Currently, the number of scandalous healthcare providers is increasing by the day. The disreputable healthcare providers have focused on scamming the systems in their institutions. Some common billing and coding schemes are used every day to perpetrate fraud. Upcoding is the most common type of fraud that medical providers do. The medical providers charge for a more complicated procedure than the one which was performed. For instance, a patient might be charged like an inpatient while they are on an outpatient visit. The role of the coder in this fraudulent act is to use a CPT code to change the payer to a more expensive and complicated service than the one performed. Unbundling is another billing and coding scheme that is done in hospitals (Coustasse et al., 2021). This occurs when a medical provider bills separately for services that should be billed once. For example, unbundling occurs when the prescription drug coverages are charged separately from the original Medicare.
When services are billed separately, the cost will be very high. The coder uses software known as an electronic health record to engage in unbundling. If someone has any proof that an organization or medical provider is performing Upcoding or unbundling, they should work with a lawyer to report the fraud, which can lead to a reward of $1, 000. Ignorance of the coding and billing rules does not provide sufficient legal protection since such cases are increasing by the day. Victims charged extra for a procedure they did not undertake are still on the rise. I would not agree to be part of any fraudulent act since it is unethical and it is our responsibility to enhance moral and legal practices.
A diagnosis code is a combination of numbers or letters assigned to a particular symptom or procedure. For instance, if a patient visits the hospital and complains of abnormal pains while urinating, the medical provider does a procedure known as urinalysis and finds various findings that indicate an infection. Once the medical provider concludes that it is a UTI infection, the provider references various codes such as N39.0. Some steps led to the diagnosis of a code; the medical provider uses ICD-10 codes to tell the patient’s diagnosis, problems, symptoms, or conditions (Ingraham et al., 2021). The first step includes identifying an alphabetical index for the code. After identifying the diagnostic term, the tabular list should be checked. All the required characters are present in the Tabular list. After the tabular list is checked, the code’s instructions should be checked. If trauma or injury is identified, a seventh character should be added. It is essential to use both the Tabular list and alphabetic list to code since the alphabetic index will not always provide the full code.
Coustasse, A., Layton, W., Nelson, L., & Walker, V. (2021). Upcoding Medicare: Is Healthcare Fraud and Abuse Increasing?
Ingraham, A., Schumacher, J., Fernandes-Taylor, S., Yang, D. Y., Godat, L., Smith, A., & Utter, G. H. (2021). General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin. Journal of Trauma and Acute Care Surgery. Web.