What is Upcoding and Downcoding?
The job of medical coders is to code the treatments and diagnosis that the patient has undergone. The bills are usually prepared according to these codes.
Upcoding is a fraudulent practice in which provider services are billed for higher CPT procedure codes than were actually performed, resulting in a higher payment by Medicare or 3rd-party payors. Downcoding is the alteration by an insurer or other third-party payer of service codes for physicians or other health care providers, to those of lesser complexity, resulting in decreased reimbursement
Upcoding is when a diagnosis is made that results in a higher reimbursement than is really medically necessary. Downcoding is the exact opposite – it the assignment of a lesser diagnosis intended to show patient improvement.