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CPT fee differentials and visit upcoding under Medicare Part B
Abstract
Medicare Part B pays outpatient physicians according to the billed Current Procedural Terminology (CPT) codes, which differ in procedure and intensity. Since many performed services merely differ by intensity, physicians have an incentive to upcode services to increase profitability of a visit. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper explores the effect of Medicare Part B fee differentials on the upcoding of general office visits (i.e. for established patient visits with CPT codes of 99212-99215). It finds strong evidence that these fee differentials influence physician's coding choice for billing purposes across a variety of specialties. For general office visits, Medicare outlays attributable to upcoding may sum to as much as 15% of total expenditures for such visits. Medicare has much to gain financially by clarifying its classification rules. Until the distinctions between types of Medicare visits are redefined in a way that eliminates ambiguity, upcoding under Medicare Part B is likely to continue.
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“A change in the way records are coded (e.g., upcoding or changes in coding systems, as described above) may alter the study population [63,75,76].”
From The Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) statement. (2015) · cites this paper as [63]
In the citing paper
“For example, the introduction of provider billing incentive codes may change the likelihood of a code being used over time [62,63].”
From The Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) statement. (2015) · cites this paper as [63]
In the citing paper
“In addition, changes in coding strategies may impact validity or consistency of data.”
From The Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) statement. (2015) · cites this paper as [63]
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Metadata
- Authors
- Brunt, C. S.
- Affiliations
- Lake Superior State University (US)
- Corresponding author
- Brunt, Christopher S.
- Venue
- Health Economics
- Publisher
- Wiley
- Published
- 2011-04-03
- Volume
- 20
- Issue
- 7
- Pages
- 831-841
- ISSN
- 1057-9230 (ISSN-L)
- OpenAlex
- W1983062388
- Cited by
- 59
- References
- 19
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 3 · 2023: 6 · 2022: 1 · 2021: 5 · 2020: 5 · 2019: 5 · 2018: 3 · 2017: 5 · 2016: 5 · 2015: 5 · 2014: 4 · 2013: 4 · 2012: 2
- FWCI
- 6.05
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Health Economics (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Blue Cross Blue Shield of Michigan Foundation
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
- Keywords
- Medicare Part B, physician billing, physician incentives, Medicare reimbursement, Medicare Current Beneficiary Survey
- MeSH terms
- Diagnosis-Related Groups, Fee Schedules, Humans, United States, Medicare Part B, Models, Econometric, Current Procedural Terminology, Clinical Coding
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