What could happen if a medical office is caught unbundling codes?

What could happen if a medical office is caught unbundling codes?

Unbundling or fragmenting billing codes illegally increases a provider’s profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid.

What is upcoding and why is it illegal?

Upcoding: Upcoding occurs when physicians or medical coders enter codes into a patient’s superbill for services not received. Typically this is done to inflate the total amount a patient owes for receiving care at a healthcare provider. Upcoding is illegal and can lead to fines and criminal prosecution.

What is bundled denial in medical billing?

Insurance deny the claim with CO 97 denial code, when procedure code is inclusive with the other procedure code billed or another service for the same patient that has already been billed and adjudicated.

What does it mean when CPT codes are bundled?

What is Bundling? When a payer bundles codes, it combines two or more codes into one. Doing so allows them to replace two codes with one overarching code and pay the provider only for the amount allowed under the more dominant code.

What is Undercoding?

Undercoding occurs when codes fail to capture all work performed. This is often due to oversight, but some practices intentionally undercode to avoid an audit. This is not recommended because it results in substantial lost revenue and creates skewed claims data that ultimately lower reimbursement rates.

What is a cost outlier?

Cost outlier — an inpatient hospital discharge that is extraordinarily costly. To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).

What is DRG creep quizlet?

DRG creep is the rise in the CMI through the coding of higher-paying principal diagnoses and of more complications and comorbidities, even though the actual severity level of the patient population did not change.

What is Undercoding in fashion?

“Undercoding” is the term used by Davis in order to describe the process by which meanings are being ascribed to dress. In the author’s view, the meaning that is given to clothes is always ambivalent, because it fluctuates between opposite polarities. The book is especially concerned with women’s dress.