AHIMA TO CONGRESSIONAL HEALTHCARE COMMITTEES: ICD-10 CAN HELP REDUCE FRAUD
’05 study calls up-to-date classification systems essential to IT-enabled fraud management programs

CHICAGO, May 16—In a letter today to four key Congressional healthcare committees, the American Health Information Management Association (AHIMA) cites two reports on healthcare anti-fraud activities that indicate implementation of ICD-10-CM and ICD-10-PCS could help reduce healthcare fraud.

“AHIMA strongly believes that ICD-10-CM and ICD-10-PCS allows for more accurate and detailed clinical information to be captured and aggregated for improved data reporting and analysis functions including identifying fraudulent or abusive practices,” said Linda Kloss, MA, RHIA, AHIMA CEO. “We have two reports on anti-fraud activities developed by authoritative industry experts that support this position.”

The reports, released in October 2005, were the result of a project conducted by the Foundation of Research and Education (FORE) of AHIMA under contract to the Office of the National Coordinator for Health Information Technology (ONC) within the U.S. Department of Health & Human Services (HHS).

The letter cites one of the Guiding Principles in a report titled, "Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities," which states, “Up-to-date classification systems that facilitate the automation of clinical coding are essential to the adoption of interoperable [electronic health records] EHR’s and the associated [information technology] IT enabled healthcare fraud management programs.”

The Guiding Principles were developed by an executive committee of cross-industry experts representing providers, payers, information technology, fraud investigative services, finance, and government and included representatives from The Office of the Inspector General of the U.S. Department of Health and Human Services, the U.S. Department of Justice and the Blue Cross Blue Shield Association.

The report also states, “The [Nationwide Health Information Network] NHIN is more likely to be using ICD-10 codes, which can more accurately document a person’s true health disposition than ICD-9 codes. Though this will not prevent fraud outright, the ‘gray area’ fraud, where up-coding can represent a situation that exaggerates the severity of a patient’s condition for provider financial gain, may be deterred somewhat.”

While this report does note that any transition to a new coding system could present an increased opportunity for fraud in the beginning, when people are less familiar with the new codes, it concludes that, in the long term, it is possible fraud could be reduced since ICD-10-CM and ICD-10-PCS are more specific and there are fewer “gray” areas in coding. In 2003, AHIMA and the American Hospital Association (AHA) conducted a field test of ICD-10-CM medical code sets. That study showed ICD-10 is a significant improvement over the current ICD-9-CM coding system and, despite minimal training, participants were able to appropriately assign ICD-10-CM codes.

The second anti-fraud report, "Automated Coding Software: Development and Use to Enhance Anti-Fraud Activities," additionally notes that the current “outdated code set” (ICD-9-CM) inhibits the use of automated coding features that may reduce fraud.

The letter, which also urged committee members to support HR 4157 (Health Information Technology Promotion Act of 2005)—a bill containing provisions for adoption of ICD-10—was sent to members of the House Committee on Energy and Commerce, the House Committee on Ways and Means, the Senate Committee on Health, Education, Labor, and Pensions, and the Senate Finance Committee.

Copies of the anti-fraud study reports are available on AHIMA’s website at http://www.ahima.org/fore/fraudrpt.asp and on the website of the Office of the National Coordinator for Health Information Technology (ONC) at www.hhs.gov/healthit/hithca.html.

About AHIMA
AHIMA is the national association of health information management (HIM) professionals. AHIMA's 51,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. For information about the Association, go to www.ahima.org.

About FORE
FORE provides financial and intellectual resources to sustain and recognize continuous innovation and advances in HIM for the betterment of the profession, healthcare, and the public. For more information, visit www.ahima.org/fore.