News: Upcoding a key concern for coders in 2025, survey says

Upcoding—when higher-level codes are assigned than are justified to increase reimbursements—will remain a major ethical dilemma in 2025 for coders, according to survey data released by Black Book Research.

Of more than 4,000 surveyed health information management professionals, 90% identified upcoding as a key concern for 2025. Additionally, 18% of respondents reported encountering pressure to engage in fraudulent coding for provider financial gain from their employer. Those who do engage in these practices may be considered involuntary accomplices to any illegal activities. As such, 99% of respondents said they expect to see a significant rise over the next decade in whistleblower cases filed under the False Claims Act.

Other challenges and concerns reported by survey respondents include:

• 80% reported concerns over the required training for transitioning to the ICD-11 system, with only 11% saying that their provider organizations have ramped up preparations
• 94% reported concerns about the accuracy of artificial intelligence-generated codes, with 97% fearing that critical human oversight will be lost
• 69% reported concerns that coding for social determinants of health may unintentionally reinforce healthcare system biases, or even affect coverage decisions
• Respondents also voiced concerns about the fairness of audits, with 85% reporting that the complexity of the current system leads to discrepancies identified during coding audits, which may lead to denied claims or repayment demands
• 55% reported that the true scope of care provided may be underestimated when services are bundled into one code

Editor’s note: This article first appeared in JustCoding. To read the Black Book Research survey findings, click here.