Is upcoding the same as fraud?

Intentional upcoding is fraud under the False Claims Act and state law. Not all upcoding is intentional, though — coding errors, ambiguous documentation, and complex coding rules can produce inadvertent upcoding. Either way, you have the right to be billed accurately and can dispute charges that don't match the services you received.

How can I tell what level my office visit should have been?

Under the 2021 E/M guidelines, visit levels are based on medical decision-making complexity or total time. Level 3 (99213) is a low-complexity problem; Level 5 (99215) is high complexity, multiple conditions, high-risk treatment plan. Request your visit notes — they document the factors that determine the level.

What is the global surgical package, and what's included in it?

The global surgical package covers the procedure, local/topical anesthesia, the immediate post-op care, routine follow-up visits within 10 or 90 days depending on the procedure, post-surgical pain management, wound care, and treatment of routine complications. Services unrelated to the surgery (a different condition) can be billed separately with modifier 24.

What is the 8-minute rule in physical therapy billing?

The 8-minute rule sets how many 15-minute units of timed PT services can be billed: 8–22 min = 1 unit, 23–37 = 2 units, 38–52 = 3 units, 53–67 = 4 units. Less than 8 minutes of timed work bills 0 units. Untimed codes (evaluations, group therapy, hot/cold packs) bill once per session regardless of duration.

How do I know which therapy session code should be used?

Psychotherapy codes are based on actual face-to-face time: 90832 (16–37 min), 90834 (38–52 min), 90837 (53+ min). Note the start and end of your sessions. If your sessions consistently run 45 minutes but you're billed 90837, the code is likely wrong. The Mental Health Parity Act also requires insurers to cover mental health no more restrictively than medical care.

Where can I report suspected upcoding or billing fraud?

Report to your insurance company's fraud hotline, the HHS Office of Inspector General (1-800-HHS-TIPS), your state attorney general, or the CMS fraud hotline (1-800-MEDICARE for Medicare fraud). Whistleblowers may be entitled to a portion of recovered funds under the False Claims Act.

Top 10 Medical Billing Errors and How to Spot Them

Medical billing errors are surprisingly common, with studies showing that a significant percentage of medical bills contain mistakes. These errors can add hundreds or even thousands of dollars to your bill. Here are the top 10 errors you should watch for.

1. Duplicate Charges

One of the most common errors is being charged twice for the same service, medication, or procedure. This often happens during shift changes or when billing departments merge records from different departments.

How to spot it: Look for identical line items with the same date, time, and description. Even if the charge amounts differ slightly, they might be duplicates.

2. Unbundling (Fragmented Billing)

Unbundling occurs when a hospital bills separately for services that should be combined into one charge. For example, if you had blood work done, the hospital might charge separately for drawing the blood, the lab analysis, and the supplies, when these should be bundled together.

How to spot it: Look for multiple small charges related to a single procedure. Medicare's National Correct Coding Initiative (NCCI) defines which procedures should be bundled together.

3. Upcoding

Upcoding happens when you're billed for a more expensive service than what you actually received — a more complex procedure than was performed, a higher-level office visit than your visit warranted, or a brand-name medication when you received a generic. Common variants include E/M level inflation (CPT 99213 at ~$110 vs 99215 at ~$250), DRG upcoding on hospital stays (where adding a complication code can shift you to a higher-paying group worth $2,000–$10,000), and being billed as a new patient (CPT 99204 ~$300) when you're an established patient (99214 ~$175). Mental health visits are particularly prone to session-length upcoding — a 30-minute session billed as 90837 (53+ minutes, ~$175) instead of 90832 (16–37 minutes, ~$80).

How to spot it: Compare the CPT codes on your bill with the actual services you received. If every visit to the same provider is billed at Level 4 or 5, that pattern can indicate systematic upcoding. Time your therapy sessions and compare against the billed code. For hospital stays, request the DRG assignment and compare against your discharge summary. Suspected upcoding can be reported to the HHS Office of Inspector General (1-800-HHS-TIPS).

4. Services You Never Received

Sometimes bills include charges for procedures, tests, or medications that were never provided. This can happen due to clerical errors or mix-ups with another patient's records.

How to spot it: Review every line item carefully. If you don't recognize a service, ask for clarification. Keep notes about your care to help verify what actually happened.

5. Incorrect Quantity

You might be charged for more units of a medication, more days in the hospital, or more physical therapy sessions than you actually received. Physical therapy is especially error-prone because of the Medicare 8-minute rule: 8–22 minutes of timed services bills as 1 unit, 23–37 as 2 units, and 38–52 as 3 units. A 30-minute session billed as 3 units is incorrect. Untimed PT codes (evaluations 97161–97163, group therapy 97150) should be billed once per session regardless of length.

How to spot it: Track your medications, therapy sessions, and hospital days. Compare these records with your bill's quantities. For PT, ask how many minutes of timed services you received and check it against the billed units.

6. Canceled Services or Procedures

If a test or procedure was ordered but then canceled before it was performed, you shouldn't be charged for it. However, billing systems may not always be updated when services are canceled.

How to spot it: If you remember a procedure being scheduled but not performed, check if it appears on your bill.

7. Surgery Billing Errors (OR Time, Global Package, Assistant Surgeon)

Surgical bills are dense and error-prone. The most common mistakes:

Operating room time inflation. OR time is billed in 15-minute increments. Billed time that exceeds actual time can double the facility fee.
Global surgical package unbundling. When a surgeon bills a procedure code (e.g., CPT 59400 for vaginal delivery, 59510 for C-section), it already includes routine post-op visits within a 0/10/90-day window. Separate E/M codes (99212–99215) billed inside that window are usually unbundling.
Unnecessary assistant surgeon fees. Modifier 80 billed on procedures where Medicare and most insurers don't allow an assistant. A wrongly-applied assistant fee is typically $1,000–$5,000.

How to spot it: Request the operative report and anesthesia record — they have exact start/end times. Compare them to the billed OR minutes and the post-op visit dates against the global period for your procedure code.

8. Out-of-Network Charges at In-Network Facilities

Even when you go to an in-network hospital, you might be treated by out-of-network providers (like anesthesiologists, radiologists, or emergency room doctors) without your knowledge or consent. Thanks to the No Surprises Act, you have protections against many of these charges.

How to spot it: Check if any providers listed on your bill are out-of-network. If the service was emergency care or you had no choice in the provider, you may be protected from balance billing.

9. Keystroke/Data Entry Errors

Simple typos can turn a $100 charge into a $1,000 charge. A misplaced decimal point or an extra zero can dramatically inflate your bill.

How to spot it: If a charge seems unusually high compared to similar items, it might be a data entry error. Compare prices across line items and look for outliers.

10. Failure to Apply Insurance Properly

Sometimes bills show charges that should have been covered by your insurance. This can happen if the hospital has outdated insurance information, codes the claim incorrectly, or fails to submit it properly.

How to spot it: Compare your Explanation of Benefits (EOB) from your insurance company with your bill. If they don't match, contact both the hospital and your insurer to resolve the discrepancy.

What to Do If You Find Errors

If you discover any of these errors on your medical bill:

Document everything: Take photos, make copies, and keep detailed notes
Contact the hospital's billing department immediately
Request an itemized bill if you don't already have one
File a formal appeal in writing
Don't pay disputed charges while the appeal is pending
Consider using Health Bill Central to help identify errors and generate appeal letters

Pro Tip: Always request an itemized bill rather than just a summary. Itemized bills show every charge in detail, making it much easier to spot errors.

If you find errors on your bill, learn how to appeal a medical bill step by step. You may also qualify for charity care programs that can reduce your bill even further.

Also watch out for hospital facility fees — a separate charge many hospital-owned clinics add on top of the provider's fee, sometimes doubling the cost of routine visits.

The Bottom Line

Medical billing errors are not just common—they're the norm. By carefully reviewing your bills and watching for these top 10 errors, you can potentially save thousands of dollars. Don't be afraid to question charges and demand corrections. It's your right as a patient, and the hospitals are legally required to provide accurate billing.

Content is for informational purposes only and does not constitute financial, legal, or medical advice. Consult a qualified professional for advice specific to your situation.