In compliance and risk management, words matter. Over the next few weeks, we will look at some ways in which word choice and characterization can help or hurt in the compliance process. 

Two words that are frequently misused in compliance are “overcoded” and “undercoded.” While these terms should not be entirely banished from use, they should be exceedingly rare.

The word “overcoded” is regularly used when a reviewer looks at an office visit and determines that the documentation is not at the level suggested by the evaluation and management documentation guidelines. For example, let’s say we have an expanded-problem focused history and exam, with moderate-complexity decision-making documented, providing that the level of service is consistent with a 99213. Assume that the service is billed as a 99214. A 99214 requires that either the history or exam be detailed. Most people would characterize a claim in this situation as being “overcoded.” Yet in fact, we don’t know that.

First, a quick reminder that for purposes of Medicare billing, “if it isn’t written, it wasn’t done” is NOT the law. Medicare requires that you furnish information to support that a service was provided as billed, but nothing limits the scope of the information to the contents of the medical record. The medical record is certainly the easiest and best way to furnish information, but it isn’t exclusive. You can support the claim in a variety of ways. For example, the fact that the physician’s total RVUs are consistent with the physician’s time in the office is compelling evidence that the work was performed. If you are skeptical about my assertion about the state of the law, or if this is news to you, drop me an email at and I will send you some more information. It is quite clear that with narrow exceptions, missing documentation does not automatically result in an overpayment of a Medicare claim.  

Let’s return to the chart. What do we know? The documentation in the record does not support the claim as billed. There are still many possibilities. It could be that work was performed, but not documented. It could be that the documentation is perfectly accurate, and the service was in fact overcoded. There is even a less obvious possibility; perhaps the documentation includes services that were not actually performed, and the service was actually a 99212. What we know is that the documentation does not support the code billed, and that is how we should label the chart. The phrase “overcoded” should be limited to situations in which we are certain that the service actually provided was lower than the code that was billed.

The same principle applies to what is often called “undercoding.” When the documentation exceeds the code billed, you don’t know that everything that was documented actually occurred. You certainly hope it was, but we don’t know for sure. It could be that someone intentionally recorded false information, or it could be that information was carried forward from a prior visit. The existence of documentation templates results in situations in which documentation can be created easily – and even accidentally. We should be purely factual. The most likely scenario is that the service was, in fact, undercoded. But without more information, it remains the most probable scenario, not a certainty. Again, let’s choose our words carefully and stick to known facts. 

When you are positive that someone billed for a service that wasn’t provided, perhaps it is appropriate to use the word “overcoded.” But when there is any uncertainty, or when the problem is insufficient documentation, stating that the documentation does not support the code billed is the proper characterization. Choosing language wisely makes this a less risky business. 

About the Author 

David M. Glaser, Esq., is a shareholder in Fredrikson & Byron’s Health Law Group. David helps clinics, hospitals, and other healthcare entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David’s goal is to explain the government’s enforcement position and to analyze whether the law supports this position. David is a popular panelist on Monitor Mondays and is a member of the RACmonitor editorial board. 

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