Fight Fraud: Upcoding Practices on Claims

June 4, 2014

The BCBSTX Special Investigations Department (SID) occasionally reviews claims for possible upcoding. Upcoding occurs when a provider submits a claim for payment to the insurance company for a higher paying service than is supported by the medical records documentation. Intentional upcoding is illegal and fraudulent. The SID has identified that a small percentage of providers may be billing high complexity Current Procedural Terminology (CPT)®’ Evaluation and Management (E/M) codes solely based upon the amount of time spent with a patient. Per CPT coding guidelines, selecting a level of E/M service based upon time is only appropriate when counseling and/or coordination of care dominates (greater than 50 percent) the encounter with the patient and/or family. This includes face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility. The extent of counseling and/or coordination of care must be documented in the medical record when time is considered as the key or controlling factor in determining a particular level of E/M service. It is important to note that selecting the appropriate level of E/M service in any other instance is based upon meeting the required key component criteria including history, examination and medical decision making for each respective E/M category and subcategory.  Appropriate clinical documentation must be present in the medical record to support code assignment. Anyone who is aware of a provider or organization that may be defrauding insurance companies by committing upcoding offenses, or any other alleged fraudulent practice, may contact the BCBSTX Fraud Hotline at 800-543-0867.

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