What is Upcoding and How to Spot It on Your Medical Bill
Upcoding is when providers bill higher-level codes than warranted. Learn to identify E/M level inflation, DRG upcoding, and CPT manipulation.
Potential savings: $50-$10,000
Upcoding is one of the most prevalent forms of medical billing fraud, costing the healthcare system billions of dollars annually. It occurs when a healthcare provider assigns a billing code that represents a more severe diagnosis, a more complex procedure, or a higher level of service than what was actually provided. While sometimes the result of honest coding errors, systematic upcoding is considered fraud under the False Claims Act.
What Is What is Upcoding and How to Spot It on Your Medical Bill?
Upcoding means using a CPT, ICD-10, or DRG code that reflects a higher level of service, severity, or complexity than what was actually documented or provided. The most common form involves Evaluation and Management (E/M) codes, where a routine office visit (99213) might be billed as an extended visit (99215). DRG upcoding in hospitals assigns a higher-paying diagnosis-related group to increase reimbursement. Both result in higher costs to patients and insurers.
Common Billing Errors
Billing a higher-level office visit than what your visit involved. A Level 3 visit (99213) involves a straightforward problem, while Level 5 (99215) requires high-complexity decision-making. Many providers routinely bill Level 4 or 5 when Level 2 or 3 is appropriate.
CPT 99213 (~$110) vs 99215 (~$250)Hospitals may assign a more severe Diagnosis-Related Group (DRG) to a hospital stay to receive higher reimbursement. This can involve adding complication or comorbidity codes that do not reflect the patient's actual condition.
DRG with CC/MCC vs without complicationsUsing a CPT code for a more complex version of a procedure than what was performed. Common examples include billing an excision code when a simpler shave removal was done, or a complex wound repair when a simple closure was used.
CPT 11602 (excision ~$400) vs 11300 (shave removal ~$150)Billing new patient visit codes (99202-99205) for an established patient. New patient codes reimburse at higher rates because they include a more comprehensive history. If you have seen the provider within the past three years, established patient codes (99211-99215) should be used. Note: CPT 99201 was deleted in January 2021.
CPT 99204 (~$300) vs 99214 (~$175)How to Spot These Errors on Your Bill
- 1
Compare the visit level code on your bill against the complexity of your actual visit and the time your provider spent with you.
- 2
Check if you were billed as a new patient when you are an established patient at that practice.
- 3
Review your diagnosis codes (ICD-10) and verify they match your actual medical condition and reason for the visit.
- 4
For hospital stays, request the DRG assignment and compare it against your discharge summary.
- 5
Look for patterns: if every visit to the same provider is billed at Level 4 or 5, it may indicate systematic upcoding.
Frequently Asked Questions
Is upcoding the same as fraud?
Intentional upcoding is considered fraud under federal and state laws, including the False Claims Act. However, not all upcoding is intentional. Coding errors, ambiguous documentation, and complex coding rules can lead to inadvertent upcoding. Regardless of intent, you have the right to be billed accurately and should dispute any charges that do not match the services you received.
How can I tell what level my visit should have been?
Under the 2021 E/M guidelines, visit levels are based on medical decision-making complexity or total time. A Level 3 visit (99213) involves a low-complexity problem, while Level 5 (99215) involves high complexity with multiple conditions. Consider the number of problems discussed, data reviewed, and risk of your treatment plan. Your visit notes, which you can request, will document these factors.
Where can I report suspected upcoding?
You can report suspected upcoding to your insurance company's fraud hotline, the HHS Office of Inspector General (1-800-HHS-TIPS), your state's attorney general, or the CMS fraud hotline (1-800-MEDICARE for Medicare fraud). Under the False Claims Act, whistleblowers may be entitled to a portion of any recovered funds.
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