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Tip: Avoid upcoding or undercoding procedures

Ambulatory Surgery Reimbursement Update, August 5, 2008

Upcoding of CPT codes is the reporting of a more comprehensive procedure code than what accurately represents the procedure that a physician performed, and is a compliance issue. Undercoding occurs when the code billed does not adequately represent a more extensive procedure that a physician performed, which costs your ASC facility revenue.

Upcoding has a higher compliance risk, because payers will reimburse your facility at a higher level than it is actually entitled to. If your facility is caught upcoding, it can flag an audit with Medicare and other payers and can result in accusations of fraud, along with stiff legal penalties. When undercoding occurs, it means potential revenue is left on the table, because you didn’t accurately code the procedure performed and missed out on reimbursement.

Upcoding and undercoding both pose another significant problem for your ASC: If a surgeon’s office is coding the procedures accurately, and your facility’s codes do not match the surgeon’s codes for the same case, it can cause denials and can also flag an audit with a payer.

This tip is brought to you by Ellis Medical Consulting, Inc.

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