Poster: Evaluating ICD Codes on Pharmacy Claim Submissions: Are They Reliable?
Clinical Insights
April 23, 2025
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Key Findings
- Most drug categories reviewed showed a consistent trend of predominantly correct ICD codes.
- Nearly half (~43.7%) of the claims pulled from eligible clients did not have an attributed ICD diagnosis code submitted with the claim
- Incorrect codes were evenly divided between those linked to a relevant diagnosis or medication and those without a relevant association. (e.g. Aimovig® and hyperlipidemia but having atorvastatin on file). Conversely, those that had no relevant medication or discernable diagnosis (e.g. Trulicity® for Type 1 Diabetes) were present but at. a considerably low percentage.
Capital Rx's Zachary Brunko, PharmD (PGY1 Managed Care Resident), Jackie Lolos (Manager, Formulary Operations), and Nisha Bhide (Senior Director, Formulary Operations) conducted a study seeking to evaluate the accuracy and reliability of ICD codes submitted on pharmacy claims. Additionally, they sought to identify patterns in ICD code submissions across client types, drug classes, disease states, pharmacy networks, and regions.
The team presented their research findings at the AMCP 2025 Annual Conference. Review or download the poster below to see their findings.
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