Tag Archives | Upcoding

Feds Crack Down on Upcoding

By the time the late President Lyndon B. Johnson signed the law establishing Medicare and Medicaid in 1965, the health care community was already figuring out how to maximize its returns from these new programs designed to insure the elderly, poor, and disabled. Those proceeds, however, have been generated over the years in ways that […]

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Healthcare Hotbed for Fraud Cases

While it might surprise some folks that five Modesto doctors are among those facing fraud charges in a $40 million medical billing and kickback case based in Southern California, it shouldn’t surprise anyone that there was yet another medical fraud case. Wherever there is money, you’ll find people or institutions are that ripe for defrauding, […]

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Upcoding vs. Downcoding: Know the Difference

“Upcoding” means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider’s documentation. For example, reporting a diagnosis of chronic bronchitis if the patient has acute bronchitis qualifies as upcoding, as would billing a level 5 evaluation and management (E&M) service (e.g., 99215) […]

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$56 Question—Are You Downcóding Your E/M Visits?

You’re not only losing revenue—you’re also coding improperly.

CMS data from previous years shows that medical practices undercodè E/M claims to the tune of over $1 billion annually—that’s money that physiciáns could have collected based on their documentation, but forfeited because they reported a lower-level codè than they should have. But remember that your responsibility as someone who submits claims to Medicarè is to codè based on the documentation—anything else is incorrect coding.

If you’re one of the practices that’s downcoding claims, take note of the following reasons that you should codè based on your documentation rather than undercoding.

Could You Be Triggering an Audit?

The number one reason that many practices undercodè is because they don’t want to “trigger an audit.” However, coding all low-level E/M codès is sure to get a payer’s attention, because the claims reviewers will be wondering why you never offer high-level evaluations to your patients.

When claims reviewers review “bell curves” to determine whether a practice is coding outside the norm, they aren’t just looking for upcoding—they are looking at trends across the board. This means that a practice with all 99212s and 99213s will be vulnerable, because nearly every practice sees more complex patients requiring high-level E/Ms at least once in a while. If an auditor reviews your rècords and determines that you’re deliberately downcoding claims, they’ll conclude that you’ve been coding improperly.

Consider Compliance Implications

If you’re deliberately undercoding your claims to stay under the radar, you’re technically violating the False Claims Act because you are knowingly submitting a false claim. “It’s a violation just as much as deliberate upcoding is a violation, but the government most likely isn’t going to pursue it because ultimately it savès the Medicarè program money,” says John B. Reiss, PhD, JD, a health care attorney…

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