Children's Long-Term Support Functional Screen Diagnoses Cue Sheet

P-00920 (12/2021) Page 1 of 29

Children’s Long-Term Support Functional Screen

Diagnoses Cue Sheet

This alphabetical list of diagnoses indicates which box screeners should check on the Diagnoses table of

the Children’s Long-Term Support Functional Screen (CLTS FS). For every diagnosis, the screener

should:

1) See if it is listed in the CLTS FS Diagnoses Table and check relevant box on the table. Use the

search icon to help find the condition you are seeking.

2) If not on the CLTS FS Diagnoses Table, look for it in this Diagnoses Cue Sheet. If present here,

check the box(es) on CLTS FS Diagnosis Table as indicated. Also list the name of the specific

condition/syndrome/diagnosis in the note section on the Diagnosis page.

3) If the diagnosis is not listed in this Cue Sheet, then check Diagnoses Table “Other,” and write it in.

a) Do not write in a diagnosis in “Other” until after making sure it is not listed in the Functional

Screen or on this Cue Sheet.

b) Contact the CLTS FS Email if there is only one diagnosis and it is not listed on Cue Sheet

4) Do not guess which diagnoses on the CLTS FS diagnosis table to check. (See instructions.)

Screeners should ignore letters or numbers before or after diagnoses. You can also ignore the following

adjectives appearing before or after diagnoses:

Words to Ignore:

Active History of (check the diagnosis IF it is still current; see instructions)

Acute Idiopathic

Adolescent Intermittent

Bilateral, left, right, Mild, Moderate

Childhood Neonatal

Classic NOS (means “not otherwise specified”)

Congenital Primary

End Stage Secondary

General, generalized Severe

Genetic S/P status post (check the diagnosis IF it is still current; see instructions)

Juvenile Status post (check the diagnosis IF it is still current; see instructions)

Chronic Recurrent

Hereditary

Common Abbreviations:

FX Fracture R/O Rule Out

LLE left lower extremity (leg) RLE right lower extremity (leg)

LLL left lower lobe of lung RLL right lower lobe of lung

LUE left upper extremity (arm) RUE right upper extremity (arm)

LE Lower extremities (legs) RUL right upper lobe of lung

NOS not otherwise specified

For “Educational diagnosis of [anything]”: Include in Note Section, do not check a diagnosis

For “Possible diagnosis of [anything]”: Include in Note Section, do not check a diagnosis

For “Suspected diagnosis of [anything]”: Include in Note Section, do not check a diagnosis

For “Rule out diagnosis of [anything]”: Include in Note Section, do not check a diagnosis

For “Allergic to [anything]”: Allergy

P-00920 (12/2021) Page 2 of 29

Chromosomal Disorders:

 There are 23 pairs of chromosomes, 46 chromosomes in all

 Mind your ps and qs; chromosome deletions are often labeled as either [p] or [q].

 In medical reports it may be noted as a deletion or minus or [-]; these are all the same.

 If the medical report indicates the specific band, for example 11.21, this is not important for purposes

of this table.

 Unbalance and Unbalance Translocation are the same thing

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

10q deletion

Genetic / Chromosomal Disorder

AND

Developmental Delay

11;22 Unbalance Translocation (Robertsonian

Translocation)

Genetic / Chromosomal Disorder

AND

Developmental Delay

12p deletion Genetic / Chromosomal Disorder

18q deletion Genetic / Chromosomal Disorder

19 Unbalanced Translocation Genetic / Chromosomal Disorder

1p deletion Genetic / Chromosomal Disorder

1p36 Deletion Mosaic

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

1p36 Deletion Syndrome

Genetic / Chromosomal Disorder

AND

Cognitive Disability

1st Degree Heart Block Cardiac Condition

22q deletion Genetic / Chromosomal Disorder

22q13 Deletion Syndrome (Phelan-McDermid

Syndrome)

Genetic / Chromosomal Disorder

AND

Developmental Delay

4-Hydroxybutyric Aciduria (SSADH-D) Metabolic Disorder

4q deletion Genetic / Chromosomal Disorder

8p deletion Genetic / Chromosomal Disorder

9p deletion (Alfi Syndrome)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Abscess of Liver Liver Disease (Hepatic Failure, Cirrhosis)

Absence Of Corpus Callosum Brain Disorder (other than seizures)

Brain Damage

Achalasia Digestive System Disorder

Achilles Tendon Contractures Contracture / Connective Tissue Disorder

Achondroplasia Musculoskeletal Disorder

Acid Peptic Disease Digestive System Disorder

Acid Reflux Digestive System Disorder

Acidosis Metabolic Disorder

Acne Include in Note Section, no Diagnosis checked

Acquired Immune Deficiency Syndrome (AIDS)

Immune Deficiency (Do not include in notes due to

confidentiality)

Acrocallosal Syndrome Brain Disorder (other than seizures)

Brain Damage

Actinic Keratosis Skin Disease

Acute Disseminated Encephalomyelitis (ADEM) Brain Disorder (other than seizures)

Brain Damage

Acute Lymphocytic Leukemia (ALL) Cancer

Acute Myelocytic Leukemia (AML) Cancer

Adaptive Behavior Delay Include in Note Section, no Diagnosis checked

Addiction To [A Drug Other Than Nicotine or

Caffeine]

Substance-Related Disorder (must verify diagnosis)

Addison’s Disease Metabolic Disorder

Adenocarcinoma Cancer

Adjustment Disorder Adjustment Disorder (must verify diagnosis)

P-00920 (12/2021) Page 3 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Adrenal Hyperplasia Endocrine Disorder (not Diabetes)

Adrenal Insufficiency Endocrine Disorder (not Diabetes)

Adrenoleukodystrophy (ALD) Metabolic Disorder

Agenesis of the Corpus Collosum (ACC) Brain Disorder (other than seizures)

Brain Damage

Aggressive Behavior Disorder Include in Note Section, no Diagnosis checked

Agoraphobia Anxiety Disorder (must verify diagnosis)

Agranulocytosis Immune Deficiency

AIDS (Acquired Immune Deficiency Syndrome)

Immune Deficiency (Do not include in notes due to

confidentiality)

Akathesia (Legs Tighten Up) Neuromuscular Disorder

Alagille Syndrome Genetic / Chromosomal Disorder

Albinism Genetic / Chromosomal Disorder

Alcohol Related Neurodevelopmental Disorder Fetal Alcohol Syndrome / Effect

Alcoholism / Alcohol Abuse or Addiction Substance-Related Disorder (must verify diagnosis)

Alfi Syndrome (9p deletion)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Allergic to [anything] Allergy

Alopecia Include in Note Section, no Diagnosis checked

Alpha-1 Antitrypsin Deficiency Metabolic Disorder

Alport Syndrome Renal Failure or Other Kidney Disease

Alternating Hemiplegia Paralysis, Other than Spinal Cord Injury

Ambiguous Genitalia Congenital Abnormality

Ambloyopia (Lazy Eye) Include in Note Section, no Diagnosis checked

Amniotic Bands Syndrome Congenital Abnormality

Amputation / Missing Limb or Part of Limb Limb Missing, Severe Limb Abnormality, Arthrogryposis

Amyoplasia Musculoskeletal Disorder

Amyotrophic Lateral Sclerosis (ALS) Multiple Sclerosis

ALS

Anencephaly Brain Disorder (other than seizures)

Brain Damage

Angina Cardiac Condition

Anophthalmia Blind

Severely Visually Impaired

Anotia Congenital Abnormality

Anoxic Encephalopathy / Brain Syndrome Brain Disorder (other than seizures)

Brain Damage

Antiphospholipid Syndrome Immune Deficiency

AODA (Alcohol or Other Drug Abuse) Substance-Related Disorder (must verify diagnosis)

Aortic Sclerosis Cardiac Condition

Aortic Valve Disease / Disorder / Stenosis Cardiac Condition

Aperts Syndrome Genetic / Chromosomal Disorder

Aphasia (Expressive or Receptive) Neuromuscular Disorder

Aplasia Cutis Congenita

Skin Disease (if severe)

Include in Note Section, no

Diagnosis checked

Aplastic Anemia Anemia (e.g., Sickle Cell, Fanconi’s)

Apnea or Sleep Apnea Respiratory Condition (other than Asthma)

Apraxia / Apraxia of Speech Neuromuscular Disorder

Aqueductal Stenosis Brain Disorder (other than seizures)

Brain Damage

Arachnoid Cyst Brain Disorder (other than seizures)

Brain Damage

Arachnoid Cysts

Brain Disorder (other than siezures)

Brain Damage (if

cysts are in the brain), OR Include in Note Section, no

Diagnosis checked

Argininosuccinate Lyase Deficiency Metabolic Disorder

Arhinia Congenital Abnormality

Arnold Chiari Malformation Brain Disorder (other than seizures)

Brain Damage

Arrhythmia Cardiac Condition

P-00920 (12/2021) Page 4 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Arthogryposis (Multiplex) Limb Missing, Severe Limb Abnormality, Arthrogryposis

Articulation Disorder Include in Note Section, no Diagnosis checked

Aspiration Include in Note Section, no Diagnosis checked

Aspiration Pneumonia Infection – Current

Recurrent Infection

Asplenia Include in Note Section, no Diagnosis checked

Astigmatism Include in Note Section, no Diagnosis checked

Astrocytoma

Brain Disorder (other than seizures)

Brain Damage

AND

Cancer

Ataxia Neuromuscular Disorder

Ataxic Gait Neuromuscular Disorder

Atelectasis Respiratory Condition (other than Asthma)

Athetoid Cerebral Palsy Cerebral Palsy (other)

Atlantoaxial Instability (AAI) Include in Note Section, no Diagnosis checked

Atonic Bladder Genitourinary System Disorder

Atonic Colon Digestive System Disorder

Atonic Diplegia Neuromuscular Disorder

Atopic Dermatitis

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Atrial Fib / Fibrillation (A-Fib) Cardiac Condition

Atrial Septal Defect Cardiac Condition

Atrioventricular Canal / Endocardial Cushion Defect Cardiac Condition

Atr-X Syndrome Genetic / Chromosomal Disorder

Attachment Disorder

Post-Traumatic Stress or Acute Stress Disorder OR

Reactive Attachment Disorder

Auditory Comprehension Delays Neuromuscular Disorder

Auditory Neuropathy Neuromuscular Disorder

Auditory Processing Disorder Sensory Disorder (other than Blind

Deaf)

Autistic Tendencies Include in Note Section, no Diagnosis checked

Autoimmune Anti-MBP Immune Deficiency

Auto-Immune Disorder Immune Deficiency

Autoimmune Enteropathy

Immune Deficiency

AND

Digestive System Disorder

Autoimmune Lymphoproliferative Syndrome

(ALPS)

Immune Deficiency

Autonomic Dysreflexia / Hyper-Reflexia Neuromuscular Disorder

Autonomic Nervous System Dysfunction Neuromuscular Disorder

Autonomic Neuropathy Neuromuscular Disorder

AV Canal Defect Cardiac Condition

Avoidance Personality Traits Personality Disorder (must verify diagnosis)

Bacterial Meningitis Infection – Current

Recurrent Infection

Balanced Chromosome Translocation Include in Note Section, no Diagnosis checked

Balanced Translocation Karotype 46xy Include in Note Section, no Diagnosis checked

Balanitis Xerotica Obliterans

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Band Heterotopia

Seizure Disorder (if present)

Include in Note Section, no Diagnosis checked

Bannayan Riley Ruvalcaba Syndrome Genetic / Chromosomal Disorder

Basal Cell Carcinoma Cancer

Basal Cell Nevus Syndrome

Cancer (if diagnosed as Basal Cell Carcinoma)

Include in Note Section, no Diagnosis checked

Basement Membrane Disease Include in Note Section, no Diagnosis checked

Bathrocephaly Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 5 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Batten-Spielmeyer-Vogt Disease Storage Disorder

Becker’s Syndrome Muscular Dystrophy

Beckwith Wiedemann Syndrome Genetic / Chromosomal Disorder

Bedsore Wound, Burn, Bedsore, Pressure Ulcer

Behavioral Disorder

Disruptive Behavior Disorder (if true)

Include in Note Section, no Diagnosis checked

Behavioral Feeding Disorder Include in Note Section, no Diagnosis checked

Behavioral Problems Include in Note Section, no Diagnosis checked

Bell’s Palsy Neuromuscular Disorder

Benign Congenital Hypotonia Musculoskeletal Disorder

Bicuspid Aortic Valve

Cardiac Condition (if symptomatic)

Congenital Abnormality

Bilateral Cataracts

Blind or Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Bilateral Coxa Valga

Musculoskeletal Disorder (if severe)

Include in Note Section, no Diagnosis checked

Bilateral Equinovarus Include in Note Section, no Diagnosis checked

Bilateral Hip Dislocation Musculoskeletal Disorder

Bilateral periventricular nodular heterotopia

(BPNH)

Seizure Disorder (if present)

Include in Note Section, no Diagnosis checked

Biliary Atresia / Duct Obstruction Digestive System Disorder

Bipolar Disorder, Rapid Cycling Bi-Polar Disorder (must verify diagnosis)

Birthmarks Include in Note Section, no Diagnosis checked

Bladder Cancer Cancer

Bladder Infection

Infection – Current

Recurrent Infection (if chronic

and

severe) OR Include in Note Section, no Diagnosis checked

Bladder Reflux Genitourinary System Disorder

Bleeding Disorder Hemophilia / Other Blood Disorder

Bleeding Ulcer Digestive System Disorder

Blepharoptosis Include in Note Section, no Diagnosis checked

Blocked Tear Duct Include in Note Section, no Diagnosis checked

Blood Infection

Infection – Current

Recurrent Infection (if chronic

and

severe) OR Include in Note Section, no Diagnosis checked

Blount Disease

Musculoskeletal Disorder (if severe)

Include in Note Section, no Diagnosis checked

Bohring-Opitz Syndrome

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Bone Dysplasia Musculoskeletal Disorder

Bone Marrow Suppression Immune Deficiency

Bor Syndrome Genetic / Chromosomal Disorder

Borderline Intellectual Functioning Developmental Delay

Borderline Personality Personality Disorder

Born Without A Vestibular System Congenital Abnormality

Bowel Impaction / Obstruction / Resection Digestive System Disorder

Brachial Plexus Paralysis / Injury Neuromuscular Disorder

Bradycardia Cardiac Condition

Brain Anoxia Brain Disorder (other than seizures)

Brain Damage

Brain Arteriovenous Malformations (AVM) Brain Disorder (other than seizures)

Brain Damage

Brain Bleed – Grade 3, Grade 4 Brain Disorder (other than seizures)

Brain Damage

Brain Cysts Brain Disorder (other than seizures)

Brain Damage

Brain Dead Brain Disorder (other than seizures)

Brain Damage

Brain Hemorrhage Brain Disorder (other than seizures)

Brain Damage

P-00920 (12/2021) Page 6 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Brain Injury Brain Injury—Traumatic (per statutory definition of TBI)

Brain Stem Glioma

Brain Disorder (other than seizures)

Brain Damage

AND

Cancer

Brain Tumor / Brain Stem Tumor Brain Disorder (other than seizures)

Brain Damage

Branchial Cleft Syndrome (Goldenhar Syndrome) Congenital Abnormality

Bridges–Good Syndrome (Chronic Granulomatous

Disease) (CGD)

Immune Deficiency

Broken Ankle Include in Note Section, no Diagnosis checked

Bronchial Asthma Asthma

Bronchiospasm F1 Respiratory Condition (other than Asthma)

Bronchitis Respiratory Condition (other than Asthma)

Bronchopneumonia Respiratory Condition (other than Asthma)

Bronchopulmonary Dysplasia (BPD) Respiratory Condition (other than Asthma)

Bulimia

Anorexia Nervosa, Bulimia,

Other Eating Disorder

(must verify diagnosis)

Bunions Include in Note Section, no Diagnosis checked

Burkett’s Lymphoma Cancer

Burn Wound, Burn, Bedsore, Pressure Ulcer

Caffey Disease Musculoskeletal Disorder

Calcaneovalgus Musculoskeletal Disorder

Callosum Cranium Syndrome Brain Disorder (other than seizures)

Brain Damage

Canavan’s Disease Brain Disorder (other than seizures)

Brain Damage

Candida / Candidiasis Infection – Current

Recurrent Infection

Carbohydrate-Deficient Glycoprotein Syndrome Metabolic Disorder

Carcinoma Cancer

Cardiac Arrest Include in Note Section, no Diagnosis checked

Cardiac Dysrhythmia Cardiac Condition

Cardiofaciocutaneous Syndrome (CFC) Genetic / Chromosomal Disorder

Cardiomegaly Cardiac Condition

Cardiomyopathy Cardiac Condition

Carnitine Deficiency Metabolic Disorder

Cat Eye Syndrome Genetic / Chromosomal Disorder

Cataplexy Neuromuscular Disorder

Cataracts

Blind or Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Celiac Disease Digestive System Disorder

Central Auditory Processing Disorder (CAPD) Sensory Disorder (other than Blind

Deaf)

Central Core Disease (CCD) Musculoskeletal Disorder

Central Core Myopathy Musculoskeletal Disorder

Central Hypoventilation Syndrome (CCHC)

Neuromuscular Disorder

AND

Respiratory Condition (other than Asthma)

Central Integrative Processing Disorder Sensory Disorder (other than Blind

Deaf)

Cerebellar Ataxia Neuromuscular Disorder

Cerebellar Hypoplasia Brain Disorder (other than seizures)

Brain Damage

Cerebellum Agenesis Brain Disorder (other than seizures)

Brain Damage

Cerebral Aneurysm Brain Disorder (other than seizures)

Brain Damage

Cerebral Atrophy Brain Disorder (other than seizures)

Brain Damage

Cerebral Dysgenesis Brain Disorder (other than seizures)

Brain Damage

Cerebral Emboli / Embolism Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Cerebral Hypoplasia Brain Disorder (other than seizures)

Brain Damage

Cerebral Infarct Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Cerebral Salt-Wasting Syndrome (CSWS) Endocrine Disorder (not Diabetes)

P-00920 (12/2021) Page 7 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Cerebral Thrombosis Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Cerebral Visual Impairment

Blind or Severely Visually Impaired (if child is blind)

Include in Note Section no Diagnosis checked

Cerebrocostomandibular Syndrome (CCM or

CCMS)

Musculoskeletal Disorder

Charcot-Marie Tooth Disease Neuromuscular Disorder

Childhood Disintegrative Disorder (CDD) Pervasive Developmental Disorder (must verify diagnosis)

Choanal Atresia Congenital Abnormality

Cholangiosarcoma Cancer

Cholecystitis Digestive System Disorder

Cholelithiasis Digestive System Disorder

Cholesterol, High Include in Note Section, no Diagnosis checked

Chondromas Musculoskeletal Disorder

Chorea Neuromuscular Disorder

Choreoathetosis Neuromuscular Disorder

Chorioretinitis

Blind or Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Chromosomal Abnormality Genetic / Chromosomal Disorder

Chromosome 13 Ring Syndrome

Genetic / Chromosomal Disorder

AND

Brain Disorder (other than seizures) or Brain Damage

Chromosome 22 Ring

Genetic / Chromosomal Disorder

AND

Developmental Delay

Chromosome Deletion Genetic / Chromosomal Disorder

Chronic Granulomatous Disease (CGD) Immune Deficiency

Chronic Granulomatous Disease (CGD) (Bridges–

Good Syndrome)

Immune Deficiency

Chronic Inflammatory

Demyelinating Polyradiculoneuropathy (CIDP)

Neuromuscular Disorder

Chronic Intestinal Dysmotility (CID) Digestive System Disorder

Chronic Lung Disease Respiratory Condition (other than Asthma)

Chronic Motor Tic Disorder Neuromuscular Disorder

Chronic Severe Pain Neuromuscular Disorder

Chylothorax Respiratory Condition (other than Asthma)

Cirrhosis Liver Disease (Hepatic Failure, Cirrhosis)

Citrullinemia Metabolic Disorder

Cleft Palate/ Cleft Lip Congenital Abnormality

Cloacal Exstrophy

Digestive System Disorder (if stomach, intestines,

anus)

OR Genitourinary System Disorder (if bladder) OR

Musculoskeletal Disorder (if spinal)

Clostridium Include in Note Section, no Diagnosis checked

Clostridium Difficile Infection – Current

Recurrent Infection

CLOVE Genetic / Chromosomal Disorder

Club Foot Congenital Abnormality

Coagulation Defects Hemophilia / Other Blood Disorder

Coarctation of the Aorta Cardiac Condition

Cocaine Exposure, Cocaine Withdrawal Include in Note Section, no Diagnosis checked

Cognitive Affective Disorder Brain Disorder (other than seizures)

Brain Damage

Cognitive Delays Developmental Delay

Cognitive Disorder-NOS Developmental Delay

Cognitive Impairment Cognitive Disability

Cold Include in Note Section, no Diagnosis checked

Colitis Digestive System Disorder

P-00920 (12/2021) Page 8 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Colobomata / Coloboma

Blind or Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Colon Disease Digestive System Disorder

Colonic Atresia Digestive System Disorder

Colpolocephaly Brain Disorder (other than seizures)

Brain Damage

Coma / Comatose Brain Disorder (other than seizures)

Brain Damage

Combined Immune Deficiency Immune Deficiency

Communication Disorder Neuromuscular Disorder

Conductive Hearing Loss

Deaf

Severely Hearing Impaired (if child is deaf),

Sensory Disorder (other than Blind or Deaf)

Congenital Anomaly Of Left Microtia Ith Atresia

Congenital Abnormality

AND

Neuromuscular Disorder (if causes hearing loss)

Congenital Central Hypoventilation Syndrome

(CCHS)

Neuromuscular Disorder

Congenital Cystic Adenomatoid Malformation

(CCAM)

Congenital Abnormality

Congenital disorder of glycosylation (CDG) Metabolic Disorder

Congenital Fiber-Type Disproportion (CFTD) Neuromuscular Disorder

Congenital Heart Defect Cardiac Condition

Congenital Hydantoin Syndrome Musculoskeletal Disorder

Congenital Lymphedema Congenital Abnormality

Congenital Volvulus Digestive System Disorder

Congestive Heart Failure (CHF) Cardiac Condition

Conjunctivitis Infection – Current

Recurrent Infection

Connective Tissue Disorder (Fibulin 4) Immune Deficiency

Constipation Include in Note Section, no Diagnosis checked

Constricted Esophagus Digestive System Disorder

Convergence Exotropia

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Convergence Insufficiency

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Cortical Blindness Blind

Severely Visually Impaired

Cortical Dysplasia Seizure Disorder

Cortisol Deficiency / Dependent Endocrine Disorder (not Diabetes)

Coxsackie Virus Infection – Current

Recurrent Infection

Craniofacial Dysplasia Musculoskeletal Disorder

Craniosynostosis (Sagital Suture Fused) Genetic / Chromosomal Disorder

Crigler-Najjar Syndrome Metabolic Disorder

Crohn’s Disease Digestive System Disorder

Cross Eyed Include in Note Section, no Diagnosis checked

Crouzon Syndrome Musculoskeletal Disorder

Cryptorchidism Include in Note Section, no Diagnosis checked

Curtis Marmorata Congenita Congenital Abnormality

Cushing’s Syndrome Endocrine Disorder (not Diabetes)

Cyclic Vomiting Disorder / Syndrome (CVS) Digestive System Disorder

Cyclothymia Bi-Polar Disorder (must verify diagnosis)

Cystic Encephalomalacia Brain Disorder (other than seizures)

Brain Damage

Cystic Hygroma Include in Note Section, no Diagnosis checked

Cystic Lung Disease Respiratory Condition (other than Asthma)

Cystinosis Storage Disorder

Cystinuria Metabolic Disorder

P-00920 (12/2021) Page 9 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Cytomegalovirus (CMV)

Infection – Current

Recurrent Infection (if congenital)

OR Include in Note Section, no Diagnosis checked

Damp Syndrome Metabolic Disorder

Dandy-Walker Syndrome / Malformation / Complex

(DWS)

Brain Disorder (other than seizures) or Brain Damage

Dandy-Walker Variant Brain Disorder (other than seizures)

Brain Damage

De Novo 46xx.Del(6)(Q25.3) Karotype

Genetic / Chromosomal Disorder

AND

Developmental Delay

Decubitus / Decubiti Wound, Burn, Bedsore, Pressure Ulcer

Deep Venous Thrombosis Hemophilia / Other Blood Disorder

Deficiency – Thiamine, Niacin, Riboflavirn, Biotin,

Pantothenic Acid, Iron, Iodine, Fluorine, Zinc,

Chromoium, Selenium, Manganese, Molybdenum,

Copper, Carnitine, B-12, B-6 Etc.

Nutritional Imbalance (e.g., Malnutrition, Vitamin

Deficiencies)

Degenerative Arthritis Arthritis

Degenerative Joint Disease Musculoskeletal Disorder

Delayed Milestones Include in Note Section, no Diagnosis checked

Delayed Myelination Neuromuscular Disorder

Delayed Occular Development Include in Note Section, no Diagnosis checked

Delayed Puberty Include in Note Section, no Diagnosis checked

Deletion of the 5th Chromosome

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Delusions of Persecution Schizophrenia or Other Psychotic Disorder

Dementia Brain Disorder (other than seizures)

Brain Damage

Dental Abnormalities Include in Note Section, no Diagnosis checked

Dental Caries Include in Note Section, no Diagnosis checked

Dental Disease Infection – Current

Recurrent Infection

Dentogenesis Imperfecta Genetic / Chromosomal Disorder

Dependent Personality Disorder Personality Disorder (must verify diagnosis)

Depressive Disorder Depression (must verify diagnosis)

Dermatillomania Impulse-Control Disorder (must verify diagnosis)

Dermatitis Infection – Current

Recurrent Infection

Dermatological Rash Include in Note Section, no Diagnosis checked

Dermatomyositis Immune Deficiency

Developmental Apraxia Neuromuscular Disorder

Developmental Arithmetic Disorder Include in Note Section, no Diagnosis checked

Developmental Coordination Disorder Developmental Delay

Developmental Dysplasia of Hip Musculoskeletal Disorder

Developmental Language Disorder Neuromuscular Disorder

Developmental Verbal Apraxia Neuromuscular Disorder

Dextrocardia Congenital Abnormality

Diabetes (Type 1) Diabetes

Diabetes Insipidus Dehydration / Fluid & Electrolyte Imbalance

Diabetes Juvenile Diabetes

Diabetes Mellitus Diabetes

Diabetic Neuropathy Neuromuscular Disorder

Diabetic Peripheral Neuropathy Neuromuscular Disorder

Diamond Blackfan Anemia Anemia (e.g., Sickle Cell, Fanconi’s)

Diaphragmatic Hernia Respiratory Condition (other than Asthma)

Diarrhea Include in Note Section, no Diagnosis checked

Diffuse Hypotonia Neuromuscular Disorder

Digestive Disorder Digestive System Disorder

P-00920 (12/2021) Page 10 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Digestive Neoplasm Cancer

Diminished Hearing Include in Note Section, no Diagnosis checked

Diplopia (Double Vision) Include in Note Section, no Diagnosis checked

Disassociative Identity Disorder Dissociative Disorder

Disedidict Dyslexia Include in Note Section, no Diagnosis checked

Disorder of Infancy, Childhood or Adolescence

NOS

Include in Note Section, no Diagnosis checked

Disorder Of Written Expression Include in Note Section, no Diagnosis checked

Disruptive Behavior Disorders Disruptive Behavior Disorder (must verify diagnosis)

Disruptive Mood Dysregulation Disorder Mood Disorder

Diverticulosis / Diverticulitis Digestive System Disorder

Dongenital Disorder Of Glycosylation (CDG) Metabolic Disorder

Dopa-Responsive Dystonia (DRD) Neuromuscular Disorder

Drug Dependency Substance-Related Disorder (must verify diagnosis)

Duane’s Syndrome

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Dubowitz Syndrome Musculoskeletal Disorder

Duchenne’s Muscular Dystrophy Muscular Dystrophy

Dumping Syndrome Digestive System Disorder

AND

Nutritional Imbalance

Duodenal Disease / Atresia Digestive System Disorder

Dwarfism Musculoskeletal Disorder

Dysarthria Neuromuscular Disorder

Dysautonomia Disorder/Syndrome Neuromuscular Disorder

Dyscalculia Include in Note Section, no Diagnosis checked

Dysgraphia Include in Note Section, no Diagnosis checked

Dyslexia Include in Note Section, no Diagnosis checked

Dysomnia Include in Note Section, no Diagnosis checked

Dyspepsia Digestive System Disorder

Dysphagia Digestive System Disorder

Dysphasia Neuromuscular Disorder

Dysplastic Kidney Genitourinary System Disorder

Dyspnea Respiratory Condition (other than Asthma)

Dyspraxia Neuromuscular Disorder

Dysthymic Disorder Dysthymic Disorder (must verify diagnosis)

Dystonia Neuromuscular Disorder

E Coli Infection – Current

Recurrent Infection

Eagle Barrett Syndrome (Prune Belly) Genitourinary System Disorder

Ear Infections Infection – Current

Recurrent Infection

Eating Disorder

Anorexia Nervosa, Bulimia,

Other Eating Disorder

(must verify diagnosis)

Ectodermal Dysplasia

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Eczema

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Eczematoid Dermatitis

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Educational Diagnosis of _________ Include in Note Section, no Diagnosis checked

Ehlers-Danlos Syndrome Musculoskeletal Disorder

Electrolyte Imbalance Dehydration / Fluid & Electrolyte Imbalance

Emanuel Syndrome (Trisomy 22)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Emotional Disorder / Disturbance Personality Disorder

P-00920 (12/2021) Page 11 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Emphysema Respiratory Condition (other than Asthma)

Empyema Include in Note Section, no Diagnosis checked

Encephalitis

Brain Disorder (other than seizures)

Brain Damage

AND

Infection – Current or Recurrent Infection

Encephalocele Brain Disorder (other than seizures)

Brain Damage

Encephalomalacia Brain Disorder (other than seizures)

Brain Damage

Encephalopathy Brain Disorder (other than seizures)

Brain Damage

Encopresis Include in Note Section, no Diagnosis checked

Endocardial Cushion Defect Cardiac Condition

Endocarditis Cardiac Condition

Enlarged Bladder Genitourinary System Disorder

Enlarged Heart Cardiac Condition

Enteritis Digestive System Disorder

Enuresis Include in Note Section, no Diagnosis checked

Eosinophilic Esophagitis Digestive System Disorder

Eosinophilic Gastroenteritis Digestive System Disorder

Epidermolysis Bullosa / Bulbosa (EB, EBS) Skin Disease

Epigastric Pain Include in Note Section, no Diagnosis checked

Epigastric Reflux Symptoms Include in Note Section, no Diagnosis checked

Epilepsy Seizure Disorder

Epileptic Encephalopathy Seizure Disorder

Epispadias Congenital Abnormality

Epstien Barr Virus (EBV) Infection – Current

Recurrent Infection

Erb’s Palsy Neuromuscular Disorder

Escobar Syndrome Limb Missing, Severe Limb Abnormality, Arthrogryposis

Esophageal Erosion / Ulcer Digestive System Disorder

Esophageal Fistula / Stricture Digestive System Disorder

Esophageal Reflux Disease Digestive System Disorder

Esophageal Varicies Digestive System Disorder

Esophagitis Digestive System Disorder

Esotropia

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

ESRD (End Stage Renal Disease) Renal Failure

other Kidney Disease

Ethmoid Sinusitis Infection – Current

Recurrent Infection

ETOH (Ethanol) Abuse / Withdrawal Substance-Related Disorder (must verify diagnosis)

Eustachian Tube Dysfunction Include in Note Section, no Diagnosis checked

Ewing’s Sarcoma / Tumor Cancer

Excessive Daytime Sleepiness (EDS) Neuromuscular Disorder

Exhibitionism Sexual or Gender Identity Disorder

Exotropia Include in Note Section, no Diagnosis checked

Explosive Disorder Conduct Disorder (must verify diagnosis)

Explosive Personality Disorder Personality Disorder (must verify diagnosis)

Expressive Aphasia Neuromuscular Disorder

Expressive or Receptive Language Disorder / Delay Neuromuscular Disorder

Exstrophy of the Bladder Congenital Abnormality

Extreme Tactile Defensive Sensory Disorder (other than Blind

Deaf)

Face Blindness Brain Disorder (other than seizures)

Brain Damage

Factitious Disorder Somatoform Disorder

Factor H Deficiency Hemophilia / Other Blood Disorder

Factor V Leiden Blood Disorder Hemophilia / Other Blood Disorder

Far Sighted Include in Note Section, no Diagnosis checked

FAS (Fetal Alcohol Syndrome) Fetal Alcohol Syndrome / Effect

P-00920 (12/2021) Page 12 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Fatty Acid Oxidation Syndrome Metabolic Disorder

Febrile Seizures Include in Note Section, no Diagnosis checked

Feeding Difficulties Include in Note Section, no Diagnosis checked

Femoral Anteversion Musculoskeletal Disorder

Fetal Alcohol Spectrum Disorder (FASD) Fetal Alcohol Syndrome / Effect

Fetal Dilantin Syndrome Musculoskeletal Disorder

AND

Congenital Abnormality

Fetal Hydantoin Syndrome Musculoskeletal Disorder

AND

Congenital Abnormality

Fetal Valproate / Valproic Syndrome Musculoskeletal Disorder

AND

Congenital Abnormality

Fetishism Sexual or Gender Identity Disorder

Fg Syndrome (Opitz-Kaveggia)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Fibromyalgia Syndrome Neuromuscular Disorder

Fibrosarcoma Cancer

Fibrous Dysplasia Musculoskeletal Disorder

Filippi Syndrome

Genetic / Chromosomal Disorder

AND

Cognitive

Disability

Fine Motor Delay Neuromuscular Disorder

Flat-Footed Include in Note Section, no Diagnosis checked

Flexion Contractures Contracture / Connective Tissue Disorder

Floating Harbor Syndrome Musculoskeletal Disorder

AND

Neuromuscular Disorder

Flynn-Aird Syndrome Neuromuscular Disorder

Focal Dermal Hypoplasia (FDH)

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Folliculitis Include in Note Section, no Diagnosis checked

Fracture Include in Note Section, no Diagnosis checked

Franconi’s Anemia, Disease, or Syndrome Anemia (e.g., Sickle Cell, Fanconi’s)

Freeman-Sheldon Syndrome Limb Missing, Severe Limb Abnormality, Arthrogryposis

Friedrich’s Ataxia Neuromuscular Disorder

Frotteurism Sexual or Gender Identity Disorder

Frozen Shoulder Musculoskeletal Disorder

Fungal Lung Disease Respiratory Condition (other than Asthma)

G6pd Deficiency

Anemia, (e.g., Sickle Cell, Fanconi’s) (if present)

Include in Note Section, no Diagnosis checked

Galactosemia Metabolic Disorder

Gallstones Include in Note Section, no Diagnosis checked

Gangliosidosis Metabolic Disorder

AND

Cognitive Disability

Gangrene Infection – Current

Recurrent Infection

Gastric Erosion / Distress / Bleed Digestive System Disorder

Gastric Esophageal Reflux Digestive System Disorder

Gastric Outlet Obstruction / Syndrome Digestive System Disorder

Gastric Ulcer / Disease Digestive System Disorder

Gastritis Digestive System Disorder

Gastroduodenitis Digestive System Disorder

Gastroenteritis Digestive System Disorder

Gastroentero Fistula Digestive System Disorder

Gastroesophageal Reflux (GE Reflux, GER, GERD) Digestive System Disorder

Gastroesophagitis Digestive System Disorder

Gastrointestinal Bleed / Hemorrhage Digestive System Disorder

Gastrointestinal Disorder Digestive System Disorder

Gastroparesis Digestive System Disorder

Gastroschisis Digestive System Disorder

Gaucher’s Disease Storage Disorder

P-00920 (12/2021) Page 13 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

GE Reflux (Gastroesophygeal Reflux) Digestive System Disorder

Gender Identity Disorder (GDI) Sexual

Gender Identity Disorder

Genetic Disease of Unknown Diagnosis Genetic / Chromosomal Disorder

Genital Herpes Infection – Current

Recurrent Infection

GER (Gastroesophygeal Reflux) Digestive System Disorder

GERD (Gastroesophageal Reflux Disorder) Digestive System Disorder

GI Bleed / Reflux Digestive System Disorder

Gilberts Syndrome Liver Disease (Hepatic Failure, Cirrhosis)

Gillespie Syndrome

Genetic / Chromosomal Disorder

AND

Neuromuscular Disorder

Glaucoma

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Gliosis Neuromuscular Disorder

Global Delays Developmental Delay

Global Hypotonia Neuromuscular Disorder

Globoid Cell Leukodystrophy Metabolic Disorder

AND

Cognitive Disability

Glomerulonephritis Renal Failure

other Kidney Disease

Glucose Transporter Deficiency Syndrome (Glut-

DS)

Neuromuscular Disorder

Glutaric Acidemia (GA) Metabolic Disorder

Gluten Sensitivity (GS)

Digestive System Disorder (if results in Celiac Disease)

OR Allergy

Glycogen Storage Metabolic Disorder

Goiter Endocrine Disorder (not Diabetes)

Goldenhar Syndrome Congenital Abnormality

Goltz Syndrome/ Goltz-Gorlin Syndrome Skin Disease

Gorlin Syndrome

Cancer (if diagnosed as Basal Cell Carcinoma)

Include in Note Section, no Diagnosis checked

Gouty Arthritis Arthritis

Graft vs Host Disease (GVHD) Immune Deficiency

Graves Disease

Immune Deficiency

AND

Endocrine Disorder (not Diabetes)

Gross Motor Delay Neuromuscular Disorder

Growth Hormone Deficiency Endocrine Disorder (not Diabetes)

Guanosine Triphosphate Cyclohydrolase I

Deficiency (GTPCH)

Metabolic Disorder

Guillian-Barre Syndrome Neuromuscular Disorder

Gum Disease Include in Note Section, no Diagnosis checked

GVHD (Graft vs Host Disease) Immune Deficiency

Hallermann-Streiff Syndrome Musculoskeletal Disorder

Hallervorden-Spatz Disease Neuromuscular Disorder

Hallux Varus Include in Note Section, no Diagnosis checked

Hashimoto's Thyroiditis Immune Deficiency

Head Injury Brain Injury—Traumatic (per statutory definition of TBI)

Headaches Include in Note Section, no Diagnosis checked

Hearing Deficit, Partial Sensory Disorder (other than Blind

Deaf)

Hearing Impairment

Deaf

Severely Hearing Impaired (if child is deaf),

Sensory Disorder (other than Blind or Deaf)

Hearing Loss

Deaf

Severely Hearing Impaired (if child is deaf),

Sensory Disorder (other than Blind or Deaf)

Heart Disease / Disorder / Defect Cardiac Condition

Heart Murmur Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 14 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Heller's Syndrome Pervasive Developmental Disorder

Hemangioma Include in Note Section, no Diagnosis checked

Hematuria Genitourinary System Disorder

Hemianopsia

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Hemifacial Microsomia Syndrome Musculoskeletal Disorder

Hemiparesis Paralysis, Other than Spinal Cord Injury

Hemiplegia Paralysis, Other than Spinal Cord Injury

Hemivertebra Musculoskeletal Disorder

Hemodialysis Renal Failure

other Kidney Disease

Hemolytic Anemia Hemophilia / Other Blood Disorder

Hemolytic Uremic Syndrome (HUS) Renal Failure

other Kidney Disease

Hemophilia Hemophilia / Other Blood Disorder

Hemorrhage, Subarachnoid Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Hemorrhagic Gastritis Digestive System Disorder

Hepatic Failure Liver Disease (Hepatic Failure, Cirrhosis)

Hepatitis Liver Disease (Hepatic Failure, Cirrhosis)

Hepatoblastoma Cancer

Hereditary Spherocytosis Hemophilia / Other Blood Disorder

Hermangiomas Include in Note Section, no Diagnosis checked

Hernia Digestive System Disorder

Herpes Simplex Infection – Current

Recurrent Infection

Herpes Zoster Infection – Current

Recurrent Infection

Heterotaxy Syndrome Congenital Abnormality

Heterotropia (Strabismus) Include in Note Section, no Diagnosis checked

Hidden Penis Include in Note Section, no Diagnosis checked

High Blood Pressure Include in Note Section, no Diagnosis checked

High Lead Level Include in Note Section, no Diagnosis checked

High Levels of Mercury Include in Note Section, no Diagnosis checked

High Myopia Include in Note Section, no Diagnosis checked

High Palate Include in Note Section, no Diagnosis checked

High Triglycerides Include in Note Section, no Diagnosis checked

Hinman Syndrome Genitourinary System Disorder

Hip Dislocation / Dysplasia Musculoskeletal Disorder

Hirschsprung's Disease Digestive System Disorder

Histrionic personality disorder (HPD) Personality Disorder (must verify diagnosis)

HIV Positive

Immune Deficiency (Do not include in notes due to

confidentiality)

Hodgkin’s Disease Cancer

HOH (Hard of Hearing)

Deaf

Severely Hearing Impaired (if child is deaf),

Sensory Disorder (other than Blind or Deaf)

Hole In Heart

Cardiac Condition

Include in Note Section, no Diagnosis checked (if repaired)

Horner's Syndrome Neuromuscular Disorder

Human Immuno Virus (HIV)

Immune Deficiency (Do not include in notes due to

confidentiality)

Hunter / Hurler’s Syndrome (MPS I or II) Storage Disorder

Huntington’s Chorea / Disease Brain Disorder (other than seizures)

Brain Damage

Hydranencephaly Brain Disorder (other than seizures)

Brain Damage

Hydrocephalus Brain Disorder (other than seizures)

Brain Damage

Hydronephrosis Renal Failure

other Kidney Disease

Hyperactivity Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 15 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Hyperacusis Sensory Disorder (other than Blind

Deaf)

Hypercalcemia Include in Note Section, no Diagnosis checked

Hypercholesterolemia Include in Note Section, no Diagnosis checked

Hyperekplexia Neuromuscular Disorder

Hyperextensive Mobility Syndrome Musculoskeletal Disorder

Hyperglycemia Diabetes

Hyperinsulinemia Endocrine Disorder (not diabetes)

Hyperkalemia Dehydration / Fluid & Electrolyte Imbalance

Hyperkeratosis Skin Disease

Hyperkinesis

Attention-Deficit Disorder, Attention-Deficit Hyperactivity

Disorder (must verify diagnosis)

Hyperkinetic Movement Disorder Neuromuscular Disorder

Hyperlexia Include in Note Section, no Diagnosis checked

Hyperlipidemia Include in Note Section, no Diagnosis checked

Hypernatremia Dehydration / Fluid & Electrolyte Imbalance

Hyperopia (with or without Astigmatism) Include in Note Section, no Diagnosis checked

Hypersplenism Hemophilia / Other Blood Disorder

Hypertension Include in Note Section, no Diagnosis checked

Hyperthyroidism Endocrine Disorder (not Diabetes)

Hypertonic Muscles Neuromuscular Disorder

Hypertriglyceridemia Include in Note Section, no Diagnosis checked

Hypertrophic Cardiomyopathy (HCM) Cardiac Condition

Hyperuricemia Include in Note Section, no Diagnosis checked

Hypocalcemia Dehydration / Fluid & Electrolyte Imbalance

Hypochondroplasia Musculoskeletal Disorder

Hypoglycemia Metabolic Disorder

Hypogonadism Endocrine Disorder (not Diabetes)

Hypohidrotic Ectodermal Dysplasia Skin Disease

Hypokalemia Dehydration / Fluid & Electrolyte Imbalance

Hypomanic Include in Note Section, no Diagnosis checked

Hypomelanosis of Ito Skin Disease

Hyponatremia Dehydration / Fluid & Electrolyte Imbalance

Hypopituitarism Endocrine Disorder (not Diabetes)

Hypoplasia of The Corpus Callosum Brain Disorder (other than seizures)

Brain Damage

Hypoplastic Left Heart Syndrome Cardiac Condition

Hypoplastic Pituitary Endocrine Disorder (not Diabetes)

Hypoplastic Right Ventricle Cardiac Condition

Hypopotassemia Dehydration / Fluid & Electrolyte Imbalance

Hypospadias Congenital Abnormality

Hypotension Include in Note Section, no Diagnosis checked

Hypothalamic Obesity Endocrine Disorder (not Diabetes)

Hypothyroidism Endocrine Disorder (not Diabetes)

Hypotonia Musculoskeletal Disorder

Hypoventilation Respiratory Condition (other than Asthma)

Hypoxia Respiratory Condition (other than Asthma)

Hypoxic Brain Injury Brain Disorder (other than seizures)

Brain Damage

Hypoxic Encephalopathy (Secondary To Drowning) Brain Disorder (other than seizures)

Brain Damage

Ichthyosis Follicularis Skin Disease

Idic 15 Neuromuscular Disorder

Idiopathic Short Stature Include in Note Section, no Diagnosis checked

Idiopathic Toe Walking Include in Note Section, no Diagnosis checked

Idiopathic Tremor Neuromuscular Disorder

P-00920 (12/2021) Page 16 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

IgA Nephropathy Renal Failure

other Kidney Disease

IGg Deficiency Immune Deficiency

Ileal Lymphoid Nodular Hyperplasia Include in Note Section, no Diagnosis checked

Ileus Include in Note Section, no Diagnosis checked

Immotile Cilia Syndrome

Respiratory Condition (other than Asthma) (if present)

Include in Note Section, no Diagnosis checked

Immune Dysfunction Immune Deficiency

Immune Mechanism Disorder Immune Deficiency

Imperforate Anus Digestive System Disorder

Incontinence Include in Note Section, no Diagnosis checked

Infectious Mononucleosis (Mono) Infection – Current

Recurrent Infection

Inflammatory Bowel Disease Digestive System Disorder

Influenza Infection – Current

Recurrent Infection

Inguinal Hernia Digestive System Disorder

Insomnia Include in Note Section, no Diagnosis checked

Institutional Autism Autism

Autism Spectrum (must verify diagnosis)

Insulin Resistance Immune Deficiency

Insulin-Dependent Diabetes Mellitus (IDDM) Diabetes

Intellectual Disability (previously referred to as

Mental Retardation)

Cognitive Disability

Intermittent Explosive Disorder Conduct Disorder (must verify diagnosis)

Intermittent Microhematuria Include in Note Section, no Diagnosis checked

Interstitial Cystitis Genitourinary System Disorder

Intracranial Bleed / Bleeding Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Intracranial Calcification Include in Note Section, no Diagnosis checked

Intracranial Hypertension Neuromuscular Disorder

Intractable Epilepsy Seizure Disorder

Intrauterine Growth Retardation Congenital Abnormality

Intraventricular Hemorrhage Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Intussesception Digestive System Disorder

Inverted X Chromosome Include in Note Section, no Diagnosis checked

Inverted Y Chromosome Include in Note Section, no Diagnosis checked

Irritable Bowel Disease / Syndrome (IBS) Digestive System Disorder

Ischemic Heart Disease Cardiac Condition

Isodicentric 15 Neuromuscular Disorder

Jacobsen Syndrome (11q deletion) Genetic / Chromosomal Disorder

Jaundice Include in Note Section, no Diagnosis checked

Joubert Syndrome Brain Disorder (other than seizures)

Brain Damage

Juvenile Rheumatoid Arthritis Arthritis

Kallman Syndrome Genetic / Chromosomal Disorder

Kartagener Syndrome (KS)

Respiratory Condition (other than Asthma) (if present)

Include in Note Section, no Diagnosis checked

Kasabach-Merritt Syndrome Hemophilia / Other Blood Disorder

Kawasaki Disease Cardiac Condition

Kearns Sayre Syndrome Genetic / Chromosomal Disorder

Kernicterus Brain Disorder (other than seizures)

Brain Damage

Ketoacidosis Metabolic Disorder

Kidney Tube Obstruction Renal Failure

other Kidney Disease

Kidney Reflux Renal Failure

other Kidney Disease

Kidney Stone Include in Note Section, no Diagnosis checked

Kleine Levin Syndrome (KLS) Neuromuscular Disorder

Klinefelter Syndrome (47, XXY) Genetic / Chromosomal Disorder

P-00920 (12/2021) Page 17 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Klippel-Trenaunay Syndrome (K-T) Congenital Abnormality

Kluver-Bucy Syndrome Brain Disorder (other than seizures)

Brain Damage

Krabbe’s Disease Metabolic Disorder

AND

Cognitive Disability

Kyphosis Musculoskeletal Disorder

Lactose Intollerance Include in Note Section, no Diagnosis checked

Lamellar Ichthyosis (LI) Skin Disease

Landau-Kleffner Syndrome

Neuromuscular Disorder

AND

Seizure Disorder (if present)

Langer-Giedion Syndrome

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Langerhans Cell Histiocytosis (LCH) Hemophilia / Other Blood Disorder

Language Based Learning Disability Include in Note Section, no Diagnosis checked

Language Disorder / Delay Neuromuscular Disorder

Larsen Syndrome Genetic / Chromosomal Disorder

Laryngomalacia Include in Note Section, no Diagnosis checked

Laryngotracheal Anomaly Congenital Abnormality

Latex Allergy, Severe Allergy

Lazy Eye Include in Note Section, no Diagnosis checked

Lead Posioning (Plumbism) Include in Note Section, no Diagnosis checked

Learning Delays / Disability / Disorder Include in Note Section, no Diagnosis checked

Learning Disorder (Non-Verbal) Include in Note Section, no Diagnosis checked

Leber’s Congenital Amaurosis Blind

Severely Visually Impaired

Legally Blind Blind

Severely Visually Impaired

Legg-Calve Perthes Disease Musculoskeletal Disorder

Lennox-Gastaut Syndrome Seizure Disorder (Lennox-Gastaut Syndrome)

Lenz Microphthalmia Syndrome

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Leukemia Cancer

Leukodystrophy Storage Disorder

Leukoencephalopathy Brain Disorder (other than seizures)

Brain Damage

Leukomalacia Brain Disorder (other than seizures)

Brain Damage

Limb Girdle Syndrome Muscular Dystrophy

Limited Tongue Movement Include in Note Section, no Diagnosis checked

Linear Nevus Sebaceous Syndrome Neuromuscular Disorder

Liver Necrosis Liver Disease (Hepatic Failure, Cirrhosis)

Lobar Holoprosencephaly

Brain Disorder (other than seizures)

Brain Damage (if

present) OR Include in Note Section, no Diagnosis checked

Lordosis Musculoskeletal Disorder

Lou Gehrig’s Disease Multiple Sclerosis

ALS

Low ACTH Metabolic Disorder

Low Muscle Tone Neuromuscular Disorder

Low Testosterone Include in Note Section, no Diagnosis checked

Low Thyroid Endocrine Disorder (not Diabetes)

Lupus Immune Deficiency

Lyme Disease Infection – Current

Recurrent Infection

Lymphangioma Congenital Abnormality

Lymphangiomatosis Congenital Abnormality

AND

Cancer (if present)

Macrocephaly Developmental Delay

Macrocephaly-Capillary Malformation Syndrome

(M-CM)

Developmental Delay

Macroglossia Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 18 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Macular Degeneration

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Malabsorption Syndrome Digestive System Disorder

AND

Nutritional Imbalance

Malignant Neoplasm Cancer

Malnutrition

Nutritional Imbalance (e.g., Malnutrition, Vitamin

Deficiencies)

Mandibular Hypoplasia Include in Note Section, no Diagnosis checked

Marden Walker Syndrome Contractures/ Connective Tissue Disorder

Marfan Syndrome Musculoskeletal Disorder

MASA Syndrome Cognitive Disability

Mastocytosis Include in Note Section, no Diagnosis checked

Mathematics Disorder Include in Note Section, no Diagnosis checked

Maxillary Sinusitis Infection – Current

Recurrent Infection

McCune-Albright Syndrome (MAS) Endocrine Disorder (not Diabetes)

MECP2 Duplication Syndrome

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Medulloblastoma

Brain Disorder (other than seizures)

Brain Damage

AND

Cancer

Megalencephaly Brain Disorder (other than seizures)

Brain Damage

Megalencephaly-Cutis Marmorata Telangiectatica

Congenita Syndrome (M-CMTC)

Brain Disorder (other than seizures) or Brain Damage

Meniere’s Disease Sensory Disorder (other than Blind

Deaf)

Meningitis

Brain Disorder (other than seizures)

Brain Damage

AND

Infection – Current or Recurrent Infection

Meningomyelocele or Myelomeningocele Spina Bifida (Myelomeningocele)

Mesial Temporal Sclerosis Seizure Disorder

Metachromatic Leukodystrophy Storage Disorder

Metal Toxicity Include in Note Section, no Diagnosis checked

Methicillin Resistant Staphylococcus Aureus

(MRSA)

Infection – Current or Recurrent Infection

Micro Syndrome Cognitive Disability

Microcephaly Developmental Delay

Microencephaly Developmental Delay

Micrognathia Include in Note Section, no Diagnosis checked

Microphthalmia

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Microscopic Polyangiitis Include in Note Section, no Diagnosis checked

Microtia Include in Note Section, no Diagnosis checked

Migraines Include in Note Section, no Diagnosis checked

Migraines Cephalalgia Include in Note Section, no Diagnosis checked

Milk Intolerance Include in Note Section, no Diagnosis checked

Missing Left Ventricle Cardiac Condition

Mitochondrial Disorder Genetic / Chromosomal Disorder

Mitochondrial Myopathy Neuromuscular Disorder

Mitochondrial Myopathy, Encephalopathy, Lactic

Acidosis, and Stroke Syndrome (MELAS)

Neuromuscular Disorder

AND

Brain Disorder (other than seizures) or Brain Damage

Mitral Valve Stenosis or Disease Cardiac Condition

Mixed Receptive/Expressive Language Disorder Neuromuscular Disorder

Moebius Syndrome Neuromuscular Disorder

Mono Virus (Infectious Mononucleosis) Infection – Current

Recurrent Infection

Monoamine Neurotransmitter Deficiency Neuromuscular Disorder

Monocular Estropia with Amblyopia Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 19 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Monosomy 20p13

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Morbid Obesity Digestive System Disorder

Morquio Syndrome Metabolic Disorder

Mosaic Down Syndrome Down Syndrome – Mosaic

Translocation

Mosaic, Mosaicism Down Syndrome – Mosaic

Translocation

Motor Coordination Disorder / Dyspraxia Neuromuscular Disorder

Motor Delays Neuromuscular Disorder

Motor Planning Delay/Disorder Neuromuscular Disorder

Motor-Tic Disorder Neuromuscular Disorder

Movement Disorder Include in Note Section, no Diagnosis checked

Mowat-Wilson Syndrome Cognitive Disability

MRSA (Methicillin Resistant Staphylococcus

Aureus)

Infection – Current or Recurrent Infection

Mucopolysaccharidosis (All types) (Sanfilippo

Syndrome)

Storage Disorder

Mullerian Agenesis Include in Note Section, no Diagnosis checked

Multicystic Kidney Renal Failure

other Kidney Disease

Multi-Organ Metabolic Disease Metabolic Disorder

Multiple Body Dysfunction Include in Note Section, no Diagnosis checked

Multiple Chemical Sensitivities Allergy

Multiple Ear Infections

Infection – Current

Recurrent Infection (if severe)

Include in Note Section, no Diagnosis checked

Murmur Include in Note Section, no Diagnosis checked

Muscle Incoordination Include in Note Section, no Diagnosis checked

Muscle Weakness Disorder Include in Note Section, no Diagnosis checked

Mute Neuromuscular Disorder

MVP (Mitral Valve Prolapse) Cardiac Condition

Myasthenia Gravis Neuromuscular Disorder

Myelopathy Neuromuscular Disorder

Myeloproliferative Disorder Hemophilia / Other Blood Disorder

Myocarditis Cardiac Condition

Myoclonus Seizure Disorder

Myofascial Pain Syndrome Musculoskeletal Disorder

Myopathy Neuromuscular Disorder

Myotonic Dystrophy Muscular Dystrophy

Nager Syndrome Musculoskeletal Disorder

Nail-Patella Renal Syndrome (NPS) Renal Failure

other Kidney Disease

Narcolepsy Neuromuscular Disorder

Near Drowning Brain Injury—Traumatic (per statutory definition of TBI)

Necrotizing Enterocolitis Digestive System Disorder

Nemaline Myopathy Neuromuscular Disorder

Neonatal Meningitis

Brain Disorder (other than seizures)

Brain Damage

AND

Infection – Current or Recurrent Infection

Neoplasm Cancer

Nephritis Genitourinary System Disorder

Nephrotic Syndrome Genitourinary System Disorder

Nerve Deafness

Deaf

Severely Hearing Impaired (if child is deaf),

Sensory Disorder (other than Blind or Deaf)

Nerve Palsy Neuromuscular Disorder

Nervous Tic Disorder Neuromuscular Disorder

Nesidioblastosis Metabolic Disorder

P-00920 (12/2021) Page 20 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Neural Tube Defect Brain Disorder (other than seizures)

Brain Damage

Neuralgia Neuromuscular Disorder

Neuroblastoma Cancer

Neurocognitive Disorder Brain Disorder (other than seizures)

Brain Damage

Neurocutanious Melanosis Congenital Abnormality

Neurofibromatosis Neuromuscular Disorder

Neurogenic Bladder / Bowel Genitourinary System Disorder

Neurological Insult Neuromuscular Disorder

Neuromuscular Disease Neuromuscular Disorder

Neuronal Ceroid Lipofuscinoses (NCL) Neuromuscular Disorder

Neuropathy Neuromuscular Disorder

Neutropenia Hemophilia / Other Blood Disorder

Niemann-Pick Disease Storage Disorder

No pupils in eyes Blind

Severely Visually Impaired

Nocutrnal Enuresis Include in Note Section, no Diagnosis checked

Non Allergic Rhinitis Infection – Current

Recurrent Infection

Non Verbal Learning Disorder / Disability Include in Note Section, no Diagnosis checked

Non-Hodgkins Lymphoblastic Lymphoma Cancer

Non-Insulin-Dependent Diabetes (NIDDM) Diabetes

Non-Verbal Neuromuscular Disorder

Noonan Syndrome Musculoskeletal Disorder

Nystagmus Sensory Disorder (other than Blind

Deaf)

Obesity

Digestive System Disorder (if child has Morbid Obesity)

OR Include in Note Section, no Diagnosis checked

OBS (Organic Brain Syndrome) Brain Disorder (other than seizures)

Brain Damage

Obstructive Urinary Tract Defect Genitourinary System Disorder

OCD Obsessive-Compulsive Disorder (must verify diagnosis)

Ocular Motor Dysfunction / Syndrome / Apraxia Neuromuscular Disorder

Oculoauriculovertebral Association Musculoskeletal Disorder

Oculocutaneous Albinism Skin Disease

ODD Oppositional Defiant Disorder (must verify diagnosis)

Ohtahara Syndrome Seizure Disorder

OI (Osteogenesis Imperfecta) Musculoskeletal Disorder

Oligodendroglioma Cancer

Omenn Syndrome Immune Deficiency

Omphalocele Digestive System Disorder

One Kidney Renal Failure

other Kidney Disease

Opitz G/BBB Syndrome Genetic / Chromosomal Disorder

Opitz Kaveggia Syndrome (Fg Syndrome)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Opitz Syndrome

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Opitz-Trigonocephaly (C Syndrome)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Opsoclonus-Myoclonus Syndrome (OMS) Neuromuscular Disorder

Optic Glioma Cancer

Optic Nerve Atrophy

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Optic Nerve Hypoplasia

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Optimum Attachment Disorder

Post-Traumatic Stress or Acute Stress Disorder

Reactive Attachment Disorder

P-00920 (12/2021) Page 21 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Oral Facial Digital Syndrome (OFD) Musculoskeletal Disorder

Oral Motor Apraxia Neuromuscular Disorder

Oral Thrush Include in Note Section, no Diagnosis checked

Oral Ulcers Include in Note Section, no Diagnosis checked

Orchitis Genitourinary System Disorder

Organic Brain Syndrome (OBS) Brain Disorder (other than seizures)

Brain Damage

Orthostatic Proteinuria Include in Note Section, no Diagnosis checked

Osgood-Schlatter Syndrome / Disease Musculoskeletal Disorder

Osteitis Include in Note Section, no Diagnosis checked

Osteoarthritis Arthritis

Osteochrondromas Musculoskeletal Disorder

Osteoid Osteoma Musculoskeletal Disorder

Osteomyelitis Infection – Current

Recurrent Infection

Osteopenia Musculoskeletal Disorder

Osteoporosis Musculoskeletal Disorder

Osteosarcoma Cancer

Osteosclerosis Musculoskeletal Disorder

Otitis Media Infection – Current

Recurrent Infection

Otopalatodigital Syndrome Musculoskeletal Disorder

Pachygyria Brain Disorder (other than seizures)

Brain Damage

Pancraniosynostosis Musculoskeletal Disorder

Pancreatitis Digestive System Disorder

Panhypopituitarism Endocrine Disorder (not Diabetes)

Panic Disorder Anxiety Disorder (must verify diagnosis)

Paralysis Paralysis, Other than Spinal Cord Injury

Paralyzed Vocal Cord Respiratory Condition (other than Asthma)

Paranoia

Post-Traumatic Stress

Acute Stress Disorder (must

verify diagnosis)

Paraphilia Sexual or Gender Identity Disorder

Paraplegia

Paralysis – Spinal Cord Injury (if true)

Paralysis, Other than Spinal Cord Injury

Paresis Neuromuscular Disorder

Paresthesia Neuromuscular Disorder

Paroxysmal Autonomic Instability And Dystonia

(PAID)

Neuromuscular Disorder

Paroxysmal Ketogenic Dystonia Seizure Disorder

Paroxysmal Kinesigenic Dystonia Neuromuscular Disorder

Paroxysmal Nocturnal Hemoglobinuria (PNH) Hemophilia / Other Blood Disorder

Partial 2p Trisomy Syndrome

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Partial Deletion Chromosome 21 Genetic / Chromosomal Disorder

Partial Growth Of Corpus Collosum Brain Disorder (other than seizures)

Brain Damage

Partial Monosomy 7p Genetic / Chromosomal Disorder

Partial Trisomy 9q Genetic / Chromosomal Disorder

Patent Ductus Arteriosus (PDA) Cardiac Condition

Pathological Bone Fracture Musculoskeletal Disorder

PDD Pervasive Developmental Disorder (must verify diagnosis)

Pectus Carinatum Musculoskeletal Disorder

Pediatric Autoimmune Neuropsychiatric Disorders

Associated with Streptococcal Infections

(PANDAS)

Immune Deficiency

Pelizaeus Merzbacher Syndrome Neuromuscular Disorder

P-00920 (12/2021) Page 22 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Pelvic Floor Dysfunction Digestive System Disorder

Pena Shokeir Syndrome Genetic / Chromosomal Disorder

Peptic Ulcer Disease (PUD) Digestive System Disorder

Pericardial Effusion Cardiac Condition

Pericarditis Cardiac Condition

Perinatal / Postnatal Depression Depression (must verify diagnosis)

Periodic Limb Movement Disorder (PLMD) Neuromuscular Disorder

Periventricular Heterotopia Genetic / Chromosomal Disorder

Periventricular Leukomalacia (PVL) Brain Disorder (other than seizures)

Brain Damage

Persistent Fetal Vasculature Syndrome (PFVS)

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Personality Change Due To General Medical

Condition Combined Type

Personality Disorder

Perthes Disease/Disorder Musculoskeletal Disorder

Peters Plus Syndrome

Developmental Delay (if present)

AND

Musculoskeletal Disorder

PHACE Syndrome

Brain Disorder (other than seizures)

Brain Damage

AND

Cardiac Condition

Pheiffer Syndrome Genetic / Chromosomal Disorder

Phelan-Mcdermid Syndrome

Genetic / Chromosomal Disorder

AND

Developmental Delay

Phelan-McDermid Syndrome (22q13 Deletion

Syndrome)

Genetic / Chromosomal Disorder

AND

Developmental Delay

Phenylketonuria (PKU) Metabolic Disorder

Pheochromocytoma Endocrine Disorder (not Diabetes)

Phlebitis Include in Note Section, no Diagnosis checked

Phobia

Anxiety Disorder (if severe)

Include in Note Section, no Diagnosis checked

Phonological Disorder Neuromuscular Disorder

Pi Type MZ Include in Note Section, no Diagnosis checked

Pierre-Robin Syndrome Digestive System Disorder

Pineal Brain Mass

Brain Disorder (other than seizures)

Brain Damage (if

present) OR Include in Note Section, no Diagnosis checked

Pituitary Insufficiency Endocrine Disorder (not Diabetes)

Plagiocephaly Include in Note Section, no Diagnosis checked

Plantar Fasciitis Include in Note Section, no Diagnosis checked

Platelet Dysfunction Hemophilia / Other Blood Disorder

Pleural Effusion Respiratory Condition (other than Asthma)

Plumbism (Lead Poisoning) Include in Note Section, no Diagnosis checked

Pneumonia Respiratory Condition (other than Asthma)

Pneumonitis Respiratory Condition (other than Asthma)

Pneumothorax Respiratory Condition (other than Asthma)

Polio Paralysis, Other than Spinal Cord Injury

Polycystic Kidney Disease Renal Failure

other Kidney Disease

Polycystic Ovarian Syndrome (PCOS) Genitourinary System Disorder

Polycythemia Anemia (e.g., Sickle Cell, Fanconi’s)

Polydipsia Polydipsia (must verify diagnosis)

Polymicrogyria (PMG) Brain Disorder (other than seizures)

Brain Damage

Polymyalgia Rheumatica Arthritis

Polysplenia Syndrome Cardiac Condition

Polysubstance Abuse Substance-Related Disorder (must verify diagnosis)

P-00920 (12/2021) Page 23 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Pompe Disease Storage Disorder

Ponto Cerebellar Hypoplasia Neuromuscular Disorder

Poor Muscle Tone Include in Note Section, no Diagnosis checked

Poor Weight Gain

Failure to Thrive (if present)

Include in Note Section, no Diagnosis checked

Porencephaly Brain Disorder (other than seizures)

Brain Damage

Porphyrias Metabolic Disorder

Possible Diagnosis of [Anything] Include in Note Section, no Diagnosis checked

Posterior Fossa Fluid Cyst / Cerebllum Include in Note Section, no Diagnosis checked

Posterior Fossa Syndrome Include in Note Section, no Diagnosis checked

Posterior Urethral Valves Genitourinary System Disorder

Post-Polio Syndrome Paralysis, Other than Spinal Cord Injury

Postural Orthostatic Tachycardia Syndrome (POTS) Neuromuscular Disorder

Potocki-Shaffer Syndrome Genetic / Chromosomal Disorder

Pragmatic Language Disorder Include in Note Section, no Diagnosis checked

Preaxial Polydactyly Musculoskeletal Disorder

Precocious Puberty Include in Note Section, no Diagnosis checked

Premature Adrenarche Genitourinary System Disorder

Prenatal Hydronephrosis Genitourinary System Disorder

Pressure Ulcer Wound, Burn, Bedsore, Pressure Ulcer

Primary Amenorrhea Genitourinary System Disorder

Primary Ciliary Dyskinesia (PCD) Genetic / Chromosomal Disorder

Primary Lateral Sclerosis Multiple Sclerosis

ALS

Primitive Neuroectodermal Tumor Cancer

Processing Delays Include in Note Section, no Diagnosis checked

Prosopagnosia Brain Disorder (other than seizures)

Brain Damage

Prostatic Hypertrophy Genitourinary System Disorder

Prostatitis Genitourinary System Disorder

Protein Losing Enteropathy Digestive System Disorder

Protruding Vertebral Disc Neuromuscular Disorder

Prune-Belly Syndrome (Eagle-Barrett) Genitourinary System Disorder

Pseudohypoparathyroidism Endocrine Disorder (not Diabetes)

Pseudostrabismus Include in Note Section, no Diagnosis checked

Psoriasis Skin Disease

Psychomotor Retardation Neuromuscular Disorder

Psychosis

Schizophrenia

and

other Psychotic Disorders (must verify

diagnosis)

Ptosis Include in Note Section, no Diagnosis checked

Pulmonary Atresia / Stenosis Respiratory Condition (other than Asthma)

Pulmonary Hemorrhage Respiratory Condition (other than Asthma)

Pulmonary Hypertension

Cardiac Condition

AND

Respiratory Condition (other than Asthma)

Pulmonary Hypoplasia Respiratory Condition (other than Asthma)

Pulmonary Valve Dysplasia Cardiac Condition

Pyloric Stenosis Digestive System Disorder

Quadriplegia Paralysis – Spinal Cord Injury

Rabies Infection – Current

Recurrent Infection

Rasmussen's Encephalitis / Rasmussen Syndrome Brain Disorder (other than seizures)

Brain Damage

Raynaud's Disease / Phenomenon / Syndrome Include in Note Section, no Diagnosis checked

Reactive Airway Disease Asthma

Reactive Attachment Disorder (RAD) Reactive Attachment Disorder (must verify diagnosis)

Reading Disorder Include in Note Section, no Diagnosis checked

P-00920 (12/2021) Page 24 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Receptive &/or Expressive Language Disorder /

Delay

Neuromuscular Disorder

Receptive Aphasia Neuromuscular Disorder

Rectal Prolapse / Rectal Stenosis Digestive System Disorder

Rectovestibular Fistula Genitourinary System Disorder

Recurring Pneumonia Infection – Current

Recurrent Infection

Reduced Oral Motor Skills And Articulation Include in Note Section, no Diagnosis checked

Reduction Deformity (hand, arm, leg or foot) Musculoskeletal Disorder

Reflux Disease Digestive System Disorder

Refsum’s Disease Metabolic Disorder

Regulatory Disorder Sensory Disorder (other than Blind

Deaf)

Renal Agenesis Renal Failure

other Kidney Disease

Renal Calculi Include in Note Section, no Diagnosis checked

Renal Insufficiency Renal Failure

other Kidney Disease

Respiratory Chain Defect Metabolic Disorder

Respiratory Distress Syndrome (RDS) Respiratory Condition (other than Asthma)

Restless Leg Syndrome Neuromuscular Disorder

Retinal Hypoplasia

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Retinoblastoma Cancer

Retinopathy

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Retinopathy of Prematurity (ROP)

Blind

Severely Visually Impaired (if child is blind)

Include in Note Section, no Diagnosis checked

Rhabdomyosacoma Cancer

Rheumatic Heart Disease Cardiac Condition

Rheumatism Arthritis

Rheumatoid Arthritis Arthritis

Rhinitis Include in Note Section, no Diagnosis checked

Rhizomelic Chondrodysplasia Punctata Musculoskeletal Disorder

Ricketts

Nutritional Imbalance (e.g., Malnutrition, Vitamin

Deficiencies)

Ritscher-Schinzel Syndrome

Developmental Delay

AND

Cardiac Condition AND

Blind or Severely Visually Impaired (if child is blind) OR

Sensory Disorder (other than Blind or Deaf)

Robertsonian Translocation (11;22 Unbalance

Translocation)

Genetic / Chromosomal Disorder

AND

Developmental Delay

Robin Malformation Sequence Digestive System Disorder

Robinow Syndrome Genetic / Chromosomal Disorder

RSV (Respiratory Syncytial Virus) Infection – Current

Recurrent Infection

Ruptured Appendix Include in Note Section, no Diagnosis checked

Ruptured Disc Neuromuscular Disorder

Russell Silver Syndrome Musculoskeletal Disorder

Sadism Sexual

Gender Identity Disorder

Sandhoff Disease Storage Disorder

Sanfilippo Syndrome (MPS III) Storage Disorder

Scabies Include in Note Section, no Diagnosis checked

Schindler Disease Storage Disorder

Schizoaffective Disorder Schizoaffective Disorder (must verify diagnosis)

Schizoid Personality Features / Traits Include in Note Section, no Diagnosis checked

Schuurs-Hoeijmakers Syndrome Genetic / Chromosomal Disorder

P-00920 (12/2021) Page 25 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Schwachman Diamond Syndrome Genetic / Chromosomal Disorder

Sciatica Neuromuscular Disorder

Scimitar Syndrome Cardiac Condition

Scleroderma Skin Disease

Scoliosis Musculoskeletal Disorder

Seasonal Adjustment Disorder Depression (must verify diagnosis)

Seasonal Affective Disorder Depression (must verify diagnosis)

Seborrheic Eczema

Skin Disease (if severe)

Include in Note Section, no Diagnosis checked

Seckel Syndrome Musculoskeletal Disorder

AND

Developmental Delay

Segawa Dystonia Neuromuscular Disorder

Selective Mutism Include in Note Section, no Diagnosis checked

Self Harm Include in Note Section, no Diagnosis checked

Self-Injurious Behaviors (SIB) Include in Note Section, no Diagnosis checked

Semi-Comatose Brain Disorder (other than seizures)

Brain Damage

Sengers Disease Cardiac Condition

Senior-Loken Syndrome Renal Failure

other Kidney Disease

Sensory Integration Disorder / Dysfunction Sensory Disorder (other than Blind

Deaf)

Sensory Issues Sensory Disorder (other than Blind

Deaf)

Sensory Neuropathy Sensory Disorder (other than Blind

Deaf)

Sensory Processing Disorder Sensory Disorder (other than Blind

Deaf)

Separation Anxiety Disorder Anxiety Disorder (must verify diagnosis)

Sepsis Infection – Current

Recurrent Infection

Septo-Optic Dysplasia Sensory Disorder (other than Blind

Deaf)

Severe Anoxic Brain Damage Brain Disorder (other than seizures)

Brain Damage

Severe Behavioral Disorder Disruptive Behavior Disorder (must verify diagnosis)

Severe Learning Problems In ________ Include in Note Section, no Diagnosis checked

Sexual Abuse Of A Child Post-Traumatic Stress

Acute Stress Disorder

Sexual Disorder, Frotteurism, Paraphilia Sexual

Gender Identity Disorder

Sexual Fetish Sexual

Gender Identity Disorder

Shaken Baby Syndrome Brain Disorder (other than seizures)

Brain Damage

Shingles Infection – Current

Recurrent Infection

Shone's Syndrome Cardiac Condition

Short Gut Syndrome Digestive System Disorder

Short-Term Memory Problems Include in Note Section, no Diagnosis checked

Shprintzen's Syndrome

Genetic / Chromosomal Disorder

AND

Immune Deficiency (if present)

Shwachman Diamond Syndrome Digestive System Disorder

Sickle Cell Disease / Traits Anemia (e.g., Sickle Cell, Fanconi’s)

Significant Oral Sensory Deficits Sensory Disorder (other than Blind

Deaf)

Silent Aspiration

Digestive System Disorder

AND

Respiratory Condition (other than Asthma)

Simpson-Golabi-Behmel syndrome (SGBS) Genetic/Chromosomal Disorder

Single Ventricle Defect Cardiac Condition

Sinusitis Infection – Current

Recurrent Infection

Skeletal Dysplasia Musculoskeletal Disorder

Skin Infections Skin Disease

Skin Rash Include in Note Section, no Diagnosis checked

Sleep Apnea Respiratory Condition (other than Asthma)

Sleep Disorder Include in Note Section, no Diagnosis checked

Slight Gait Disturbance Include in Note Section, no Diagnosis checked

Small Bowel Atresia Digestive System Disorder

P-00920 (12/2021) Page 26 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Small Kidneys Renal Failure

other Kidney Disease

Social Phobia

Anxiety Disorder (if severe)

Include in Note Section, no Diagnosis checked

Socialization Disorder / Issues Include in Note Section, no Diagnosis checked

Soft Palate Deformity Congenital Abnormality

Sotos Syndrome Genetic / Chromosomal Disorder

Spasms Neuromuscular Disorder

Spastic Diplegia Cerebral Palsy (other)

Spastic Dystonia Neuromuscular Disorder

Spastic Quadraplegia

Paralysis – Spinal Cord Injury (if true)

Paralysis, Other than Spinal Cord Injury

Spastic Quadriparesis Musculoskeletal Disorder

Spasticity of Muscles Neuromuscular Disorder

Speech and Language Issues Include in Note Section, no Diagnosis checked

Speech Apraxia Neuromuscular Disorder

Speech Delay / Impairment / Disorder Neuromuscular Disorder

Speech Phobic Select Mutism

Anxiety Disorder (if severe)

Include in Note Section, no Diagnosis checked

Spina Bifida (Occulta) Spina Bifida (other)

Spinal Cord Arteriovenous Malformation (AVM) Neuromuscular Disorder

Spinal Muscle Atrophy (Infantile) Spinal Muscular Atrophy

Spinal or Lumbar Stenosis Musculoskeletal Disorder

Spinal Subluxation Musculoskeletal Disorder

Split Hand / Split Foot Anomalies Congenital Abnormality

Spondylolistheses Musculoskeletal Disorder

Static Encephalopathy Brain Disorder (other than seizures)

Brain Damage

Status Epilepticus Seizure Disorder

Stevens Johnson Syndrome Skin Disease

Stickler Syndrome Genetic / Chromosomal Disorder

Stimulant Abuse Substance-Related Disorder (must verify diagnosis)

Strabismus (Heterotropia) Include in Note Section, no Diagnosis checked

Strep Throat (Streptococcal pharyngitis) Infection – Current

Recurrent Infection

Stroke Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Sturge-Weber Syndrome Neuromuscular Disorder

Stuttering Include in Note Section, no Diagnosis checked

Subarachnoid Hemorrhage (SAH) Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Subdural Empyema Infection – Current

Recurrent Infection

Subglottic Stenosis Respiratory Condition (other than Asthma)

Subluxation of [any joint] Musculoskeletal Disorder

Submucous Cleft Palate Congenital Abnormality

Superior Vena Cava (SVC) Obstruction/Syndrome Cardiac Condition

Supernumerary Ring - Chromosome 20 Genetic / Chromosomal Disorder

Suprabulbar Palsy Neuromuscular Disorder

Supraventricular Tachycardia (PSVT)

Cardiac Condition (if severe)

Include in Note Section, no Diagnosis checked

Suspected Autism or PDD Include in Note Section, no Diagnosis checked

Sydenham's Chorea Neuromuscular Disorder

Symbolic Language Disorder Neuromuscular Disorder

Syndactyly Musculoskeletal Disorder

Syringohydromyelia

Paralysis – Spinal Cord Injury (if true)

Neuromuscular Disorder

P-00920 (12/2021) Page 27 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Syringomyelia / Syrnix

Paralysis – Spinal Cord Injury (if true)

Neuromuscular Disorder

Systemic Lupus Erythematosus (SLE) Immune Deficiency

Systemic Mastocytosis Immune Deficiency

Tachycardia Cardiac Condition

Tay-Sachs Disease Storage Disorder

TB / Tuberculosis Respiratory Condition (other than Asthma)

T-E Fistula Respiratory Condition (other than Asthma)

Temporal Lobe Syndrome Brain Disorder (other than seizures)

Brain Damage

Temporomandibular Joint Disorder (TMJ) Include in Note Section, no Diagnosis checked

Teschler-Nicola and Killian Syndrome Genetic / Chromosomal Disorder

Tethered Spinal Cord Neuromuscular Disorder

Tetralogy of Fallot Cardiac Condition

THC Abuse Substance-Related Disorder (must verify diagnosis)

Thoracic Insufficiency Syndrome Respiratory Condition (other than Asthma)

Thoracic Myelomeningocele Musculoskeletal Disorder

Thoracogenic Scoliosis Musculoskeletal Disorder

Thrombocytopenia Hemophilia / Other Blood Disorder

Thrombocytopenia Absent Radius Syndrome (TAR)

Genetic / Chromosomal Disorder

AND

Hemophilia / Other Blood Disorder

Thrombocytopenia Purpura Hemophilia / Other Blood Disorder

Thromboembolus - Cerebral Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Thyroid Disorder / Dysfunction Endocrine Disorder (not Diabetes)

TIA (Transient Ischemic Attack) Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Tic Disorder Neuromuscular Disorder

TMJ (Temporomandibular Joint Disorder) Include in Note Section, no Diagnosis checked

Toe Walking Spasticity Musculoskeletal Disorder

Toriello-Carey Syndrome Brain Disorder (other than seizures)

Brain Damage

Torsade De Pointes Cardiac Condition

Torsion Dystonia Neuromuscular Disorder

Torticollis Musculoskeletal Disorder

Total Anomalous Pulmonary Venous Return Cardiac Condition

Tourette Syndrome Tourette's Syndrome

Toxic Effect of Mercury Include in Note Section, no Diagnosis checked

Toxic Effect of Unspecified Lead Compound Include in Note Section, no Diagnosis checked

Toxoplasmosis

Infection – Current

Recurrent Infection (if congenital)

OR Include in Note Section, no Diagnosis checked

Tracheal Bronchial Malacia Respiratory Condition (other than Asthma)

Tracheitis Infection – Current

Recurrent Infection

Tracheoesophageal Fistula (TE Fistula) Respiratory Condition (other than Asthma)

Tracheomalacia Respiratory Condition (other than Asthma)

Transient Ischemic Attack (TIA) Cerebral Vascular Accident (CVA) (Pre

or Postnatal)

Transient Tic Disorder Neuromuscular Disorder

Transposition of Great Vessels Cardiac Condition

Transsphenoidal Encephalocele Congenital Abnormality

Transverse Myelitis Neuromuscular Disorder

Treacher Collins Syndrome

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Tricho-Rhino-Phalangeal Syndrome

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Tricuspid Atresia Cardiac Condition

P-00920 (12/2021) Page 28 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Trifunctional Protein Deficiency (TFP) Metabolic Disorder

Trigeminal Neuralgia Neuromuscular Disorder

Triplegic

Paralysis – Spinal Cord Injury (if true)

Paralysis, Other than Spinal Cord Injury

Trisomy 14 Mosaic

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Trisomy 1q Genetic / Chromosomal Disorder

Trisomy 20 Genetic / Chromosomal Disorder

Trisomy 21 Down Syndrome – Trisomy 21

Trisomy 22 (Emanuel Syndrome)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Trisomy 2q3

Genetic / Chromosomal Disorder

AND

Developmental Delay

Trisomy 3q

Genetic / Chromosomal Disorder

AND

Developmental Delay

Trisomy 4p

Genetic / Chromosomal Disorder

AND

Developmental Delay

Trisomy 5p

Genetic / Chromosomal Disorder

AND

Developmental Delay

Trisomy 5q

Genetic / Chromosomal Disorder

AND

Musculoskeletal Disorder

Trisomy 8 Genetic / Chromosomal Disorder

Trisomy D (Trisomy 13, Pateau Syndrome)

Genetic / Chromosomal Disorder

AND

Cognitive Disability

Truncus Arteriosus Cardiac Condition

Tuberculosis Respiratory Condition (other than Asthma)

Turner’s Syndrome Genetic / Chromosomal Disorder

Twin to Twin Transfusion Syndrome Include in Note Section, no Diagnosis checked

Ulcerative Colitis Digestive System Disorder

Ulcers – Duodenal, Intestinal, Gastric, or Peptic Digestive System Disorder

Underdeveloped Right Lung Respiratory Condition (other than Asthma)

Undersocialized Conduct Disorder, Aggressive Type

Conduct Disorder (must verify diagnosis)

Undifferentiated Sarcoma Cancer

Upper Airway Obstruction Respiratory Condition (other than Asthma)

Upper Respiratory Tract Infection (URTI) Infection – Current

Recurrent Infection

Urea Cycle Disorder Metabolic Disorder

Urethral Stenosis / Atresia Genitourinary System Disorder

Urinary Incontinence Include in Note Section, no Diagnosis checked

Urinary Tract Infection (UTI) Infection – Current

Recurrent Infection

URTI (Upper Respiratory Tract Infection) Infection – Current

Recurrent Infection

Valproic Syndrome Musculoskeletal Disorder

Valvular Heart Disease Cardiac Condition

Vancomycin Resistant Enterococcus (VRE) Infection – Current

Recurrent Infection

VATER Syndrome VACTERL

Vein Of Galen Malformation Cardiac Condition

Velocardiofacial Syndrome (VCFS) (22q11

deletion)

Genetic / Chromosomal Disorder

Velopharyngeal Dysfunction / Incompetence /

Insufficiency

Include in Note Section, no Diagnosis checked

Ventricular Septal Defect (VSD) Cardiac Condition

Ventricular Tachycardia Cardiac Condition

P-00920 (12/2021) Page 29 of 29

If You See This Diagnosis Check This on CLTS FS Diagnosis Table

Ventriculomegaly

Brain Disorder (other than seizures)

Brain Damage (if

Hydrocephalus is present) OR

Include in Note Section, no Diagnosis checked

Verbal Tics Neuromuscular Disorder

Vertical Talis Multiple Sclerosis

ALS

Vertigo Include in Note Section, no Diagnosis checked

Vesicoureteral Reflux Genitourinary System Disorder

Viral Enchephalitis Infection – Current

Recurrent Infection

Visceral Hyperalgesia Digestive System Disorder

Vision Impairment

Blind

Severely Visually Impaired (if child is blind)

Sensory Disorder (other than Blind or Deaf)

Visual Perception Disorder Sensory Disorder (other than Blind

Deaf)

Vitamin [Any] Deficiency

Nutritional Imbalance (e.g., Malnutrition, Vitamin

Deficiencies)

Vitiligo Skin Disease

Vocal Cord Paralysis

Respiratory Condition (other than Asthma) (if severe)

Include in Note Section, no Diagnosis checked

Voice and Resonance Disorder Include in Note Section, no Diagnosis checked

Von Willebrand Disease Hemophilia / Other Blood Disorder

VRE (Vancomycin Resistant Enterococcus) Infection – Current

Recurrent Infection

VRSA (Vancomycin Resistant Staphylococcus

Aureus)

Infection – Current or Recurrent Infection

VSD (Ventricular Septal Defect) Cardiac Condition

Waardenburg Syndrome

Genetic / Chromosomal Disorder

AND

Deaf or Severely Hearing Impaired

WARG Syndrome

Renal Failure

other Kidney Disease (if present)

AND

Genitourinary System Disorder (if present) AND

Cognitive Disability (if present)

Warts Include in Note Section, no Diagnosis checked

White Matter Disease Neuromuscular Disorder

Wilms Tumor Cancer

Wolff Parkinson White Syndrome (WPW) Cardiac Condition

Worster-Drought Syndrome Cerebral Palsy (other)

Wound Infection

Wound, Burn, Bedsore, Pressure Ulcer

AND

Infection-Current or Recurrent Infection

XXX Syndrome (Triple X Syndrome) Genetic / Chromosomal Disorder

XYY Syndrome (Klinefelter) Genetic / Chromosomal Disorder

Yeast Infection Infection – Current

Recurrent Infection