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California Upcoding Defense Lawyer

Upcoding happens when a healthcare provider bills the payer – a private insurance company or a government payer like Medicare or Medicaid (Medi-Cal) – for a more expensive service than what was actually provided, or when a different person provided the service, such as wrongfully claiming a doctor or specialist delivered the service instead of a nurse. Upcoding at your medical practice can lead to an OIG investigation, a prosecution by the Department of Justice, or a civil False Claims Act case brought on the government’s behalf by one of your own employees who believes they are blowing the whistle on Medicare fraud. Your medical practice, your professional license, and even your very freedom could be in jeopardy. Let an experienced healthcare law attorney at the Law Offices of Art Kalantar advise you and defend you against fraud charges and help you get the best result. Call our experienced California upcoding defense lawyer today for a free case evaluation and immediate assistance.

Common Examples of Upcoding Errors

Medical services and procedures are billed to Medicare through a series of codes, called Current Procedural Terminology codes, or simply CPT codes. Every conceivable service has a CPT code attached to it, and these codes are constantly being updated, added to, and revised by the American Medical Association (AMA). Extensive, ongoing training for your billing staff is required to keep them competent and up-to-date on the latest codes. Putting in the wrong code for the service provided can result in an upcoding mistake that forms the ground for an investigation or enforcement action from the Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), or other agencies.

According to CMS, somewhere around 7.5% of Medicare payments involve improper code reporting, amounting to $30 billion in annual payments ascribed to fraud. Upcoding errors are a leading source of these mistakes. Some of the most common upcoding errors involve the following:

  • A procedure is billed as though it was performed by a doctor, when in fact it was conducted by a nurse, a physician’s assistant, or some other staff member whose rate of pay is less than that of the provider who was billed as performing the service.
  • Only one x-ray is taken, but the billing reflects that multiple views were taken.
  • A sedation procedure is billed under the more expensive anesthesia code.
  • A follow-up visit on an existing patient is coded as a new patient visit, which generates higher Evaluation & Management (E&M) reimbursement rates.
  • The E&M Modifier 25 code is used when the doctor later performs an additional service to the same patient on the same day, but the service is considered insignificant or an inseparable part of the initial service provided.

Upcoding Can Lead to Civil and Criminal Prosecution

Medicare and Medi-Cal have systems in place to identify upcoding or other coding errors, and any improper coding, however innocent the mistake may be, can provide the basis for a government investigation and criminal prosecution. To secure an upcoding conviction, however, the government must prove that the provider intentionally upcoded for the purpose of receiving money from the payer it was not entitled to. As an experienced healthcare law and coding error defense lawyer, attorney Art Kalantar vigorously defends his clients against charges they intentionally engaged in improper coding such as upcoding with the intent to defraud the payer.


Intent to defraud is not necessarily required to impose liability in the civil context, however. The government can initiate a lawsuit under the federal False Claims Act for upcoding and impose monetary penalties if the provider is found to have acted improperly. Employees at the medical practice are often the ones who report upcoding to the government in the hopes of sharing in up to 30% of any monies the government recovers from the practice. The Law Offices of Art Kalantar can help you identify and remedy any upcoding errors before the government gets involved to keep you in compliance and out of trouble, or provide strong, effective defense of any charges that are brought.

Contact an Experienced California Upcoding Defense Lawyer Today

If you or your medical practice is under investigation for upcoding or other coding errors, or if you have been charged with Medicare or Medi-Cal fraud, get help right away to protect your rights and put you in the best position for a positive outcome in your case. Call the experienced California upcoding defense lawyer at the Law Offices of Art Kalantar today at 310-773-0001 for a free case evaluation and practical, strategic advice.

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