Avoid upcoding to ensure revenue integrity in your medical practice
Overcoding (sometimes referred to as upcoding) occurs when medical practices report more lucrative medical codes than what’s warranted. As you can imagine, it can get providers into big trouble. Specifically, they could become the target of payer audits and costly recoupments.
While there are ‘bad actors’ out there, the reality is that most providers don’t intentionally report the wrong medical codes to make more money. However, mistakes do happen because let’s face it: Medical coding is complicated. There are many nuanced rules and guidelines to follow, and those rules and guidelines change frequently.
Aside from the compliance implications of upcoding, there’s also the financial effect on patients themselves. More specifically, upcoding can lead to higher-than-necessary medical bills. The codes medical practices report directly affect the patient financial responsibility, and in an era of high deductible health plans, it’s important to get it right. Keep in mind that today’s healthcare consumers are savvier than ever before. There’s a growing awareness of Medicare fraud and abuse, for example, and the Centers for Medicare & Medicaid Services continues to educate consumers on how to report it.
One word of caution: A fear of upcoding can cause some medical practices to undercode or downcode services. That’s equally as detrimental to revenue integrity. The goal is to report the codes that most accurately depict the services rendered.
What is upcoding?
Here are three examples of medical upcoding that can trap even the most well-intentioned physicians, medical coders, and medical billers.
1. Evaluation and management (E/M) codes. Think: Billing a level four E/M code for a simple problem or a level five E/M code when the physician only spends a few minutes with the patient. Overly-templated documentation and/or the ability to quickly copy and paste information make it far too easy for physicians and their medical coding/billing staff to unknowingly upcode.
2. Unbundling. This occurs when physicians or their medical coding/billing staff separately report multiple components of a procedure that should be billed as a single charge. Here’s an example of upcoding fraud: A physician might provide a panel of blood tests, and instead of billing a single medical code for the panel, they might incorrectly bill each test separately.
3. Diagnosis codes for risk adjustment. Upcoding occurs when physicians or their medical coding/billing staff inappropriately report one or more diagnosis codes that artificially inflate the patient’s risk of morbidity and mortality. For example, they might report a more severe diagnosis than what the patient has, or they might report a diagnosis the patient doesn’t have at all.
How to avoid upcoding
The good news is that there are several ways medical practices can avoid upcoding and mitigate risk. Consider the following:
Budget for continuing education. Be sure to include medical coders, billers, and physicians. Focus on the perils of upcoding using examples relevant to your specialty.
Encourage physicians to validate any medical codes the electronic health record (EHR) suggests. Physicians should always ask themselves this question: Does the code make sense given the presenting problem and medical complexity of the patient?
Hire certified coders—or work with an outsource partner that does.
Leverage technology. Take advantage of look-up tools and software to help identify components of a procedure that should be bundled. This technology can also identify when modifiers may or may not be appropriate.
Perform an internal audit of your coding, billing, and documentation. Be on the lookout for examples of medical upcoding. Hire an external auditor to validate internal audits and share industry best practices.
Use copy and paste functionality with caution. Consider creating a policy for when physicians will and will not use copy and paste.
Conclusion
Upcoding happens. It’s what you do about it that matters most. Do you strive for proactive compliance, or do you ignore a potentially growing problem? Medical practices that take the time to identify and mitigate risk not only improve their overall compliance, they also enhance the patient financial experience. Don’t put your revenue at risk. Be mindful of examples of medical coding and strive for revenue integrity. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
