Upcoding is a type of fraud that service providers commit when they charge more for a service than it costs. Upcoding happens when service providers use different or higher CTP’s that are necessary. A CTP stands for Current Procedural Terminology, and it creates a code for to every conceivable medical procedure, and how much they will get reimbursed for it. An example of Upcoding is a doctor saw a patient for a regular check-up, CTP coded for a reimbursement of $60, but the doctor used the CTP for an extended check-up, which reimburses $100.
Medical procedures become bundled together when they are related or usually performed together, such as incisions and closures incidental to surgeries, and Medicare/Medicaid has lower reimbursements for these procedures when combined than when performed separately. Unbundling is another type of fraud that occurs when service providers charge separately for such procedures, thus increasing their Medicare/Medicaid reimbursements.