"Kentucky Determination Criteria Checklist for Serious Mental Illness (Smi)" - Kentucky

Kentucky Determination Criteria Checklist for Serious Mental Illness (Smi) is a legal document that was released by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities - a government authority operating within Kentucky.

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Kentucky Determination Criteria Checklist for Serious Mental Illness (SMI)
Relates to KRS 210.005 and 907 KAR 15:060, 15:065, 15:050, and 15:055
___________________________ _______________________ ________________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as
seriously mentally ill (SMI). In order to designate an individual as SMI, all of the criteria in Sections
1, 2, 3 and 4 shall be met.
Please check the following criteria for age, diagnoses, disability and duration.
YES NO
CRITERIA
1. Age:
Is a person aged 18 years or over (calculated at the time of service)
AND
YES NO
2. Diagnosis (please circle applicable diagnosis)
Has one or more of the following mental health diagnoses as designated in the latest
edition of the Diagnostic and Statistical Manual of Mental Disorders:
Schizophrenia Spectrum and Other Psychotic Disorders
Delusional Disorder
297.1
F22
Schizophreniform Disorder
295.40
F20.81
Schizophrenia
295.90
F20.9
SchizoAffective Disorder
295.70
F25.0 Bipolar Type
F25.1 Depressive Type
Other Specified Schizophrenia Spectrum
298.8
F28
and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and
298.9
F29
Other Psychotic Disorder
Bipolar and Related Disorders
Bipolar I Disorder
296.41
F31.11 Mild, Manic
296.42,
F31.12 Manic
296.43
F31.13 Severe, Manic
296.51
F31.31 Mild, Depressed
296.52
F 31.32 Moderate,
Depressed
296.53
F31.4
Severe, Depressed
296.44
F31.2
With Psychosis,
Manic
296.45
F31.73 In Partial Remission,
Manic
296.40
F31.0 Unspecified, Manic
296.54
F31.5 With Psychosis,
2/28/2020
Kentucky Determination Criteria Checklist for Serious Mental Illness (SMI)
Relates to KRS 210.005 and 907 KAR 15:060, 15:065, 15:050, and 15:055
___________________________ _______________________ ________________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as
seriously mentally ill (SMI). In order to designate an individual as SMI, all of the criteria in Sections
1, 2, 3 and 4 shall be met.
Please check the following criteria for age, diagnoses, disability and duration.
YES NO
CRITERIA
1. Age:
Is a person aged 18 years or over (calculated at the time of service)
AND
YES NO
2. Diagnosis (please circle applicable diagnosis)
Has one or more of the following mental health diagnoses as designated in the latest
edition of the Diagnostic and Statistical Manual of Mental Disorders:
Schizophrenia Spectrum and Other Psychotic Disorders
Delusional Disorder
297.1
F22
Schizophreniform Disorder
295.40
F20.81
Schizophrenia
295.90
F20.9
SchizoAffective Disorder
295.70
F25.0 Bipolar Type
F25.1 Depressive Type
Other Specified Schizophrenia Spectrum
298.8
F28
and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and
298.9
F29
Other Psychotic Disorder
Bipolar and Related Disorders
Bipolar I Disorder
296.41
F31.11 Mild, Manic
296.42,
F31.12 Manic
296.43
F31.13 Severe, Manic
296.51
F31.31 Mild, Depressed
296.52
F 31.32 Moderate,
Depressed
296.53
F31.4
Severe, Depressed
296.44
F31.2
With Psychosis,
Manic
296.45
F31.73 In Partial Remission,
Manic
296.40
F31.0 Unspecified, Manic
296.54
F31.5 With Psychosis,
2/28/2020
Depressed
296.55
F31.75 In Partial
Remission,
Depressed
296.50
F31.30 Unspecified,
Depressed
Bipolar II Disorder
296.89
F31.81
Cyclothymic Disorder
301.13
F34.0
Other Specified Bipolar and Related
296.89
F31.89
Disorder
Unspecified Bipolar and Related Disorder
296.80
F31.9
Depressive Disorders
Major Depressive Disorder
296.21
F32.0 Mild,Single
296.31
F33.0 Mild, Recurrent
296.22
F32.1 Moderate, Single
296.32
F33.1 Moderate, Recurrent
296.23
F32.2 Severe, Single
296.33
F33.2 Severe, Recurrent
296.24
F32.3 With Psychosis, Single
296.34
F33.3 With Psychosis,
Recurrent
296.25
F32.4 In Partial Remission,
Single
296.35
F33.41 In Partial Remission,
Recurrent
296.20
F32.9 Unspecified, Single
296.30
F33.9 Unspecified,
Recurrent
Persistent Depressive Disorder
300.4
F34.1
(Dysthymia)
Other Specified Depressive Disorder
311
F32.8
Unspecified Depressive Disorder
311
F32.9
Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder
309.81
F43.10
AND
YES NO
3. Disability (Please circle domains with impairments)
Clear evidence of functional impairment in two or more of the following domains:
 Societal/Role Functioning: Functioning in the role most relevant to his/her
contribution to society and, in making that contribution, how well the person
maintains conduct within societal limits prescribed by laws, rules and strong social
mores.
 Interpersonal Functioning: How well the person establishes and maintains
personal relationships. Relationships include those made at work and in the family
settings as well as those that exist in other settings.
2/28/2020
 Daily Living/Personal Care Functioning: How well the person is able to care for
him/herself and provide for his/her own needs such as personal hygiene, food,
clothing, shelter and transportation. The capabilities covered are mostly those of
making reliable arrangements appropriate to the person’s age, gender and culture.
 Physical Functioning: Person’s general physical health, nutrition, strength,
abilities/disabilities and illnesses/injuries.
 Cognitive/Intellectual Functioning: Person’s overall thought processes,
capacity, style and memory in relation to what is common for the person’s age,
gender, and culture. Person’s response to emotional and interpersonal pressures
on judgments, beliefs and logical thinking should all be considered in making this
rating.
AND
YES NO
4. Duration (Please circle at least one duration condition)
One or more of these conditions of duration:
 Clinically significant symptoms of mental illness have persisted in the individual for
a continuous period of at least 2 (two) years.
 The individual has been hospitalized for mental illness more than once in the past 2
(two) years.
 There is a history of one or more episodes with marked disability and the illness is
expected to continue for a two-year period of time.
This individual meets the criteria for the designation of Serious Mental Illness (SMI). Documentation of the
existence of these criteria of Age, Diagnosis, Disability and Duration is present in the individual’s medical
record and assessment has been conducted by a qualified, licensed behavioral health professional.
__________________________/_____________________________
___________________
Print Name/Credentials
Signature
Date
2/28/2020
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