Upcoding and Unbundling Charges in Medical Billing Review

//Upcoding and Unbundling Charges in Medical Billing Review

Upcoding and Unbundling Charges in Medical Billing Review

MBE’s Medical Billing review experts are experienced in identifying and addressing upcoding and Unbundled charged that are otherwise very complex to understand.  While it is well-known practice to bill with so-called UCR – usual customary and reasonable charges when you are dealing with personal injury matter, yet so many providers are still not following best billing practices and submits fraudulent bills by upcoming and unbundling of various services.

MBE’s Medical billing review process focus on two major issues:


Upcoding is a fraudulent medical billing practice in which a provider bills a health insurance payer (whether private, Medicaid or Medicare) using a CPT code for a more expensive service that was performed.

Different codes correspond to specific procedures or services and can have a different cost associated. When a provider upcodes, they assign a code for a more expensive service or procedure than what was performed.

Examples of Upcoding:

  • Level 1 vs Level 4 E/M – Reporting higher level of Evaluation & Management (E/M) codes than the actual service level provided.
  • Chronic vs. Acute – Reporting a diagnosis as a “Chronic” vs “Acute” is considered upcoding.
  • Cast vs. Crutches – When a doctor charges a CPT code for putting the patient in a cast and then again charge for removing cast where the patient was actually given crutches is considered upcoding. There are two different codes for these two services.
  • Physician vs. Nurse – Home Health services are charged with codes used for physician services where service was actually provided by a registered nurse. Physician services are reimbursed at a higher rate than services provided by a nurse.
  • CPT Time Rule – A psychiatrist billing for “45-minute session” vs the actual time spent was less than the billed amount. There is something called “CPT Time Rule” when it comes to therapy sessions with a psychiatrist and therefore affecting billing amount.


Unbundling is a fraudulent medical billing practice when a provider bills separately for components that are supposed to be billed in a bundled package. When separate codes are used to bill for supplies and services, the cost can be significantly higher.

Examples of Unbundling:

  • unbundling cardiac and anesthesia services – Using a modifier “59” to the codes in order to unbundle services related to cardiac procedures where anesthesia services should be billed together. According to the CPT manual, a modifier “59” is only used when “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”
  • unbundling of lab tests – A Laboratory service provider unbundles the panel or group of lab tests that generally are needed at the same time for certain suspected illnesses and therefore have a separate code which is at a much lower billing rate.
  • Unbundling Skilled Nursing Facility Charges – A SNF provider supposed to receive payment from Medicare at a bundled rate to care for patients including supplies that are provided by DME suppliers, yet SNF bills for these supplies separately to Medicare is considered unbundling charges.

Arti Modi is the president of MBE, a Med League Support Services Company, and an elect-secretary of AAPC’s Clinton, NJ Chapter as well as a member of AALNC.

MBE’s medical billing experts are here to assist plaintiff or defense attorney to help achieve the highest settlement possible for your client by a comprehensive review of the medical records and bills to ensure you have a clear understanding of what is “fair and reasonable.”  Our Medical Billing Experts can testify to the validity of all medical charges, incurred by injured client. Contact us today!

By | 2018-10-24T13:42:38+00:00 October 10th, 2018|Blog|0 Comments

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