Insurance Fraud: How ICD-10 coding will help and hinder detection

Carl Natale
by Carl Natale

Healthcare payers have a fairly sophisticated system to detect fraud and abuse.

Basically, they use mathematical formulas that examine claims. The formulas are based upon patterns of abuse and fraud using ICD-9 codes.

So what happens when medical claims switch to ICD-10 codes Oct. 1, 2014?

A Jvion whitepaper, An Innocent Mistake or Intentional Deceit—ICD-10 and Healthcare Fraud Detection, predicts longer reimbursement cycles and more denials or requests for information. After Oct. 1, 2014, there won't be patterns using ICD-10 codes. The formulas won't be as effective.

As more data is collected, new formulas will get better at detecting fraud and freeing reimbursements for legitimate medical claims. The whitepaper calls for more technology that will assess the ICD-10 data more quickly and lead to more accurate fraud-detection formulas.

Defining the Core Clinical Documentation Set for Coding Compliance

There's a lot of discussion about the need to improve clinical documentation to support the specificity of ICD-10-CM/PCS coding. This American Health Information Management Association (AHIMA) whitepaper looks at specific elements you need to examine in your documentation. (

Electronic Documentation Templates Support ICD-10-CM/PCS Implementation

This week I looked at integrating EHRs into ICD-10 implementation. This in-depth article looks at how to change your EHR templates. (Journal of AHIMA)

7 Steps for Surgery Centers to Prepare for ICD-10

This is a pretty good seven-step plan:

  1. "Start anatomy and physiology training for coders"
  2. "Start training physicians on documentation"
  3. "Talk to your vendors about their transition plans"
  4. "Talk to commercial payors about their transition plans"
  5. "Make contingency plans for workers' compensation"
  6. "Follow the "day in the life" of a diagnosis code"
  7. "Consider outsourcing coding and billing functions'

The post also warns about the need to keep using ICD-9 coding for workers' compensation cases. It also suggests locking in outsourcing with long-term contracts. (Becker's ASC Review)

Physicians still reluctant to embrace ICD-10 implementation

There's still a lot of vigorous griping. (ICD10 Watch)

Aligning ICD-10 Efforts with Broader Strategic Goals

A computer assisted coding (CAC) system can use natural language processing (NLP) to make ICD-10 implementation easier. But Anand Shroff  looks at other applications of NLP and how it can help healthcare providers. (ADVANCE for Health Information Professionals)

Common ICD-10 Assessment Findings and Impacts

Keith Fulmer takes a pretty good look at some of the ICD-10 challenges that should be addressed in your ICD-10 impact assessment. (Keith Fulmer's Blog)

ICD-10 Debunked & Confirmed: Learning about ICD-10 from the Past, and the North

Doris Gemmell is director of coding services at Accentus, based in Ottawa, Ontario, knows a few things about ICD-10 implementation. She offers a fresh look at the transition and "myths" that came out of it:

  1. ICD-10 is Only a Coding Issue
  2. Skipping Ahead to ICD-11 is a Viable Option
  3. GEMS Solve all Translation Issues
  4. CAC Mitgates Productivity Losses
  5. Patient Outcomes Improve with ICD-10
  6. ICD-10 Will Not Benefit Physicians
  7. ICD-10 is Worth the Hard Work

It's also worth noting that the ICD-10-CA code set that the Canadian healthcare system uses is different from the impending ICD-10-CM and Canada uses a single-payer system that does not reimburse healthcare providers according to ICD codes. (Journal of AHIMA)

Providers look to Canada for lessons in ICD-10 implementation

Pretty much a rehash of implementation problems in Canada that I've covered. Inadequate training and attitude were issues that led to a major productivity drop. (

Want to Know If You’re Up to Speed on ICD-10? Take Our Short Quiz

Just for fun. That's it. (

3 Steps Hospitals Must Take With Their Coding Compliance Policies

While you're assessing the impact of ICD-10 implementation, maybe you should check current compliance standards. (Becker's Hospital Review)

Estimating the costs of ICD-10 implementation

This is a broad introduction to budgeting ICD-10 implementation costs and relies on a white paper, Equipping Physicians for ICD-10 Compliance: Addressing the Revenue Disruption Associated with the Transition to ICD-10, by MediMobile.  The whitepaper relies on the often quoted Nachimson Advisors study that puts the cost at $83,000 for a three-physician practice. It's worth noting that more than half of the estimate is for changes in clinical documentation. (

How Do Electronic Superbills Increase Efficiency?

Perhaps electronic superbills can solve a problem created by the increase in the number of ICD-10 codes. (Power Your Practice)

Leading the Change to ICD-10 from Any Seat

Not just executives should be encouraged to take leadership roles in the ICD-10 transisition. (ADVANCE for Health Information Professionals)

Not Just ICD-10-“CM”, but also “PCS”!

An introduction to the ICD-10-PCS code set. (CollaborateMD)

ICD-101: Use in-house expertise for ICD-10 training

Some ICD-10 coding examples and a way you can use in-house resources to train your staff. . (ICD10 Watch)