CFE Orientation Practice Test

In healthcare fraud indicators, what does 'upcoding' mean?

Billing for a higher level of service than provided Coding for a service not performed Delaying claims submission Splitting one service into multiple claims

Correct Answer:

Coding for a service not performed

Explanation:

Upcoding means billing for a higher level of service than was actually provided or documented. It seeks more reimbursement by misrepresenting how complex or extensive the care was. For example, coding a level 4 office visit when the record supports only a level 2 or level 3 visit. This inflates payments and is considered fraudulent. It's a different issue from coding for a service not performed (false or phantom billing) and from delaying claims submission or splitting one service into multiple claims, which are separate fraud schemes with different aims.

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