Current Procedural Terminology (CPT) is a system of codes in the healthcare system used to describe medical, surgical, and diagnostic services. Healthcare providers use these codes to bill health insurance companies and government programs like Medicare and Medicaid for the services administered to patients.

How CPT Codes Relate to Whistleblowing

Whistleblowers as insider employees or auditors in the healthcare system can play a critical role in identifying and reporting fraudulent billing practices involving CPT codes. They can help identify:

• Upcoding and Downcoding: Whistleblowers may report instances where healthcare providers are upcoding (billing for more complex services than were actually provided) or downcoding (billing for less complex services to avoid scrutiny) to increase or decrease reimbursement.
• Unbundling: This occurs when a single procedure is broken down into multiple codes to increase reimbursement.
• Phantom Billing: This involves billing for services that were not actually provided.
• Medical Necessity: Whistleblowers may report instances where services were billed that were not medically necessary. By reporting these types of fraud, whistleblowers can help protect taxpayers and ensure that healthcare resources are used appropriately.

Whistleblower protection laws, such as the False Claims Act, can incentivize individuals to report such fraudulent activities.