Upcoding
Upcoding is a fraudulent practice in healthcare billing where a healthcare provider assigns a diagnostic or procedural code that represents a higher level of complexity or severity than is justified by the patient’s actual condition or the services provided. This unethical practice aims to increase reimbursement rates from insurance companies or government healthcare programs beyond what is warranted based on the medical documentation.
Upcoding can involve exaggerating the intensity of services rendered, misrepresenting the patient’s diagnosis to justify higher-paying codes, or improperly using modifiers to inflate the billed amount. It is illegal and can result in financial penalties, loss of professional licensure, and damage to a healthcare provider’s reputation.