutism Spectrum Disorder

ASD(C3I) Assistant Secretary of Defense for Command, Control, Communications, and Intelligence

ASD(HA) Assistant Secretary of Defense (Health Affairs)ASD (MRA&L) Assistant Secretary of Defense for Manpower, Reserve Affairs, and LogisticsASP Average Sale PriceASRM American Society for Reproductive MedicineATA American Telemedicine AssociationATB All Trunks BusyATO Approval to OperateAVM Arteriovenous MalformationAWOL Absent Without LeaveAWP Average Wholesale PriceB&PS Benefits and Provider ServicesB2B Business to BusinessBAA Business Associate AgreementBACB Behavior Analyst Certification BoardBART BRACAnalysis Large Rearrangement TestBBA Balanced Budget Act

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BBP Bloodborne PathogenBBRA Balanced Budget Refinement ActBC Birthing CenterBCaBA Board Certified Assistant Behavior Analyst BCAC Beneficiary Counseling and Assistance CoordinatorBCBA Board Certified Behavior AnalystBCBA-D Board Certified Behavior Analyst - DoctoralBCBS Blue Cross [and] Blue ShieldBCBSA Blue Cross [and] Blue Shield AssociationBCC Biostatistics CenterBE&SD Beneficiary Education and Support DivisionBH Behavioral HealthBI Background InvestigationBIA Bureau of Indian AffairsBIPA Benefits Improvement Protection ActBL Black LungBLS Basic Life SupportBMI Body Mass IndexBMT Bone Marrow TransplantationBNAF Budget Neutrality Adjustment FactorBOS Bronchiolitis Obliterans SyndromeBP Behavioral PlanBPPV Benign Paroxysmal Positional VertigoBPC Beneficiary Publication CommitteeBRAC Base Realignment and ClosureBRCA BReast CAncer (genetic testing)BRCA1/2 BReast CAncer Gene 1/2BS Bachelor of ScienceBSGI Breast-Specific Gamma ImagingBSID Bayley Scales of Infant DevelopmentBSR Beneficiary Service RepresentativeBT Behavior TechnicianBWE Beneficiary Web EnrollmentC&A Certification and AccreditationC&P Compensation and PensionC/S Client/ServerCA Care AuthorizationCA/NAS Care Authorization/Non-Availability StatementCABG Coronary Artery Bypass GraftCAC Common Access CardCACREP Council for Accreditation of Counseling and Related Educational ProgramsCAD Coronary Artery Disease

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PFCRA Program Fraud Civil Remedies ActPFP Partnership For PeacePFPWD Program for Persons with DisabilitiesPGD Preimplantation Genetic DiagnosisPhen-Fen Pondimin and ReduxPHI Protected Health InformationPHIMT Protected Health Information Management ToolPHP Partial Hospitalization ProgramPHS Public Health ServicePI Program Integrity (Office)PIA Privacy Impact Assessment (Online)PIC Personnel Investigation CenterPIE Pulsed Irrigation EvacuationPII Personally Identifiable InformationPIN Personnel Identification NumberPIP Personal Injury Protection

Personnel Identity ProtectionPIRFT Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)PIT PCM Information TransferPIV Personal Identity VerificationPK Public KeyPKE Public Key EnablingPKI Public Key InfrastructurePKU PhenylketonuriaPLS Preschool Language ScalesPM-DRG Pediatric Modified-Diagnosis Related GroupPMPM Per Member Per MonthPMR Percutaneous Myocardial Laser RevascularizationPNET Primitive Neuroectodermal TumorsPNT Policy Notification TransactionPOA Power of Attorney

Present On AdmissionPOA&M Plan of Action and MilestonesPOC Pharmacy Operations Center

Plan of CarePoint of Contact

POL May 1996 TRICARE/CHAMPUS Policy Manual 6010.47-MPOS Point of Sale (Pharmacy only)

Point of ServicePublic Official’s Statement

POV Privately Owned VehiclePPACA Patient Protection and Affordable Care ActPPC-PCMH Physician Practice Connections Patient-Centered Medical Home

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PPD Per Patient DayPPN Preferred Provider NetworkPPO Preferred Provider OrganizationPPP Purchasing Power ParityPPS Prospective Payment System

Ports, Protocols and ServicesPPSM Ports, Protocols, and Service ManagementPPV Pneumococcal Polysaccharide VaccinePQI Potential Quality Indicator

Potential Quality IssuePR Periodic ReinvestigationPRC Program Review CommitteePRFA Percutaneous Radiofrequency AblationPRG Peer Review GroupPRO Peer Review OrganizationProDUR Prospective Drug Utilization ReviewPROM Programmable Read-Only MemoryPRP Personnel Reliability ProgramPRPP Pharmacy Redesign Pilot ProjectPSA Prime Service Area

Physician Scarcity AreaPSAB Personnel Security Appeals BoardPSCT Peripheral Stem Cell TransplantationPSD Personnel Security DivisionPSF Provider Specific FilePSG PolysomnographyPSI Personnel Security InvestigationPST Pacific Standard TimePT Pacific Time

Physical TherapistPhysical TherapyProthrombin Time

PTA Pancreas Transplant AlonePercutaneous Transluminal Angioplasty

PTC Processed To CompletionPTCA Percutaneous Transluminal Coronary AngioplastyPTK Phototherapeutic KeratectomyPTNS Posterior Tibial Nerve StimulationPTSD Post-Traumatic Stress DisorderPVCs Premature Ventricular ContractionsQA Quality AssuranceQABA Qualified Applied Behavior AnalysisQASP Qualified Autism Services Practitioner

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QC Quality ControlQI Quality Improvement

Quality IssueQII Quality Improvement InitiativeQIO Quality Improvement OrganizationQIP Quality Improvement ProgramQLE Qualifying Life EventQM Quality ManagementQUIG Quality Indicator GroupRA Radiofrequency Annuloplasty

Remittance AdviceRADDP Remote Active Duty Dental ProgramRAM Random Access MemoryRAP Request for Anticipated PaymentRAPIDS Real-Time Automated Personnel Identification SystemRARC Remittance Advice Remark CodeRBT Registered Behavior TechnicianRC Reserve ComponentRCC Recurring Credit/Debit Charge

Renal Cell CarcinomaRCCPDS Reserve Component Common Personnel Data SystemRCN Recoupment Case Number

Refund Control NumberRCS Report Control SymbolRD Regional Director

Registered DietitianRDBMS Relational Database Management SystemRDDB Reportable Disease DatabaseREM Rapid Eye MovementRF RadiofrequencyRFA Radiofrequency AblationRFI Request For InformationRFP Request For ProposalRHC Rural Health ClinicRHHI Regional Home Health IntermediaryRhoGAM RRho (D) Immune GlobulinRIA RadioimmunoassayRM Records ManagementRN Registered NurseRNG Random Number GeneratorRO Regional OfficeROC Resumption of CareROFR Right of First Refusal

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ROM Read-Only MemoryRough Order of Magnitude

ROMF Record Object Metadata FileROT Read-Only TableROTC Reserved Officer Training CorpsROVER RHHI OASIS VerificationRPM Record Processing ModeRRA Regional Review AuthorityRRS Records Retention ScheduleRTC Residential Treatment CenterrTMS Repetitive Transcranial Magnetic StimulationRUG Resource Utilization GroupRV Residual Volume

Right Ventricle [Ventricular]RVU Relative Value UnitSAAR System Authorization Access RequestSAD Seasonal Affective DisorderSADMERC Statistical Analysis Durable Medical Equipment Regional CarrierSAFE Sexual Assault Forensic ExaminationSAMHSA Substance Abuse and Mental Health Services AdministrationSAO Security Assistant OrganizationsSAP Special Access ProgramSAPR Sexual Assault Prevention and ResponseSAS Sensory Afferent StimulationSAT Service Assist TeamSAVR Surgical Aortic Valve ReplacementSBCC Service Branch Classification CodeSBI Special Background InvestigationSCA Service Contract ActSCH Sole Community HospitalSCHIP State Children’s Health Insurance ProgramSCI Sensitive Compartmented Information

Spinal Cord InjurySCIC Significant Change in ConditionSCOO Special Contracts and Operations OfficeSCR Stem Cell RescueS/D Security DivisionSD (Form) Secretary of Defense (Form)SEP Sensory Evoked PotentialsSES Senior Executive ServiceSelRes Selected ReserveSF Standard FormSFTP Secure File Transfer Protocol

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