Diagnosis Code Requirement on Certain Pharmacy Claims
Effective January 25, 2024, the MO HealthNet Division (MHD) began requiring ICD10 diagnosis codes on pharmacy claims for select drugs and drug classes in order to gain further insight into actual real-world utilization of drug products for on and off-label indications. This will allow MHD to potentially improve the transparent processing of pharmacy claims for these select drugs and drug classes. Pharmacists will also be able to utilize the diagnosis information to meaningfully enhance the pharmacist-patient ProDUR interactions.
Select drugs and drug classes that require ICD10 diagnosis codes on the pharmacy claim:
- Checkpoint Inhibitors – including CTLA-4 inhibitors, PD-1 inhibitors, and PD-L1 inhibitors
- Complement Inhibitors (excluding intravitreal) - reference the following for further criteria:
- FGFR inhibitors
- Immunoglobulins (IVIG and SCIG) - reference Immunoglobulins (IVIG and SCIG) Clinical Edit | mydss.mo.gov for further criteria
- PARP inhibitors
- Targeted Immune Modulators - reference the following for further criteria:
- Cryopyrin-Associated Periodic Syndrome (CAPS) Agents PDL
- Targeted Immune Modulators, Interleukin-6 (IL-6) Receptor Inhibitors PDL
- Targeted Immune Modulators, IL-17A Antibody/IL-17 Receptor Antagonists PDL
- Targeted Immune Modulators, IL-23 Inhibitors & IL-23/IL-12 Inhibitors PDL
- Targeted Immune Modulators, Janus Kinase (JAK) Inhibitors PDL
- Targeted Immune Modulators, Misc. Allergy and Asthma Related Monoclonal Antibodies PDL (formerly Respiratory Monoclonal Antibody PDL)
- Targeted Immune Modulators, Select Agents PDL Edit
- Targeted Immune Modulators, Small Molecule Janus Kinase (JAK) Inhibitors Clinical Edit
- Targeted Immune Modulators, Tumor Necrosis Factor (TNF) Inhibitors PDL Edit
MHD has accepted ICD10 diagnosis codes on pharmacy claims since August 16, 2020. Before including the ICD-10 code on the pharmacy claim, the pharmacy should verify that the code is billable. As an example, the code F20 Schizophrenia is a non-billable code. It lacks the full specificity needed to be billable. The list of billable ICD-10 codes for Schizophrenia is below, and the exact diagnosis code should come from the prescriber of the medication and will be subject to audit. For the diagnosis of paranoid schizophrenia, the diagnosis code should be submitted as F200.
- F20 Schizophrenia
- F200 Paranoid schizophrenia
- F201 Disorganized schizophrenia
- F202 Catatonic schizophrenia
- F203 Undifferentiated schizophrenia
- F205 Residual schizophrenia
- F2081 Schizophreniform disorder
- F2089 Other schizophrenia
- F209 Schizophrenia, unspecified
In the pharmacy’s point-of-sale software, the diagnosis code should be entered into the NCPDP field 492-DO without the period.
Pharmacies must stay informed about the latest updates to standards and requirements in the pharmacy industry. This includes staying current with the NCPDP Telecommunication Standard.
Pharmacies should contact their software vendors or pharmacy system providers to inquire about the capabilities of their systems, including support for NCPDP fields such as 492-DO, to ensure pharmacies are meeting the necessary claims processing requirements.