upcoding

upcoding

Medicare A fraudulent practice in which provider services are billed for higher CPT procedure codes than were actually performed, resulting in a higher payment by Medicare or 3rd-party payors. See Coding, CPT coding, Health care fraud, HIPPA Act, Prompt payment law, Rebundling, Unbundling. Cf Downcoding.
References in periodicals archive ?
Therefore, we are uncertain as to whether there will be a positive or negative relationship between patients' income and upcoding.
There was a period of time in which CMS and the Department of Health and Human Services' Office of the Inspector General thought physicians were upcoding everything "and went on a witch hunt," Dr.
* Billing for a service not furnished as billed; i.e., upcoding.
Ample evidence of facility confusion has surfaced over the years, most particularly in the recent OIG study disclosing a mishmash of PPS upcoding and downcoding without apparent reason.
* More than $403 million to resolve civil claims arising from "upcoding," where false diagnosis codes were assigned to patient records in order to increase reimbursement to the hospitals by Medicare, Medicaid, TRICARE and the Federal Employees' Health Benefits Program.
The partners in a group practice are in formed by the clinic manager that one member of the group has been repeatedly upcoding procedures for a specific diagnosis.
The two major problem areas were identified as billing for services that were not medically necessary and upcoding services to secure a higher reimbursement than justified.
As is said, "that was then and this is now." Some of the articles and editorials that have appeared in the national and health care press seem a bit disingenuous registering their shock and surprise at the allegations of "upcoding" at Columbia/HCA and improper billing or over-serving Medicare home care patients.
Overbilling, billing for services not rendered, "upcoding" to receive higher reimbursements than deserved, kickbacks and inducements for referrals have all been cited as particularly problematic.
In 1986, physician fees increased mainly as a result of overcharging through unbundled billing and upcoding. These trends are expected to continue into the 1990s as physicians and hospitals seek additional revenue to attract registered nurses into an evaporating nursing market and to keep up with the escalating costs of advanced medical technology.
The key to success lies with implementing a method of identifying the leakage through proven medical bill audits and injury evaluation decision support tools that address benchmark medical pricing, relatedness and duration of treatment coupled with deceptive practices such as upcoding, unbundling or modifier abuse, causation, severity, venue specificity and negotiation improvement.
I have about six examples in which a quarter of a million dollars is the usual penalty for upcoding to the tune of $8,000 or $10,000.