“Defensive” Undercoding Is Indefensible

“Defensive” Undercoding Is Indefensible

Undercoding, or reporting a lesser service than was performed and documented, is sometimes employed as a defensive strategy to stave off claims denials or audits. But, undercoding can make a provider an outlier, and may create consequential patient care, compliance, and financial liabilities. For example:

  • Undercoding leaves money on the table, driving down provider reimbursement. As stated in “Over coding? Under coding? RIGHT coding!” by Novitas, a Medicare contractor in Delaware, Maryland, New Jersey, Pennsylvania, and Washington, D.C., “…under coding impacts your practice revenue. You are not being appropriately paid for the level of service you provide to your patients. Correcting under coded claims can mean costly appeals.”
  • Undercoding leads to improperly paid claims. Per Novitas, “When there is an underpayment due to under coding… it is counted as an improper payment error…. Under coding errors can statistically impact calculated error rates in the tens of millions of dollars[emphasis in the original].”
  • Undercoding affects patients negatively, and skews the data that Medicare and other payers use to calculate payments. Novitas states,“Under coding misrepresents the true level care that is provided to Medicare beneficiaries. These statistics are used to calculate future Medicare payments and track trends in healthcare delivery.”
  • Undercoding may increase your risk of audit. Novitas notes, “Patterns of under coding may be viewed as aberrant and open your practice up to audits and reviews.”

Finally, undercoding—just like overcoding—can create false claims liability. In short, Novitas concludes, “It’s important to code the level service that is supported by your documentation….”

John Verhovshek

John Verhovshek

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.
John Verhovshek

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About Has 605 Posts

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.

3 Responses to ““Defensive” Undercoding Is Indefensible”

  1. T. Thivierge MHA ,CBCS, CPC says:

    Yes, oh yes, abstracting with medical coding in doing this job correctly means in this profession you must be a life long learner. All medical coders staying up to date on coding per assigned their medical setting (inpatient, outpatient, urgent care, Etc.) is vital to get the proper amount of revenue . Communication among staff, webinars, conferences, reading the AAPC Knowledge website and CPC forum helps us immensely plus understanding the provider’s documentation. Coders accessing these avenues helps us not to under code or lose funding

  2. T. Thivierge MHA ,CBCS, CPC says:

    Yes, oh yes, abstracting with medical coding in doing this job correctly means in this profession you must be a life long learner. All medical coders staying up to date on coding per assigned their medical setting (inpatient, outpatient, urgent care, Etc.) is vital to get the proper amount of revenue . Communication among staff, webinars, conferences, reading the AAPC Knowledge website and CPC forum helps us immensely plus understanding the provider’s documentation. Coders accessing these avenues helps us not to under code or lose funding

  3. Adam Negron says:

    This is very informative and helpful, especially for someone such as myself who is starting out in the industry as a coder and wanting to ensure that I do and follow correct protocol.

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