Which term describes the act of using a higher level of coding than what is supported by the documentation?

The term that describes the act of using a higher level of coding than what is supported by the documentation is upcoding. Upcoding occurs when a healthcare provider submits a claim for a service at a higher code level than what was actually rendered, leading to increased reimbursement that is not justified by the patient’s medical records or the actual services provided.

This practice is considered unethical and can lead to significant penalties, including fines and exclusion from Medicare and Medicaid programs. It undermines the integrity of the coding system and contributes to rising healthcare costs.

In contrast, terms like fraud and abuse have broader implications. Fraud refers to intentional deception or misrepresentation that results in financial gain, which can encompass upcoding but is not limited to it. Abuse usually involves practices that result in unnecessary costs or services but may not necessarily contain the element of intentional deception found in fraud. Unbundling refers to the practice of billing separately for services that are typically included in a single comprehensive code, which is a different aspect of improper billing. Understanding these distinctions is critical for compliant coding practices.