Health Information Management

Tip: Recognize fraud potential in ICD-10

APCs Insider, June 28, 2013

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Organizations could face potential post-payment liability if coders continually default to unspecified ICD-10-CM codes.

Physicians may default to a code that gets them paid, like they do in ICD-9. Physicians commonly document "diabetes" without any additional specifications because they know they will get paid when the coder reports ICD-9 code 250.00. Odds are, physicians will still look for codes they know will be paid in ICD-10-CM.

Just because you get paid doesn't mean you should be paid. Also, by documenting a code based on reimbursement and not accurately reflecting the patient's clinical condition, providers open themselves up to potential fraud allegations.

Physicians unfortunately have fallen into the routine of looking for a code that will get them paid instead of the code that best reflects the patient's condition. They have forgotten about the step where they have to validate that the patient has the condition.

This tip is adapted from “Check out the view from the industry as ICD-10 implementation draws closer” in the June issue of Briefings on APCs.



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