“Upcoding” occurs when a healthcare provider submits codes to Medicare, Medicaid or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed.
Healthcare providers use billing codes to identify the services and procedures that they provide to patients. Each code corresponds to a particular service or diagnosis and reflects the complexity of the work that the healthcare provider did. Government and private insurers use these codes to determine how much to pay for the services and procedures.
When providers upcode medical bills for Medicare and Medicaid patients, they cheat those healthcare programs of needed funds.