"Kentucky Checklist for the Identification of Moderate to Severe Substance Use" - Kentucky

Kentucky Checklist for the Identification of Moderate to Severe Substance Use 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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  • Released on February 28, 2020;
  • The latest edition currently provided by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities;
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Kentucky Checklist for the Identification of Moderate to Severe Substance Use
______________________________
___________________________ _________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to receive targeted case
management for Substance Use Disorder (Moderate, Severe).
CRITERIA
YES
NO
1. Diagnosis (please circle diagnoses)
Individual meets criteria for one or more of the specific Substance Use Disorder diagnoses listed
below, as designated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition:
Alcohol-Related Disorders
Alcohol Use Disorder-Moderate
303.90
Alcohol Use Disorder-Severe
303.90
Cannabis-Related Disorders
Cannabis Use Disorder-Moderate
304.30
Cannabis Use Disorder-Severe
304.30
Hallucinogen-Related Disorders
Phencyclidine Use Disorder-Moderate
304.60
Phencyclidine Use Disorder-Severe
304.60
Other Phencyclidine Use Disorder-Moderate
304.50
Other Phencyclidine Use Disorder-Severe
304.50
Inhalant-Related Disorders
Inhalant Use Disorder-Moderate
304.60
Inhalant Use Disorder-Severe
304.60
Opioid-Related Disorders
Opioid Use Disorder-Moderate
304.00
Opioid Use Disorder-Severe
304.00
Sedative-,Hypnotic-,or Anxiolytic-Related Disorders
Sedative, Hypnotic, or Anxiolytic Use Disorder-
304.10
Moderate
Sedative, Hypnotic, or Anxiolytic Use Disorder-Severe
304.10
Stimulant-Related Disorders
Amphetamine-type substance-Moderate
304.40
Cocaine-Moderate
304.20
Other or unspecified stimulant-Moderate
304.40
Amphetamine-type substance-Severe
304.40
Cocaine-Severe
304.20
Other or unspecified stimulant-Severe
304.40
Other (or Unknown) Substance-Related Disorders
Other (or Unknown) Substance-Related Use
304.90
Disorder-Moderate
Other (or Unknown) Substance-Related Use
304.90
Disorder-Severe
This individual meets the criteria for the status of Substance Use Disorder (Moderate, Severe).
Documentation of the existence of these criteria 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
Kentucky Checklist for the Identification of Moderate to Severe Substance Use
______________________________
___________________________ _________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to receive targeted case
management for Substance Use Disorder (Moderate, Severe).
CRITERIA
YES
NO
1. Diagnosis (please circle diagnoses)
Individual meets criteria for one or more of the specific Substance Use Disorder diagnoses listed
below, as designated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition:
Alcohol-Related Disorders
Alcohol Use Disorder-Moderate
303.90
Alcohol Use Disorder-Severe
303.90
Cannabis-Related Disorders
Cannabis Use Disorder-Moderate
304.30
Cannabis Use Disorder-Severe
304.30
Hallucinogen-Related Disorders
Phencyclidine Use Disorder-Moderate
304.60
Phencyclidine Use Disorder-Severe
304.60
Other Phencyclidine Use Disorder-Moderate
304.50
Other Phencyclidine Use Disorder-Severe
304.50
Inhalant-Related Disorders
Inhalant Use Disorder-Moderate
304.60
Inhalant Use Disorder-Severe
304.60
Opioid-Related Disorders
Opioid Use Disorder-Moderate
304.00
Opioid Use Disorder-Severe
304.00
Sedative-,Hypnotic-,or Anxiolytic-Related Disorders
Sedative, Hypnotic, or Anxiolytic Use Disorder-
304.10
Moderate
Sedative, Hypnotic, or Anxiolytic Use Disorder-Severe
304.10
Stimulant-Related Disorders
Amphetamine-type substance-Moderate
304.40
Cocaine-Moderate
304.20
Other or unspecified stimulant-Moderate
304.40
Amphetamine-type substance-Severe
304.40
Cocaine-Severe
304.20
Other or unspecified stimulant-Severe
304.40
Other (or Unknown) Substance-Related Disorders
Other (or Unknown) Substance-Related Use
304.90
Disorder-Moderate
Other (or Unknown) Substance-Related Use
304.90
Disorder-Severe
This individual meets the criteria for the status of Substance Use Disorder (Moderate, Severe).
Documentation of the existence of these criteria 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