Two forms of medical billing fraud are upcoding and downcoding
. While upcoding assigns a diagnosis that warrants a bigger reimbursement than medically necessary, downcoding does the opposite and inaccurately reports a lesser diagnosis, often to show fraudulent patient improvement.
Upcoding
Physicians normally upcode as they are not well educated on coding though sometimes upcoding is intentional too. If you think a doctor in your practice is upcoding, you may want to consider engaging an independent third party to conduct a chart review to confirm or rid your suspicions.
Downcoding
Downcoding is quite common among family physicians. They may down code as they are apprehensive of a third-party audit or as theyre not well-informed about coding. Downcoding is particularly pervasive in small communities where people have lower incomes and doctors are apprehensive about their ability to pay. Doctors also down code as they know theyve done a poor job of documentation. Rather than make the effort to know how to document their services appropriately, they simply choose a lower code hoping this will cover them in case of an audit.
Downcoding leads to lost revenues and it can seriously threaten the profitability. Itll also hurt the practice should it ever move into capitation as capitation rates are based on prior utilization.
Many providers are of the opinion that downcoding is a safe practice to stay under the radar of a government audit. But according to the OIG and CMS, both upcoding and downcoding are considered prosecutable forms of fraud.
To know more about upcoding and downloading, sign up for a one-stop medical coding website.