Prescriber Notice: Diagnosis Code Requirement for Certain Medications

As part of ongoing efforts to ensure compliance with regulatory requirements, Highmark has identified a billing documentation gap related to certain high-cost and/or potentially abused maintenance medications.

During Medicaid drug claim reviews, auditors require documentation of a corresponding diagnosis that aligns with the FDA-approved indication for the prescribed medication. To ensure compliance and maintain the integrity of clinical records, providers must include the corresponding ICD-10 diagnosis code with all billed medical encounters involving prescribed maintenance medications on an annual basis, at a minimum.

This requirement is especially important for the following therapeutic drug classes, which are flagged for review:

• Stimulants (e.g., Adderall, Ritalin)
• Inflammatory Conditions (e.g., Entyvio, Cosentyx, Taltz, Humira, Rinvoq)
• Bowel Conditions (e.g., Trulance, Pentasa, Linzess, Sulfasalazine)
• Movement Disorders (e.g., Austedo, Ingrezza, Tetrabenazine)

Accurate and complete documentation, including diagnosis codes, not only supports appropriate clinical review and regulatory compliance, but also facilitates timely claims processing and continuity of care.