Medical coders play a vital role in many areas of a successful practice. A coder’s expertise and accuracy prove essential for maintaining a healthy bottom line, contribute to patient safety and satisfaction, and promote the elimination of compliance risk in a medical practice. To be the best in our field, coders are responsible for adhering to our industry’s code of ethics that goes way beyond just being able to accurately assign a code.
Integrity, respect, commitment, competence, fairness and responsibility are all ethical principles of professional conduct as defined by the American Academy of Professional Coders (AAPC). These standards sound simple enough and should be part of our everyday lives, but what about some of the stickier situations that we might encounter that could compromise our ethics? What is the best way to deal with them?
Almost every industry association has its own governed ethical code of conduct, and your employer most likely does as well. It is important to know your ethical duties to your employer, your association and most importantly, yourself. Coding may seem as simple as black or white, as basic as right or wrong. But all coders have probably had at least one experience that left them wondering what to do.
In medical coding, unethical behavior can be construed as fraudulent behavior, leaving you and the practice exposed to financial and legal risk. Coding mistakes happen — that’s a reality. A simple transposition of a number can translate 99024 (a post-op/no charge visit) into a 99204 (a new patient visit of moderate complexity). Correct the mistake, refund the payment and find ways to prevent repeating the error in the future. Perhaps it’s a simple misprint on the superbill or doctor’s coding worksheet. Mistakes are not fraud, unless they reveal a pattern.
Upcoding (coding for services at levels higher than received), coding for services that aren’t performed or not medically necessary, or submitting diagnoses that aren’t documented to get the claim paid are other examples of unethical behavior in coding that can be easily construed as fraudulent behavior and, if identified, can be very costly to the practice. It’s not a matter of if your coding and billing patterns will be reviewed, but when. Payers review claims data and billing patterns and may request a formal review of records if your billing patterns appear out of the norm in relation to your peers.
Coders sometimes express pressure from their superiors to “just get the claim out the door,” and some fear for their jobs if they don’t do what is asked of them, ethical or not. Do you want to work for an organization whose culture and ethics don’t mirror yours? Is your job worth the worry and stress of knowing you aren’t doing the right thing?
Avoid conversations with other employees, friends or anybody other than the patient, their doctor and the insurance company. It’s not only the right thing to do, it’s illegal and unethical to do otherwise.
Just say no when pressured to do the wrong thing, such as upcoding or unbundling for better reimbursements. The Office of Inspector General (OIG) defines fraud as knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain payment for which no entitlement would otherwise exist. Anyone, not just providers, who engages in incorrect coding, upcoding or billing for services that were not provided may be subject to administrative, civil or criminal liability, as well as exclusion from participation in all federal healthcare programs for a period of time. That exclusion could cost you your job.
Confidentiality is another area requiring ethical behavior. We are human, and it is human to be curious. It is our responsibility to avoid sharing information about patients and every aspect of their privacy by not disclosing what we read in their medical record. Avoid conversations with other employees, friends or anybody other than the patient, their doctor and the insurance company. It’s not only the right thing to do, it’s illegal and unethical to do otherwise.
Most coders are monitored and some even incentivized by their productivity. Cutting corners to gain higher numbers can affect patient safety by not fully and accurately abstracting all pertinent medical codes. Professional certified coders are held to higher standards of excellence. In my experience, I have valued the coder who maintained high levels of accuracy, not just who could code the most charts.
Make sure you know your organization's code of ethics and make sure it compares to yours.