Excluded pediatric codes
The following pediatric diagnosis codes are excluded from the physical medicine and therapies
component of our Physical Medicine program for members aged 17 and younger. Services are
subject to benefit limitations.
Code
Description
Code
Description
D82.1
E75.00
E75.01
Di George's syndrome
GM2 gangliosidosis, unspecified
Sandhoff disease
Q03.8
Q03.9
Q030
E75.02
Tay-Sachs disease
Q031
E75.09
E75.10
Other GM2 gangliosidosis
Unspecified gangliosidosis
Q038
Q039
E75.11
Mucolipidosis IV
Q04.0
E75.19
E75.23
E75.25
E75.29
E75.4
E78.71
Other gangliosidosis
Krabbe disease
Metachromatic leukodystrophy
Other sphingolipidosis
Neuronal ceroid lipofuscinosis
Barth syndrome
Q04.1
Q04.2
Q04.3
Q04.4
Q04.5
Q04.6
E78.72
Smith-Lemli-Opitz syndrome
Q04.8
F70
Mild intellectual disabilities
Q04.9
F71
F72
F73
F78
F79
Moderate intellectual disabilities
Severe intellectual disabilities
Profound intellectual disabilities
Other intellectual disabilities
Unspecified intellectual disabilities
Specific developmental disorder of motor
function
Specific developmental disorder of motor
function
Autistic disorder
Autistic disorder
Rett's syndrome
Rett's syndrome
Other childhood disintegrative disorder
Asperger's syndrome
Other pervasive developmental disorders
Pervasive developmental disorder,
unspecified
Other disorders of psychological
development
Unspecified disorder of psychological
development
Unspecified behavioral and emotional
disorders with onset usually occurring in
childhood and adolescence
Q044
Q045
Q05.0
Q05.1
Q05.2
Other congenital hydrocephalus
Congenital hydrocephalus, unspecified
Malformations of aqueduct of Sylvius
Atresia of foramina of Magendie and
Luschka
Other congenital hydrocephalus
Congenital hydrocephalus, unspecified
Congenital malformations of corpus
callosum
Arhinencephaly
Holoprosencephaly
Other reduction deformities of brain
Septo-optic dysplasia of brain
Megalencephaly
Congenital cerebral cysts
Other specified congenital malformations of
brain
Congenital malformation of brain,
unspecified
Septo-optic dysplasia of brain
Megalencephaly
Cervical spina bifida with hydrocephalus
Thoracic spina bifida with hydrocephalus
Lumbar spina bifida with hydrocephalus
Q05.2
Lumbar spina bifida with hydrocephalus
Q05.3
Sacral spina bifida with hydrocephalus
Q05.4
Q05.5
Q05.6
Q05.7
Unspecified spina bifida with hydrocephalus
Cervical spina bifida without hydrocephalus
Thoracic spina bifida without hydrocephalus
Lumbar spina bifida without hydrocephalus
Sacral spina bifida without hydrocephalus
Spina bifida, unspecified
Spina bifida, unspecified
Congenital malformation of spinal cord,
unspecified
Arnold-Chiari syndrome without spina bifida
or hydrocephalus
F82
F82
F84.0
F84.0
F84.2
F84.2
F84.3
F84.5
F84.8
F84.9
F88
F89
F98.9
G11.1
Early-onset cerebellar ataxia
Revised May 17, 2017
Q05.8
Q05.9
Q05.9
Q06.9
Q07.00
Q07.01
Arnold-Chiari syndrome with spina bifida
Q07.0
2
Arnold-Chiari syndrome with hydrocephalus
Q07.0
3
Arnold-Chiari syndrome with spina bifida
and hydrocephalus
G12.0
Infantile spinal muscular atrophy, type I
[Werdnig-Hoffman]
Q07.9
G12.1
Other inherited spinal muscular atrophy
Q90.1
G31.84
G71.0
Mild cognitive impairment, so stated
Muscular dystrophy
Q90.2
Q90.9
G71.0
Muscular dystrophy
Q900
G71.11
Myotonic muscular dystrophy
Q91.0
G71.12
Myotonia congenita
Q91.1
G71.13
G71.14
Myotonic chondrodystrophy
Drug induced myotonia
Q91.2
Q91.3
G71.19
Other specified myotonic disorders
Q91.4
G71.2
Congenital myopathies
Q91.5
G80.0
G80.0
Spastic quadriplegic cerebral palsy
Spastic quadriplegic cerebral palsy
Q91.6
Q91.7
G80.1
Spastic diplegic cerebral palsy
Q920
G80.1
Spastic diplegic cerebral palsy
Q921
G80.2
Spastic hemiplegic cerebral palsy
Q922
G80.2
Spastic hemiplegic cerebral palsy
Q925
G80.4
Ataxic cerebral palsy
Q9261
G80.4
Ataxic cerebral palsy
Q9262
G80.8
Other cerebral palsy
Q927
G80.8
Other cerebral palsy
Q928
G80.8
Other cerebral palsy
Q929
G80.9
G80.9
G91.0
Cerebral palsy, unspecified
Cerebral palsy, unspecified
Communicating hydrocephalus
Q93.3
Q93.4
Q93.5
G91.1
Obstructive hydrocephalus
Q93.7
G91.3
Post-traumatic hydrocephalus,
unspecified
G91.8
Other hydrocephalus
G91.9
Hydrocephalus, unspecified
Q93.8
1
Q93.8
8
Q93.8
9
G93.1
Anoxic brain damage, not elsewhere
classified
Q93.9
G93.40
Encephalopathy, unspecified
Q930
G93.5
Compression of brain
Q931
Revised May 17, 2017
Congenital malformation of nervous
system, unspecified
Trisomy 21, mosaicism (mitotic
nondisjunction)
Trisomy 21, translocation
Down syndrome, unspecified
Trisomy 21, nonmosaicism (meiotic
nondisjunction)
Trisomy 18, nonmosaicism (meiotic
nondisjunction)
Trisomy 18, mosaicism (mitotic
nondisjunction)
Trisomy 18, translocation
Trisomy 18, unspecified
Trisomy 13, nonmosaicism (meiotic
nondisjunction)
Trisomy 13, mosaicism (mitotic
nondisjunction)
Trisomy 13, translocation
Trisomy 13, unspecified
Whole chromosome trisomy, nonmosaicism
(meiotic nondisjunction)
Whole chromosome trisomy, mosaicism
(mitotic nondisjunction)
Partial trisomy
Duplications with other complex
rearrangements
Marker chromosomes in normal individual
Marker chromosomes in abnormal
individual
Triploidy and polyploidy
Other specified trisomies and partial
trisomies of autosomes
Trisomy and partial trisomy of autosomes,
unspecified
Deletion of short arm of chromosome 4
Deletion of short arm of chromosome 5
Other deletions of part of a chromosome
Deletions with other complex
rearrangements
Velo-cardio-facial syndrome
Other microdeletions
Other deletions from the autosomes
Deletion from autosomes, unspecified
Whole chromosome monosomy,
nonmosaicism (meiotic nondisjunction)
Whole chromosome monosomy, mosaicism
(mitotic nondisjunction)
G93.7
Reye's syndrome
Q932
G93.89
Other specified disorders of brain
Q952
G93.9
Disorder of brain, unspecified
Q953
G93.9
Q99.2
Q998
Other specified chromosome abnormalities
Q999
Chromosomal abnormality, unspecified
R62.0
Delayed milestone in childhood
Q01.0
Disorder of brain, unspecified
Disorder of central nervous system,
unspecified
Other disorders of nervous system
Preterm newborn, unspecified weeks of
gestation
Hydrops fetalis not due to hemolytic
disease
Frontal encephalocele
Chromosome replaced with ring, dicentric
or isochromosome
Balanced autosomal rearrangement in
abnormal individual
Balanced sex/autosomal rearrangement in
abnormal individual
Fragile X chromosome
Q01.1
Nasofrontal encephalocele
R62.59
Q01.2
Occipital encephalocele
R620
Q01.8
Encephalocele of other sites
R6250
Q01.9
Encephalocele, unspecified
R6251
Q02
Microcephaly
R6259
Q03.0
Malformations of aqueduct of Sylvius
Atresia of foramina of Magendie and
Luschka
R633
T74.4X
XA
T74.4X
XD
G96.9
G98.8
P0730
P83.2
Q03.1
Revised May 17, 2017
R62.50
R62.51
Unspecified lack of expected normal
physiological development in childhood
Failure to thrive (child)
Other lack of expected normal physiological
development in childhood
Delayed milestone in childhood
Unspecified lack of expected normal
physiological development in childhood
Failure to thrive (child)
Other lack of expected normal physiological
development in childhood
Feeding difficulties
A Shaken infant syndrome, initial encounter
D Shaken infant syndrome, subsequent
encounter