In medical coding, we have to report the procedure in the form of a numerical code called as CPT Code. Medical code comprises of CPT , ICD 10, HCPCS codes & modifiers. These are the major elements in medical coding to understand first. ICD 10 codes are used report diagnosis present in the medical report and CPT for procedure formed. Upcoding and downcoding is related to medical codes, which are responsible for billing or payment of medical claims.
Modifier are used along with CPT codes, to modify the definition of the exam performed. For example, 59 modifier or X{EPSU} modifier is used to differentiate between to exam which can get included another major procedure. If you want to know more about modifiers you can refer the below post on modifiers.
What is Upcoding & Downcoding?
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. Let us learn both of them with an example.
Suppose, in a medical report a physician has performed a Ultrasound, abdomen limited exam (CPT code 76705). But, while coding the medical coder has reported an Ultrasound complete exam (CPT code 76700). Now, when you see the RVU (Relative value units) of these codes below, you will know how much upcoding affect the medical billing or payment.
RVU for 76705 – 0.59
RVU for 76700 – 0.81
Now for downcoding, the same procedure if performed as complete ultrasound abdomen 76700, and reported by medical coder as limited 76705, will be considered as downcoding.
RVUs includes physician productivity, expense and malpractice expense. RVUs value varies for Facility and Non-Facility setting.
Read also: Common errors in Pregnancy ICD 10 coding
Consequences of Upcoding and Downcoding
Upcoding and Downcoding can directly be called a FRUAD. Yes, these things can be done to earn extra money or dollar using these malpractices. The main consequnce of upcoding & downcoding will be denial of claims. Yes, medical claims can be denied as well if medical codes are not reported correctly.
Incorrect coding can create a problem in medical billing as well. The services that you claimed are reimbursed in lower rates. You won’t receive any explanation for lower reimbursement. To detect downcoding errors, you must be familiar with the fee schedule and compare that to the amount mentioned on the EOB form.
Same goes with upcoding errors as well, you must be familiar with the NCCI edits and mutual exclusive elements. If a minor procedure is completely included in a major exam then, only the major procedure should be billed. For example, the barium swallow procedure code (74220) is included in modified barium swallow (CPT code 74230) procedure. Below are the NCCI results for this code pair.
NCCI Edit Results:
Edit exists with 74230. 74220 is a Column 2 code. If both 74230 and 74220 are submitted, only 74230 will be paid.
– NO modifiers associated with the CCI are allowed to be used with this code pair.
– Rationale: More extensive procedure
How to avoid Downcoding & Upcoding
These errors can be avoided with a healthy knowledge about modifiers, CPT codes & ICD 10 codes. Moreover, the NCCI (National Correct Coding Initiative) should be used whenever it is applicable between two or more medical codes.
Always audits all the coding files before sending them to medical billing. Do not depend on software completely for coding and auditing.
