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False ICD codes used

In our Los Angeles Employment Attorney office, we see many examples of health care fraud. One of the most prevalent areas which our whistle blower clients report to us comes from the world of ICD coding. This is a common, short-hand expression for International Statistical Classification of Diseases and Related Health Problems. These codes date back to 1893. In 1948 the World Health Organization took over, releasing ICD-9. Since then, this code system has been updated several times. The most recent version is ICD-10, but the US remains on ICD-9-CM (standing for clinical modification). the United States Department of Health and Human Services expects to transfer to ICD 10-CM in October, 2014. But, enough history. Here’s what the current issues are that our whistle blower clients in the health care industry bring to us:

Those good folks who actually enter codes into billing are called “coders”, they are not medical care providers or treaters. They are normally required to do a certain amount of billing or charts per day and have little to no interaction with t he treater who charted the information. There is an entire industry of software providers (such as the HSI regrouper), and there are approximately 200 different programs. When the greater selection of codes under ICD-10 is in place, there will be conversion problems and higher errors. Industry spokesmen say it will take six months to come back up to speed in billing. Here are some major changes and problems to expect:

Built-in cause codes and third parrty billing codes will mean almost instant lien placement on a patient’s insurance rights, in many cases beffore they are even home from the hospital!

Upcoding will be more prevalent due to many more third-party coding choices. There is a major concern that the coder may be pressured into upcoding incidents where reimbursement rates 9say, are higher, like third-party insurance, than properly billing the HMO rate.

New coding standards will necessarily involve calling in expert ┬átestimony in many cases in which patient medical bills are reviewed for “ordinary and necessary” standards.

In our practice, we will call in coding experts with knowledge as to whether complaints brought by our clients (many times coders, or other back office personnel, including managers, represent actual or “reasonably-regarded as” illegalities. We’d be honored to let our attorneys in our Los Angeles Employment Attorneys office review your health care whistle blower case.

Department of Fair Employment and Housing


United States (Federal) Department of Labor