What is an example of upcoding?

Upcoding refers to the practice of billing for a higher level of service or procedure than what was actually provided, often to increase reimbursements from insurers.

In this case, reporting a motorized wheelchair when a cane was provided serves as a prime example of upcoding. The claim is substantially higher in cost because a motorized wheelchair is significantly more expensive than a cane. By submitting a claim for the motorized wheelchair when a less costly item was actually provided, this action misrepresents the service rendered and results in the potential for greater reimbursement than what would be justified by the actual care provided.

The other options, while they involve billing inaccuracies, do not fit the specific definition of upcoding. For instance, reporting three different vaccine injections for one combination vaccine revolves around over-reporting, rather than billing at a higher level for an individual service. A treatment provided but never rendered describes fraudulent claims more so than upcoding. Lastly, billing for a procedure performed by a non-physician professional refers to the provider’s qualifications rather than inflating the complexity or cost of the service itself.