Question

One of the issues that might happen when assigning a code is upcoding and downcoding. Describe this issue and how it can be solved?

Answer 1

Solution:

Downcoding is often utilized as a means of avoiding red flags or suspicion of fraud. This method is counter-

intuitive, as downcoding is often just as damaging as upcoding – though for some different reasons. Downcoding

occurs because of insufficient documentation that fails to assign levels of services to the highest levels of specificity.

Whereas;

Upcoding involves billing and/or reporting a higher-level service, or a more complex (expensive) diagnosis than

what is reflected in the patient’s true treatment plan. These higher service levels are not supported by medical

necessity, facts, or even provider documentation. Medicare pays for physician services with Evaluation and

Management (E/M) codes, which rely heavily upon medical necessity being confirmed for each level of service

reported. Upcoding has proven to be an issue in Evaluation and Management audits because the reporting of high

levels of service equals more money in the provider’s pocket.

Hence;

Both upcoding and downcoding can occur by mistake or as a deliberately deceptive practice. While they are

distinctly different, both are a serious compliance risk for medical practices and increase healthcare costs for

patients.Downcoding may not be financially harmful to payers, but it does lead to the misallocation of funds.

To solve these issues:

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