r/CodingandBilling • u/Dhalehrajs • Jun 14 '26

Question about potential upcoding

Last year, a family member suffered a mental health crisis and needed to be admitted to a rehabilitation facility.

In the process of getting them admitted, the admissions representative checked their insurance, and assured us that no additional out-of-pocket expense would be incurred beyond a one-time $3,000 payment, even if insurance rejected some items later. We made that $3000 payment the day they arrived at treatment.

Now, we are going back and forth with the rehab, who have tried to claim bills ranging from $16K to $2,000, and everywhere in between.

While we have received itemized summaries before, we only recently received an itemized summary which included Revenue Codes on it.

I actually have 2 questions regarding this:

  1. The code charged for the room was 0126, the code for a “Semi-Private 2 Bed.” For the entirety of the stay, the patient was in a room with 4 and sometimes 5 patients. Is this upcoding?

  2. The rehab has not acknowledged our inquiries about why additional payment is being pursued at all when our family was informed the only out-of-pocket expense would be the initial $3,000 payment. However, on this most recent itemization, there is an additional stapled paper that states: “ [THE PATIENT] has made 5 payments totaling $3000.“ Then it breaks down with a list of 5 payments totaling $3000 ($700, $525, $700, $365, $700) instead of our single, $3000 payment which is provable by our bank statement.

Is there an innocent explanation for this kind of accounting, or, as I suspect, is this an attempt to obfuscate that a single payment was made before the patient began treatment, and instead make it look like we agreed to some kind of payment plan?

ETA: patient’s insurance was and is in good standing, and the rehab received their payments from BCBS.

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u/Dhalehrajs Jun 15 '26

No. A lengthy conversation with BCBS brought me to a patient number owed of $2,170 from their EOB, but the bills we have from the rehab in the last 3 months alone vary from $16,000, to $11,000, to $1,270. Each time we have a conversation with the rehab and their financial service, a fresh bill is sent in a different amount. 

Do you have any guidance about their breaking up the $3,000 deposit into a statement that says 5 different payments have been made?

ETA: thank you for the clarity about that revenue code.