Which of the following is considered fraud?

• A. The billing and coding specialist unbundles a code to receive higher reimbursement
• B. Upcoding a service
• C. Billing for a non-covered service
• D. Misrepresenting the procedure

Answer: (A)

Deliberately unbundling a procedure into separate codes to boost reimbursement is fraud. This happens when components of a single service that should be billed together are split into multiple codes to obtain more money. In CPT/HCPCS coding, many parts of a procedure are bundled and should be reported with one code that reflects the full service; unbundling bypasses that rule and amounts to intentionally misrepresenting what was done to receive higher payment. That clear, intentional manipulation of coding for financial gain is the classic example of fraud in medical billing.

While other improper practices like upcoding, billing for a non-covered service, or misrepresenting the procedure can also be fraudulent, the scenario here most directly illustrates the fraudulent act of unbundling to inflate payment.