Billing trends could signal rise in upcoding

Physicians have been billing Medicare for increasingly complex--and more expensive--procedures over the past 10 years, signaling a growing upcoding trend that adds $11 billion to healthcare costs, according to an analysis by the Center for Public Integrity.

Hospitals increased their use of the highest-reimbursing codes for emergency room visits, while doctors ramped up their use of higher-paying codes for office visits between 2001 and 2010, largely abandoning the lower-paying ones.

According to hospitals and physicians, the rise in fees stem from the growing complexity and time it takes to treat seniors. However, the analysis found little proof that Medicare patients have been getting sicker or need longer and more complicated care, noted a Center for Public Integrity article in The Washington Post.

The analysis did point out that higher billing rates could stem from electronic medical records. According to one EMR firm, thanks to its product, each patient visit will jump one coding level, which could add $225,000 in new revenue.

The uptick in more expensive Medicare billing codes also could reflect an inherent flaw in the billing system, according to Thomas Scully, a former Medicare administrator under President George W. Bush. "You are going to pedal faster and code more aggressively," Scully told the Center for Public Integrity. "I'm not sure it's malicious. It's a fact a life," he said.

But when it is malicious, improperly billing Medicare, as well as Medicaid, for higher-paying codes to receive more federal reimbursements can be considered healthcare fraud, the organization noted.

For example, Baltimore's Good Samaritan Hospital faced federal charges of submitting inflated rates of patients suffering from malnutrition to Medicare and Medicaid for four years. Similarly, state and federal authorities are investigating California-based Prime Healthcare for possible Medicare fraud related to unusually high rates of septicemia among its older patients.

For more:
- read the article in the Post
- here's the Center for Public Integrity analysis