Downcoding Is as Bad as Upcoding

Downcoding Is as Bad as Upcoding

Coders and providers (rightly) worry about upcoding, or coding at a “higher level” than supported by documentation or medical necessity; however, “downcoding,” or coding at a level lower than the level or service supported by documentation or medical necessity, is equally damaging, from a compliance perspective. The National Correct Coding Initiative (NCCI) General Correct Coding Policies, Chapter 1, states:
Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report 19302 Mastectomy, partial…; with axillary lymphadenectomy. A physician should not report 19301 Mastectomy, partial… plus 38745 Axillary lymphadenectomy; complete.
Bottom line: Undercoding is not compliant. In every case, you are required to report services exactly to the level of the service provided, and as supported by medical necessity. Anything less is noncompliant.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Downcoding Is as Bad as Upcoding”

  1. Andrea says:

    How do I code chronic renal failure 3 noted in past medical history. It’s supported with meds. I do not want to undercode or upcode. Provider did not assess this condition as being active.

  2. Stephen Fletcher says:

    i am at a academic center. We surgeons bill the same codes for a procedure. Depending on the insurance company where the bills are submitted, they change the code based on the likelihood of payment. This in my opinion hurts my productivity numbers, but also improves their numbers in terms of collection percentages. It also avoids for them the ‘followup’ nuisances that occur when fighting for dollars. In other words they are content to do the easy bill. I believe this is a particular worry for a fraud issue