News: Hospital upcoding resulted in billions of extra payments, study shows

From 2011 to 2019, the frequency of the highest intensity care being coded from patient documentation increased by 41% in five states in the United States, according to a recent study published in Health Affairs. After adjusting for patient demographics and other factors, researchers estimated that 13% of that increase was due to coding changes and contributed to $14.6 billion in payments in 2019. Of the $14.6 billion in extra payments due to upcoding, $5.8 billion came from commercial payers and $4.6 billion from Medicare, Becker’s Hospital Review reported.

Researchers analyzed thousands of hospital stays for 239 conditions in Florida, Kentucky, New York, Washington, and Wisconsin. The largest increase in upcoding involved conditions such as heart failure and shock, simple pneumonia, chronic obstructive pulmonary disease, and septicemia.

“These findings add to the evidence that hospitals may move patients into the highest billing category in order to increase the amount they are paid for patient care,” said Daniel Crespin, lead author of the study and an economist at Rand, a nonprofit research organization. “This suggests that government programs and private payers are paying billions more each year than what would be expected based on historical rates.”

Study authors said further research is needed to differentiate between fraudulent and accurate coding practices.

Editor’s note: To read Becker’s Hospital Review’s coverage of this story, click here. To access the Health Affairs study, click here.