What is Medical Billing Upcoding?

  • October 01, 2019


  • Upcoding is fraudulent medical billing in which medical coders send a bill for health services that are more expensive than they should have been based on the service(s) that were performed, and can cost insurance companies as well as patients thousands of dollars.

    While upcoding is not the norm, it can occur when a patient receives diagnostic services, medical procedures, or visits their healthcare provider.

    The Truth about Upcoding

    Every surgery or procedure performed by a medical professional has a corresponding Current Procedural Terminology (CPT) code attached to it, which is set by The American Medical Association. This code allows the healthcare provider to charge Medicare, Medicaid, insurance or even the patient themselves.

    At the point when any medical professional sends a code to the patient or their insurance company, the CPT code decides the amount the doctor will be paid. With upcoding, the CPT code used will be one for a procedure that is more costly than what was actually performed.

    Upcoding is considered fraud, but that doesn't stop certain providers from trying to find ways to take advantage of the system. Healthcare providers that are attempting to cheat the system will use upcoding to bill for a procedure that is more costly than what was actually performed.

    Why Upcoding Happens

    GREED! Even though upcoding is considered fraud and is illegal, there are medical practices and healthcare providers that continue to upcode to cheat the system and in doing so, reap hundreds of thousands, or even millions of dollars.

    Upcoding Costs Consumers Money

    The most fundamental effect of upcoding is the increased cost to health payers, which unfortunately winds up being passed on to consumers.

    When government payers end up paying excessive dollars for healthcare, this is reflected in taxes. When health insurance companies overpay, they increase the cost of healthcare premiums to consumers as a way to offset their monetary loss.

    If you have any questions, please feel free to contact RevPro Healthcare Solutions below or call us at 561-578-8400.