Medicare 'upcoding' accounts for $11 billion in extra costs, investigation finds

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Medicare providers increasingly are using higher-paying codes instead of using less complex, lower-paying codes, an investigation has found. This practices, known as “upcoding,” has added $11 billion or more to their fees over 10 years.

Despite the fact that Medicare beneficiaries on the whole are not any older or sicker than previous generations of beneficiaries, physician practices, hospitals and other providers are using higher-paying codes, according to a Center for Public Integrity investigation. In a year-long analysis of Medicare claims, CPI found that upcoding, or “code creep” to be most rampant in doctors office visits, though it happens in nursing homes, hospitals and emergency department visits.

Experts told the Washington Post that the push for electronic health records could inflate the problem. They add that proving a provider has upcoded is difficult. According to the newspaper, the average overcharge per claim is $43. It costs the federal government an average of $30 to $55 to review a claim.

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