Upcoding vs. downcoding: Know the difference

“Upcoding” means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider’s documentation. For example, reporting a diagnosis of chronic bronchitis if the patient has acute bronchitis qualifies as upcoding, as would billing a level 5 evaluation and management (E&M) service (e.g., 99215) for a minor patient problem, or coding for excision of a 2.5 cm skin lesion (e.g., 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm) when the lesion actually measured 1 cm (e.g., 11401 … excised diameter 0.6 to 1.0 cm).

“Upcoding” means reporting a higher-level service or procedure or a more complex diagnosis, than is supported by medical necessity, medical facts, or the provider’s documentation. For example, reporting a diagnosis of chronic bronchitis if the patient has acute bronchitis qualifies as upcoding, as would billing a level 5 evaluation and management (E&M) service (e.g., 99215) for a minor patient problem, or coding for excision of a 2.5 cm skin lesion (e.g., 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm) when the lesion actually measured 1 cm (e.g., 11401 … excised diameter 0.6 to 1.0 cm).

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Upcoding vs. downcoding: Know the difference