Fundamentals of Nursing Q 50

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A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

  

     A. Unbundling

     B. Overbilling

     C. Upcoding

     D. Misrepresentation

    

    

Correct Answer: C. Upcoding

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Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. An upcoded bill can be sent to any payer—whether a private health insurer, Medicaid, Medicare, or the patient. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.

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Option A: Unbundling refers to using multiple CPT codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment.

Option B: Overbilling (sometimes spelled as over-billing) is the practice of charging more than is legally or ethically acceptable on an invoice or bill.

Option D: A misrepresentation is a false statement of a material fact made by one party which affects the other party’s decision in agreeing to a contract. If the misrepresentation is discovered, the contract can be declared void, and depending on the situation, the adversely impacted party may seek damages.

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