CFE – Financial Transactions and Fraud Schemes — Question 22

A particular back surgery contains two basic components (an incision and muscle repair), but it is supposed to be billed using a single procedure code. Heather performs this back surgery on a patient and submits a claim using three codes: one for the full procedure, one for the incision, and one for muscle repair. Which scheme BEST describes Heather’s actions?

Answer options

Correct answer: B

Explanation

Heather's use of multiple codes instead of a single procedure code represents 'Upcoding', which is the practice of billing for more complex services than were actually performed. The other options do not accurately reflect her actions: 'Unnecessary services' implies providing services that are not needed, 'Over-utilization' suggests excessive services beyond necessity, and 'Unbundling' refers to separating components that should be billed together, but in this case, Heather is incorrectly increasing the code count.