Upcoding involves overbilling a patient, while downcoding is the reverse of upcoding. It entails under-billing patients. Upcoding disadvantages patients as they are forced to pay for services they never received.
What is “downcoding?
“Downcoding” occurs when a health insurer unilaterally reduces an E/M service level. The typical scenario occurs when a practice submits a claim for a patient visit based on a CPT code definition (for example, new patient visit code
What is the difference between documented and downcoding?
Conversely, if the code that is documented is at a lower level of complexity or cost than what is documented, it is called downcoding. The motive for downcoding may also be associated with the intent of avoiding claim denials or audits, but at what cost?
What are the consequences of downcoding in healthcare?
Apart from the missing or sufficient documentation, incorrect coding and medically unnecessary services, Medicare auditors found coding errors where providers shortened themselves by downcoding. Downcoding is a very serious mistake that has the same effect as upcoding and can have a significant impact on your revenue.
How do you stop upcoding and downcoding?
One of the most effective ways to detect and eliminate upcoding and downcoding is to perform periodic internal audits. You may also be better off contracting out your coding needs, since many practices are losing thousands in revenue due to poor coding practices.
What is upcoding and Downcoding in medical billing?
Upcoding, as the name suggest, is coding a higher dollar value medical code which is not actually performed or documented in the report. Downcoding is exactly opposite of upcoding, in which the medical coder assign a medical code, which has less dollar value than the actual procedure performed in the medical report.
What is an example of Downcoding?
Examples of downcoding: If a unilateral partial mastectomy with axillary lymphadenectomy is performed, the proper CPT code would be 19302 (Mastectomy, partial… with axillary lymphadenectomy) rather than 19301 (Mastectomy, partial…) plus the additional code of 38745 (Axillary lymphadenectomy; complete).
What is Downcoding?
Downcoding refers to coding at a lower level than the level or service supported by medical documentation or medical necessity. This is also known as undercoding and usually results from insufficient documentation. Its impact is given as follows. Undercoding is damaging to your practice from a compliance perspective.
How do you determine Downcoding?
Conduct Coding Audits – One of the best ways to detect and prevent downcoding is to conduct coding audits for downcoding (as well as for upcoding). One must make sure to share audit findings. This will allow the auditor to come up with certain suggestions for accurate coding.
What is Downcoding in healthcare?
"Downcoding" is the opposite side of the upcoding coin. Typically, downcoding occurs because the provider fails to provide relevant documentation details to assign a service, procedure, or diagnosis to the optimal level of specificity. For example, diabetes is frequently undercoded.
Which is worse Upcoding or Downcoding?
While the layperson may think that a medical practice downcoding a procedure is only bad for the provider's bottom line, it is just as bad as upcoding in that it is also not compliant and therefore leaves providers susceptible if an audit is performed.
Is Downcoding allowed?
No you may never down code or up code any procedure on any claim at any time.
Can Downcoding increase reimbursements?
Downcoding can increase reimbursements. Downcoding and upcoding are illegal practices, and medical assistants can be prosecuted for either practice.
What problems can result from Downcoding?
Downcoding also leaves you vulnerable to an audit, which is never good. But, it can also cost a practice thousands of dollars a year in lost revenue because you're not getting the higher rate of pay that you would if you had recorded the service properly. According to the National Correct Coding Initiative (NCCI):
How is Upcoding detected?
The use of electronic health records (EHR) software can facilitate upcoding and unbundling. With EHR software, providers can copy and paste notes from a patient's previous visit into each current treatment note, which can make it appear that the provider has diagnosed and treated every condition on that list.
What is Upcoding in medical billing?
A common type of false claim is "upcoding," which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided.
What are 3 potential consequences of upcoding?
Fines might be imposed, the doctor may lose his or her license, and some could even face jail time. Not only is this practice unethical and illegal, but it also can result in negative consequences for the patient.
What does it mean when a payer Downcodes?
Reduce the value and code of a claim when the documentation does not support the level of service billed by a provider. Learn more about medical coding and billing, training, jobs and certification.
What is an unbundled CPT code?
Unbundling refers to using multiple CPT codes for the individual parts of the procedure, either due to misunderstanding or in an effort to increase payment. Upcoding. Example: You are a physician in a specialty, such as oncology, that often has highly complex patients.
What is Upcoding in medical billing?
A common type of false claim is "upcoding," which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided.
Why would an office Downcode a claim quizlet?
Downcoding may occur because the procedure's place of service is an emergency department, but the patient's problem is not considered an emergency. Claims may also be downcoded because the documentation fails to support the level of service claimed.
Why is downcoding important?
The practice of downcoding claims is another important reason for physicians to assure that the medical record supports the level of services reflected in the claim.
Can insurance downcode based on diagnosis code?
Sometimes health insurers downcode based solely on the diagnosis code. In other words, the insurer assumes (most likely through a software system) that when a patient presents with certaindiagnoses, the clinical evaluation can never be more complicated than a certain E/M level, regardless of the specifics of the individual case.