Reminder: Include ICD-10-CM Diagnosis Codes on Pharmacy Claims
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This reminder describes that ICD-10-CM diagnosis codes will be required on pharmacy claims for adjudication and applies to pharmacy providers and prescribers submitting Medi‑Cal Rx pharmacy claims.
Effective fall 2026, ICD-10-CM diagnosis code(s) will be required for pharmacy claim adjudication.
Medi‑Cal Rx accepts up to five ICD-10-CM diagnosis codes on submitted pharmacy claims.
Existing Code I drug-specific ICD-10-CM requirements remain in effect and claims for those drugs without required codes are denied.
Claim Adjudication Requirements
ICD-10-CM requirement for claim adjudication
Claims adjudication requirement and consequences
Code I drug-specific ICD-10-CM requirements
Drug-specific requirements
ICD-10-CM Coding on Pharmacy Claims
| Up to five ICD-10-CM diagnosis codes accepted on pharmacy claims; specific drugs on the CDL may require particular ICD-10-CM codes. |
Required Actions for Providers and Prescribers
Include ICD-10-CM diagnosis code(s) on all pharmacy claims
Pharmacy providers must include ICD-10-CM diagnosis code(s) on all pharmacy claim submissions; prescribers should provide the appropriate ICD-10-CM diagnosis code(s) with the prescription so pharmacies have the information and can document codes in the member's health record. Claims submitted without an ICD-10-CM diagnosis code will deny and must be resubmitted with the required information.
- Pharmacy providers may contact the prescriber if the ICD-10-CM diagnosis code(s) is not listed on the prescription.
- The ICD-10-CM diagnosis code(s) on the pharmacy claim should match the prescriber-reported code(s).
- Medi‑Cal Rx accepts up to five ICD-10-CM diagnosis codes on submitted pharmacy claims.
Key Definitions
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