Billing for services at a level higher than the documentation supports is considered up coding. Being accused of up coding is mortifying, especially when it is not intended.

Many times, up coding occurs and physicians are shocked because they assume that documentation in a prior encounter will provide the information needed to support their code selection.  In a legal or regulatory dispute, local policies that result in systematic up-coding can be disastrous for the billing company or the physician involved. Systematic up-coding that is felt to be intentional to charge more money is considered fraudulent and resulting penalties can be severe.