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What is Upcoding?

upcodingUpcoding is a form of healthcare fraud that involves manipulation of Current Procedural Terminology or CPT codes. Healthcare providers, such as doctors and hospitals, use CPT codes to bill Medicare or Medicaid for their services. Each medical service has its own unique CPT code. A healthcare provider’s bill to Medicare or Medicaid includes a list of these CPT codes for the services supposedly rendered to patients.

The government reimburses different amounts of money for different CPT codes. Reimbursement means the amount of money the provider receives from the government.

As an example, a brief visit to the doctor might call for reimbursement of X, while a longer, more complex visit to the doctor might call for reimbursement of 2X. There are different CPT codes for short routine visits and longer more complex visits.

As another example, a magnetic resonance imaging or MRI test might call for reimbursement of X. But an MRI test with contrast might call for reimbursement of 2X. Contrast is a procedure whereby the patient is injected with a contrast agent that allows the MRI machine to produce additional data, which is necessary for some, but not all, patients. Adding contrast to the MRI test increases the amount of money the healthcare provider receives for giving the test.

A healthcare provider engages in upcoding when he or she lies to the government about the services he or she rendered by using a false CPT, in other words, a CPT code that calls for a higher level of reimbursement (more money). Using the above examples, a provider might lie to the government about the amount of time that was spent with the patient during a visit, or a provider might lie about the type of MRI test that was given to the patient.

This type of fraud not only cheats the taxpayers, it also endangers patient safety since it puts false information into the patient’s medical file.

Whistleblowers who know about upcoding may be able to bring a False Claims Act case to help the government recover its losses from this type of fraud.

Please Note: Rabin Kammerer Johnson provides these FAQs for informational purposes only, and you should not interpret this information as legal advice. If you know about government fraud and want advice as to how the law might apply to the specific facts and circumstances of your case, please click here to contact one of our attorneys.

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