Sample Letter Disputing a Coding Level (Possible Upcoding)
What does a coding-level dispute look like?
Upcoding means a service was billed at a higher level than the care provided. Evaluation and management codes are a common place to look. Emergency department visits, for example, are billed in levels from 99281 to 99285, and office visits in levels such as 99213 and 99214. Those are only examples of how levels work.
The difference between levels can be real money, so it is reasonable to ask about it. But a higher level can be correct when the doctor's documentation supports it, so frame the letter as a question, not an accusation.
When is the letter worth sending?
Send it when the bill's level seems out of step with your experience: a brief visit with a routine concern billed at a high level, a charge for a procedure that was not performed, or a total far above the allowed amount on your EOB.
- The visit was short and simple, but the code suggests a complex one
- The bill lists a procedure you do not remember receiving
- Your EOB describes the service differently than the provider's bill does
- Related charges appear to be billed separately when they were part of one visit
How do you customize it?
Write down what happened in plain terms: how long you were there, what the clinician did, what tests were run. Do not guess at the code that should have been used. You do not need to be a coder, and the letter should not claim to be one.
Name the code or service description exactly as printed on your itemized bill. If you only have a summary, send the itemized-bill request letter first.
What should you attach?
Attach the itemized bill and your EOB. If you have your visit summary or after-visit paperwork, include it. Consider also requesting the relevant portion of your records, since HIPAA gives patients a right of access to records in the designated record set, generally with a response in 30 days.
What to expect afterward
The provider's coding or compliance staff may review the chart. Possible results are a corrected bill at a lower level, a written explanation that the documentation supports the original level, or a request for more information. If you disagree with the explanation, ask your insurer to review the claim and consider a complaint to your state insurance department. Medical Bill Dispute Pro can flag possible coding concerns from the bill you upload, but it cannot see your chart, so the final judgment rests with you.
Sample letter
[YOUR NAME] [YOUR ADDRESS] [CITY, STATE ZIP] [PHONE / EMAIL] [DATE] [PROVIDER NAME] Attn: Billing and Coding Review [PROVIDER BILLING ADDRESS] Re: Request for review of coding level Patient: [PATIENT NAME] Account number: [ACCOUNT NUMBER] Date of service: [DATE OF SERVICE] Charge in question: [DESCRIPTION OF CHARGE / CODE] for [AMOUNT] To the Billing and Coding Department: I am writing to ask you to review the service level billed for the visit above. The itemized bill lists [DESCRIPTION OF CHARGE / CODE], which appears to be a higher level of service than the care I received. My visit lasted approximately [LENGTH OF VISIT]. During the visit, [BRIEF DESCRIPTION OF WHAT HAPPENED]. Based on that experience, I do not understand how the billed level was determined. I request that you: 1. Review the documentation for this visit and confirm the service level that it supports. 2. If the level is not supported, correct the charge, resubmit the claim to my insurer as needed, and send me a corrected statement. 3. If you believe the level is correct, explain the basis in writing and provide a copy of the documentation used to determine it. 4. Hold the account, and do not refer it to collections, while this review is in progress. I have enclosed the itemized bill and my Explanation of Benefits. Please respond in writing within 10 business days of receiving this letter. I reserve the right to contact my health plan and the appropriate state regulator if the matter cannot be resolved. Sincerely, [YOUR NAME] [YOUR PHONE NUMBER]
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Frequently asked questions
Is upcoding the same as fraud?
Not necessarily. A wrong level can come from a documentation mistake or a coding misunderstanding. Intentional billing for services not provided is a different and more serious matter. For a first letter, ask for a review and avoid accusations, which tend to slow things down.
Can I see which code was billed?
Yes. An itemized bill normally shows a billing code next to each service, and your EOB lists what the insurer processed. If you cannot find codes, ask the provider for an itemized statement that includes them.
What if the doctor says the level is right?
Ask for the explanation in writing and for the chart documentation that supports the level. If you still believe it is wrong, you can ask your insurer to review it, or consult a medical billing advocate.
Will my insurer reduce my share if the code is lowered?
Usually the insurer reprocesses the claim based on the corrected code, which can change your patient responsibility. The provider may need to submit a corrected claim. Ask for a new EOB afterward so you can confirm the figures.
Sources and further reading
Related guides
Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.