What is upcoding and unbundling?

Upcoding and unbundling are examples of healthcare billing fraud that involve the improper use of billing codes by health care providers.

Billing codes (known as CPT codes) are a part of the Medicare healthcare program. The program uses a set of tables to determine how much a provider should be compensated for each type of procedure. Fraud occurs when providers manipulate these codes to maximize compensation. 

It’s important that all healthcare workers understand these types of fraud because being involved in either of them can expose you to serious criminal liability. Reporting them, on the other hand, can make you eligible to receive a portion of all the funds that are recovered from the fraud.

In this short guide, you’re going to learn what upcoding and unbundling are. You’ll also get to review some examples of this fraud, along with real cases that have involved them. Let’s start by taking a deeper look at upcoding.