Coding was not invented so providers get paid. Providers were always paid whenever they requested so from the time they took chicken and eggs for payment until cash has become the main form of payments.
Coding was invented so complicated clinical terms, including those with multiple spellings, can be presented in a numeric (then alphanumeric) codes computers and everybody can agree they mean one thing. CPT, HCPCS, and ICD codes are also universal. It means no matter what language the provider speaks, the code is always the same.
Coding serves two purposes. The one purpose most providers think about is reimbursement and that is right. However, coding also allows for public and population health management. In other words, different policy makers rely on those codes to determine the health state of the public in their respective geographic area.
Yes upcoding is fraud and the government rarely makes the difference between intentional or unintentional upcoding, expect in terms of assessing the appropriate consequences. Downcoding is also a misrepresentation of facts as they happened in the visit room. The American Academy of Professional Coders (AACP) argues that downcoding is an offense to the False Claim Act that bans organizations and individuals to make a false claim to the government.
The important thing is providers must tell the story exactly as it went down in the visit room. To understand this point, imagine that a doctor sees a patient for a headache and documents a toe nail. Is that documentation acceptable? Do you think it is OK if that doctor using English words – not codes – always wrote knees instead of necks, or hand instead of foot? You get the point. Putting L60.8 (other nail disorder) instead of G44.221 (chronic tension-type headache) is not acceptable either. One is a mistake, 10 times is suspicious, and many times is fraud even if not premeditated.
The same applies to Evaluation & Management (E&M) levels. Putting a level four instead of a level three or two is not acceptable. Frequency may indicate an attempt to acquire enhanced payments for a lesser quality services. Putting a level two instead of a three or a four may seem OK and safe. It is a misrepresentation no different that toe nails instead of a headache or upcoding.
In summary, providers should not second guess themselves. They should try their best to portray as an accurate version of the facts as they can. This is also important if said providers want to look back at their productivity over a period of time. Downcoding and upcoding would be misleading as to what the actual cost is.
If upcoding cheats payors, downcoding cheats the practice.
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