Upcoding

Upcoding refers to the practice of coding services which are not actually provided. This can be intentional or unintentional. Radiology coders should be aware that coding all that is documented in the conclusion of radiology reports can result in upcoding. For example, if a multibody CT Scan is done to access the extent of malignancy, the coders should not pick codes for cholelithiasis, kidney stones, calcifications if documented in the result of the CT Scan, as these are incidental findings and are not related to the purpose of imaging i.e. to access the malignancy. In the same way, if abdomen x-ray is done for abdominal pain, the radiologist may document degeneration of lumbar intervertebral disk which should not be coded.