Know the Difference: Upcoding and Downcoding in Medical Billing

Therefore, in order for practices to be fairly compensated for the medical services they offer to their patients in times of need, they must present an accurate medical bill. Medical records need to be clear and readable throughout, not just for the documenting provider but also for the auditor.

Upcoding and downcoding are terms that are introduced to us in medical coding.

The definitions, variations, and applications of upcoding and downcoding in the context of medical billing are examined here. It is imperative that both payers and providers comprehend terminology to prevent any billing-related issues or delays. Put another way, in order to move further without any problems, a solid grasp of the phrases upcoding and downcoding is required. Downcoded claim appeals need a lot of work and effort. Documentation must be gathered, and providers need to follow up frequently.

Difference Between Upcoding and Downcoding

What does medical payment upcoding mean? Upcoding is the practice of overcharging a patient by marking a code for services that are far more expensive than the actual service rendered. In order to obtain greater reimbursements, many people take advantage of this unwarranted advantage, which ultimately leads to the earning of money through immoral ways.

Many of them are ignorant of the serious legal and financial repercussions that practicing upcoding can have. A healthcare provider who wishes to overcharge a patient may assign a code on the bill for a diagnostic procedure for a more serious health condition than the patient actually has, or for services that are more expensive than what was provided during the visit.

The patient’s insurance company is required to pay an excessive amount of the medical bill that is the result of this practice. In such cases, healthcare providers might try to defend the overcharging, but if found guilty, they could face criminal charges. Even though upcoding is against the law and immoral, it is one of the most prevalent types of fraud in the healthcare sector.

Share the audit findings with the providers, the coding and billing staff, and implement procedures and education (such as follow-up audits) to ensure that mistakes are corrected moving forward. Even more beneficial at breaking unhealthy behaviors might be quarterly audits. You might even think about occasionally hiring an outside auditor to confirm your results.Conversely, downcoding is the reverse of upcoding and is comparable to it. The process of applying a minor code that indicates a less expensive service than what was actually supplied to the patient is known as “downcoding.” Inaccurate documentation may be a primary cause of downcoding, leading to the practice’s loss or receiving less money. Although using lesser codes will not be seen as dishonest, doing so may eventually cause revenue loss and compromise the accuracy of medical billing. Proper documentation always accurately reports and records diagnoses, treatments, and procedures. Less than that is not acceptable.

Numerous things, including code management, confusing medical records, and ambiguous paperwork, might lead to downcoding. Insurance firms and government health programs utilize standard codes to calculate appropriate payment amounts. Healthcare providers and payers disagree over the appropriate value of rendered services when downsizing takes place. read more