Upcoding

The NCCI policy manual states the rule plainly: a code may be reported only if every service it describes was performed. Its example is a physician who performs the superficial lymph node procedure coded 38740 but reports 38745, the code for the complete version. On visit claims, the same error is a level higher than the documentation supports. CMS’s fraud and abuse booklet also notes that new patient E/M codes pay more than established patient codes, so the patient’s status on the claim matters as much as the level.

CMS treats upcoding at two levels. Misusing codes on a claim, such as upcoding, is listed as an example of abuse. Knowingly billing at a higher complexity level than was provided or documented is listed as fraud, and the booklet says the difference between the two depends on the facts, intent and knowledge. Either way the exposure is real: providers who upcode may face administrative, civil or criminal liability. The booklet also names a specific form, misusing modifier 25 to get paid for an E/M service that was not medically necessary, not distinct from the procedure, or no more than the care that comes with the procedure.

The defense is documentation that matches the code, line by line. The booklet repeats a common saying that applies to Medicare billing as much as to malpractice: an undocumented service is treated as if it never happened. A periodic internal review that compares billed codes with the notes, provider by provider, can surface a pattern of drift before a payer’s review does.