Current Procedural Terminology (CPT) codes help determine billing charges, depending on the services provided. Upcoding is when a healthcare provider logs a code that gives them a higher payout than the code for the actual service provided. This can be dangerous, as it affects the patient’s medical records, which might influence future treatment in some cases.


These are serious charges for a healthcare provider to face. Although it is sometimes done fraudulently, many times it is the result of a clerical mistake or simple misunderstanding. Healthcare providers who find themselves facing these charges should begin taking steps to defend themselves and prove that upcoding was not present or that any instances of upcoding were not fraudulent.

Defenses to Upcoding Charges

The allegation of intentionally and fraudulently overcharging an insurance company—whether private insurance, Medicare or Medicaid—is not an issue to be taken lightly. On the surface it can easily appear to be a case of fraud – doctors and other healthcare providers just trying to make some extra money.

But the system for coding medical procedures can be quite complex, resulting in unintentional mistakes. Determining which code(s) to use can also be very time-consuming, resulting in a doctor inadvertently choosing the wrong one. Or it may be that in trying to decipher which code to use, a doctor misinterprets the factors necessary to justify using a particular code.

If investigated for fraud, a healthcare provider may need to prove that the billing codes assigned were justified. This may require providing documentation to demonstrate that a particular service was in fact provided to the patient.

Of course, some cases of upcoding are simple clerical errors. The code may have been input incorrectly or there may be miscommunication between office staff regarding the service provided to a particular patient. According to, “Medical Billing Advocates of America, a national association that checks bills for consumers, says 8 out of 10 hospital bills its members scrutinize contain errors.”

Seeking Help from an Attorney When Charged with Upcoding

If there is a consistent pattern of billing errors, this can definitely lead to the appearance of fraudulence. Therefore, it’s important to seek legal advice upon any allegation of fraudulent billing. By addressing the matter early, instances of coding errors may be spotted so the healthcare provider and his or her attorney can work to rectify the situation.

Even if upcoding charges have already been filed, an attorney can help. To learn more about defending one’s rights, contact The Law Offices of Robert David Malove.