What is Upcoding and Downcoding?

downcoding
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What is Upcoding and Downcoding?

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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

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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.