When you start a career as a medical biller, you might hear the term upcoding in conversation. But, what is upcoding?

Upcoding happens when a healthcare provider submits codes to Medicare, Medicaid, or other insurance providers for more expensive diagnoses or procedures than the provider diagnosed or performed.

It is the act of submitting a claim with a diagnosis/procedure code to the payor, which in most cases is a health insurance firm, that is more severe or costly than what is appropriate.

For example, if a patient is treated for a broken arm, the hospital may upcode the service and bill for a more expensive code corresponding to treating a broken arm with surgery. This can result in higher medical bills for the patient.

Upcoding is not only unethical, it might cost you your job. If someone suggests that you upcode something – even if it’s a slight difference – you should report that person immediately.

Types of Upcoding

There are various types of upcoding, but all result in the provider receiving more reimbursement than they should.

One kind of upcoding is overcoding. Overcoding happens when a provider submits a claim with a diagnosis or procedure code that is more severe than what actually happened. It can also occur if a healthcare provider adds more to the bill than what happened.

Another type is miscoding, when a provider offers a claim with a diagnosis or procedure code that does not accurately reflect what was diagnosed or performed. Sometimes this is a simple error. However, it can be done to charge an insurance company and patient more.

Why do health providers and medical billers upcode?

Healthcare providers may engage in this unethical practice to increase their profits, but it can also be used as a tool for fraud.

By submitting claims with more serious or costly procedures than what was performed, the provider can receive more reimbursement from the payor than they should. This can result in significant losses for the payor and taxpayers, who fund Medicare and Medicaid.

It can result in improper payments to the provider and, ultimately, higher premiums for everyone else. It also leads to higher costs for government programs like Medicare and Medicaid.

What does upcoding cost taxpayers?

It isn’t easy to come up with an accurate estimate of how much Medicare spends each year on upcoding.

Upcoding is a problem that affects Medicare patients across the country. That’s because upcoding is a complex issue that is very difficult to measure. Upcoding is also not confined to a particular region, type of provider, or patient.

When a hospital upcodes, the billers assign a code for a more expensive service or procedure in medical billing than the performed one.

However, it is important to note that not every hospital or provider is guilty of upcoding, and many healthcare administrators and professionals work hard to provide accurate billing information.

If you want to be one of the healthcare professionals that prevents damage from upcoding, get started today on your medical billing course. With a career as a medical biller, you’ll be ready to help your community.