4-1-1 on Comp: Upcoding and Workers’ Compensation

Bruce Burk

Upcoding is the practice of a medical provider billing a medical event on a more expensive code than the service that the provider actually gave to the patient. Upcoding can occur in four different forms.

Service Based Upcoding

Service based upcoding refers to the practice of billing for a much more expensive procedure, such as surgery, when the provider actually performed a much cheaper procedure.

Location Based Upcoding

Location based upcoding is when a medical provider bills for a procedure as if it happened in a more expensive facility when it in fact it occurred somewhere else.

Time Based Upcoding

Time based upcoding happens when a doctor sees a patient for just a short period of time but then bills for a much larger amount of time.

Party Based Upcoding

Party based upcoding is when doctors bill for visits that are actually conducted by a physician’s assistant, nurse, etc.

Upcoding can cause problems in future litigation. For example, if you see a doctor for high blood pressure but the doctor uses a CPT code for a cardiovascular conditions, your medical records may reflect that you have a heart condition. This could make it more difficult to get future medical treatment if the conditions are claimed as work related. Moreover, you could be prescribed medication incorrectly based on these false notations in your medical report which could cause you harm. Upcoding can also cause your health insurance premiums to be higher, even though you cannot be denied care under your health insurance for pre-existing conditions.

Upcoding can cause problems for doctors as well. If a doctor is told to up-code, then it puts them in an ethically compromised position that may require action such as reporting to the authorities.

Upcoding is a form of fraud and can have severe consequences in workers’ compensation. The majority of states in the U.S. have some form of workers’ compensation fee schedule. The states that do not have workers’ comp fee schedules are Indiana, Iowa, Missouri, New Hampshire, New Jersey, Washington, DC, and Wisconsin. In the states that do have fee schedules, doctors must comply with fee schedules or risk being de-authorized.

Most importantly, upcoding can lead to serious federal charges regarding health care fraud.

Recently, a physician in Ohio plead guilty to defrauding the Ohio Bureau of Workers’ Compensation of more than $260,000 by upcoding his medical visits. Red flags were raised when it became clear that this doctor of osteopathic medicine with a small practice prescribed more than a million doses of Schedule II and Schedule III substances in a year. The doctor would also engage in a form of party based upcoding by billing visits that were conducted by a physician’s assistant as if they had been done by the doctor.

To read recent WorkersCompensation.com Featured News coverage on upcoding, click here.