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Upcoding

mitchellde

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Upcoding is coding a higher level of service that what is rendered. Also using a dx code for a payable condition rather that for what is documented is regarded as upcoding.
 

mitchellde

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billing a level 99214 when the documentation supports a 99213 is upcoding the visit level.
billing a 20553 when the provider injected only 2 different muscles is upcoding from a 20552.
Using 238.2 dx code instead of the 709.9 in order to obtain reimbursement when the payer would not pay for the 709.9 code.
I am not certain what the confusion is on this, do you have a more specific issue?
 

Suriya Narayanan

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Thanks a lot Debra A. Mitchell . Now i'm more clear on this .
Chart warrant for Critical Care and provider does not document Critical care time and Coder coded that chart as level 5 and educate Provider.
Shall i consider this scenario as upcoding???
 

mitchellde

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Maybe, it will depend on the documentation. To bill a level 5 the provider must document all the elements of a level 5. You cannot just use a level 5 because the provider calls it critical care without time documentation. so using the E&M guidelines and either Er levels or inpatient or what set is appropriate for the setting, you must be able to arrive at a solid level 5 in order to be able to code and bill it, if not then yes that is upcoding.
 
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