Question

Assigning a diagnosis code that does not match patient documentation for the purpose or increasing reimbursement through the DRG system is known as:

Select one:
a. upcoding
b. downcoding
c. unbundling
d. bundling

Answer 1

Assigning a diagnosis code intentionally higher than what the patient documentation supports for higher reimbursement is known as upcoding. The correct answer is option a.

Step-by-step explanation:

Assigning a diagnosis code that does not match patient documentation for the purpose of increasing reimbursement through the Diagnosis-Related Group (DRG) system is known as upcoding. This practice involves selecting a diagnosis code that suggests a more serious condition.

It's a serious offense that can result in legal consequences and is considered a form of healthcare fraud. Conversely, downcoding occurs when a healthcare provider assigns a lower-level code than what is supported by the documentation, often to avoid audits or penalties.

Both upcoding and downcoding can have significant impacts on healthcare costs and quality of care. Unbundling and bundling refer to the practice of separating billing of services that should be combined into one charge, or incorrectly combining multiple services, respectively.