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Know your ethical obligations regarding coding and documentation

Association of Clinical Documentation Improvement Specialists, August 4, 2009

What would you do? Know your ethical obligations
In late June, Johns Hopkins’ Bayview Medical Center in Baltimore agreed to pay nearly $3 million to settle allegations by two of its inpatient coders that the hospital’s physicians reported secondary diagnoses they had not identified or treated, according to a June 30 press release from the United States Attorney for the District of Maryland. You can read the press release here.

During the period from July 1, 2005, through February 28, 2007, the medical center allegedly submitted to federal health benefits programs fraudulent claims stating, in many instances, that patients suffered from malnutrition and acute respiratory failure despite the patients never being diagnosed or treated for those conditions.

The two coders, whose primary responsibility included assisting with clinical documentation, claimed they were asked to review inpatient medical records to determine whether the hospital could increase reimbursement by changing the severity of certain patients’ secondary diagnoses. Bayview denied all allegations but agreed to pay the settlement to avoid further litigation.

Coding ethics gets little attention because of more immediate concerns such as keeping accounts receivable days to a minimum. But the topic deserves attention all of the time, at least as coders’ underlying theme, says Kathy DeVault, RHIA, CCS, manager of professional resources at the American Health Information Management Association (AHIMA) in Chicago. “As coders, we need to be aware of what we’re being asked to do and how that fits within our standards of ethics,” DeVault says.

Do you know what ethical guidelines coders in your facility follow? How about whether they understand how they should and/or can proceed in ethically challenging situations? If you answered “no” or “I don’t know” to either question, perhaps it’s time to revisit the topic.

Know the ethical guidelines
Both AHIMA and the American Academy of Professional Coders (AAPC) have established coding ethics guidelines, upon which the Association of Clinical Documentation Improvement Specialists (ACDIS) based its own Code of Ethics. AHIMA’s 11 standards range from relatively straightforward suggestions (e.g., apply accurate and consistent coding practices, advance coding knowledge through continuing education) to those that are more complex and harder to implement (e.g., refuse to participate in or conceal unethical coding behavior).

The AAPC’s code of ethics similarly focuses on helping coders maintain high personal and professional ethical standards. The organization’s code states, for example, that AAPC members shall never:

  • Use illegal or unethical means in professional dealings 
  • Pardon or condone (by remaining silent) those who act fraudulently, deceptively, or illegally 
  • Exploit for personal gain relationships with patients, employees, or clients

Those who don’t follow the AAPC’s code of ethics risk losing their credentials and AAPC membership. Coders don’t need to memorize each and every ethics standard, DeVault says. However, they should know that the guidelines exist and read through them at least once. “As coders, we just shouldn’t be making assumptions [about how to handle situations],” she says. “We should be using the resources provided to us to make those decisions.” CDI specialists should keep the same advice in mind.

Realize potentially unethical situations
Sometimes it’s easier said than done to use the resources available, particularly because reading guidelines in the abstract is quite different than putting them into practice. DeVault offers the following tips for how to proceed in scenarios that may pose ethical dilemmas:

Understand your personal limits. Coders face stress from all sides—finance, physicians, and other coders. But stress shouldn’t push coders to report diagnoses without having sufficient documentation just so they can send the claim, DeVault says. One of DeVault's best managers used to tell coding staff members never to drop a chart they couldn’t stand behind.

Stand your ground. “Be true to yourself when you’re coding,” DeVault says. “That can be very hard,” especially in a stressful environment. When you know a chart needs additional documentation to justify reporting certain codes, speak up. Conduct research ahead of time to strengthen your case. For example, search through and print out applicable issues of Coding Clinic. The more backup documentation you have, the more likely your superiors will support you.

Speak up. If you see or hear other coding professionals acting in an unprofessional manner, don’t confront them hostilely, but offer them a solution, DeVault suggests. Point out applicable Coding Clinic information or offer to talk through the case with them.

Use your manager as a resource. Some situations require more weight behind them than others. For example, if your conversation with a colleague does nothing to dissuade unethical behavior, bring your manager into the loop. Or if you know you need to query a physician regarding a chart that might yield a high reimbursement, but that physician is out for seven days, enlist your manager’s help to keep the chart until the physician returns. If the hospital doesn’t want to wait to code the chart, ask to be removed from the case.

Look at medical record notations from ancillary staff consults. In most scenarios, coders are not allowed to code from documentation by anyone other than a physician, but notes from ancillary staff members may drive a physician query, DeVault says. For example, if a dietitian consultation suggests that a patient is malnourished, but the physician does not document this anywhere, you may be able to use the dietitian’s clinical information as the impetus for querying the physician.

Foster a comfortable, open environment at your facility. “Coders tend to be quieter people,” DeVault says. “They’re ... not necessarily comfortable walking in and having a confrontation or conversation, especially if they’re in an environment that doesn’t support that.”

DeVault says she’s been lucky to have always worked with managers who stood by their staff and offered an open-door policy. But not all facilities are like that, she notes. Those that are not can start by making small adjustments; set aside designated time to talk through issues or create a support system among colleagues.

“As peers, we need to encourage each other,” DeVault says.

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