What is the term for deliberate manipulation of CPT codes for increased payment?

The term for deliberate manipulation of CPT codes for increased payment is known as upcoding. Upcoding occurs when a healthcare provider assigns a code that represents a more complex or higher-paying service than what was actually provided to the patient. This practice is unethical and constitutes fraud because it intentionally misrepresents the services rendered to inflate reimbursement from insurance providers.

Understanding the specific nuances in medical coding is crucial for compliance and ethical billing practices. Upcoding is often scrutinized during audits and can lead to significant penalties for healthcare providers, as it violates both legal statutes and ethical guidelines within the healthcare system.

In contrast, while some of the other terms like overcoding and fraudulent billing may seem similar, they have different connotations or specific applications. Overcoding may refer to the overall process of coding that does not accurately reflect the services rendered, whereas fraudulent billing involves a broader range of deceptive practices beyond just coding. Misrepresentation similarly refers to inaccuracies in billing or services that do not align with the actual treatment provided, but it does not specifically denote the act of escalating the code for higher payments. Thus, upcoding precisely describes the intentional action of increasing the payment by manipulating the coding system.