Upcoding and Downcoding

Upcoding is reporting a higher-paying code than the documentation supports (e.g., billing 99214 when chart only supports 99213). Downcoding is the opposite. Upcoding is fraud. Downcoding is also a problem: it leaves revenue on the table. OIG audits routinely find that 30 to 45 percent of 99213 visits should have been 99214 based on the documentation. Both errors are fixed through Clinical Documentation Improvement training and chart review.