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Attack Bogus Billing in Personal Injury Cases

Compliant coding is the best defense against falsified bills for personal injury suits.

By Jeremy Reimer, CPC
Bogus billing is a big problem in personal injury cases, and it’s getting worse. Unlike health insurance companies—which scrutinize every bill submitted for payment—auto insurance companies and self-insured carriers often have little recourse to dispute medical charges. To make matters worse, unethical physicians sometimes seize the opportunity to submit exaggerated bills. A coding analysis is one weapon to combat these fraudulent practices.
There are several ways providers can falsify bills for personal injury suits. In any other setting, these bills would not be reimbursable due to the provider’s failure to comply with coding rules and regulations.


Upcoding occurs when a provider bills for a more complex and/or higher-cost procedure than was actually performed. Upcoding predominantly occurs with evaluation and management (E/M) visits, and often is seen on a patient’s initial visit. Although the patient may present with minor complaints, the physician will bill a level 4 or 5 office visit. The patient might return for one or more follow-up visits, with the same complaints and symptoms or to refill medication. Per CPT® guidelines, these visits would be coded as a level 1 or 2 visit. Dishonest medical providers may try to upcode these to level 4 or 5 visits.
Surgical procedures are another place to look for upcoding. The physician performs “surgery” on the patient that consists of a minimally-invasive procedure, performed via needle puncture of the skin. Rather than report a percutaneous procedure code, the provider bills an “open” procedure. Reimbursement for an open procedure can be as much as three times that of a percutaneous procedure.


Another trick used to inflate medical bills is unbundling. This is when a medical provider bills separately for the components of an all-inclusive procedure, and occurs most frequently when hospitals and physicians charge separately for the components of a surgery. Most surgeries are part of a global package that includes:

  • A preoperative visit before surgery
  • Intra-operative services, devices, implants, and anesthesia (technical component)
  • Surgical aftercare
  • Office visits during the post-operative period of the surgery (typically 90 days) that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies
  • Other miscellaneous services

If the treating physician unbundles these charges and bills for each one separately, the result is a much higher bill.

Inconsistent Coding

Personal injury doctors may also code inconsistently. This might occur when multiple patients in the same accident go to the same doctor. Despite the patients’ separate complaints, the physician assigns the same diagnosis to each of them.
Inconsistent coding can also be found in records where a patient underwent a surgical procedure. For example, a patient sees a physician after an accident and the physician diagnoses the patient with various ailments in order of significance (e.g., neck pain, headaches, shoulder pain, low back pain). In cases with inconsistent coding, the patient’s main diagnosis changes to correspond with the planned procedure; for example, low back pain becomes the primary diagnosis when lumbar back surgery is scheduled.
Another example of inconsistent coding is when the procedure(s) listed on the physician’s bill do not match the procedure(s) on the facility’s bill. For example, if the physician’s bill contains an “unlisted” procedure, and the facility’s bill shows a spinal fusion, it is an immediate red flag that one or both of the bills is not coded properly.
What effect do coding violations have on a personal injury case? First, these violations work to increase the patient’s bills. Coding violations also falsify the patient’s injuries (and medical record) to support the treatments that have been (inappropriately) rendered.

Recognize and Question Bogus Billing

Recognizing the potential for coding violations is the first step in fighting these unscrupulous practices. The next step is to have the bills evaluated by a coding expert or to consult with an attorney with expertise in this area. If it is determined coding violations exist, a coding expert can offer trial testimony to educate the jury about the coding and billing abuse and its significance. By challenging a physician’s coding, defense attorneys can get the jury to question the validity of the bills generated by the physician. The more attention you bring to these phony billing practices, the more difficult it will be for these practices to continue.
Jeremy Reimer, CPC, is president of Medical Coding Litigation Services, which provides medical coding and billing review to insurance carriers, legal counsel, and companies involved in personal injury litigation. He is vice-president of AAPC’s Brandon, Fla. chapter, a member of the American College of Forensic Examiners, and a frequent lecturer on medical coding and billing fraud. Mr. Reimer can be reached at: jreimer@mcls.co.

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