A patient comes in for a basic level office visit which involves a brief history and a problem-focused examination. The medical assistant, while coding the visit, selects a code for a comprehensive visit that includes a detailed history and examination. This coding practice is an example of:
Selecting a code for a more complex and costly service than was actually performed is known as upcoding. It is considered a form of healthcare fraud and can lead to overcharges to patients or insurers, legal penalties, and loss of credibility for the healthcare provider. Thus, it is imperative that medical assistants accurately code for the level of service provided to avoid legal and ethical issues.
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