Association of Clinical Documentation Improvement Specialists (ACDIS)

Sections:

• Preamble – Provides the ethical obligation of the members and credentialed nonmembers.
• Values – Summarizes the core values based on the mission of the Association.
• Purpose – Delineates the five purposes for the Code of Ethics.
• Application of the Code of Ethics – Describes how ACDIS members and credentialed nonmembers should use the Code.
• Ethical Principles – Describes the 12 ethical principles to which members and credentialed nonmembers should adhere.
• How to Interpret the Code of Ethics – Provides guidelines to help members and credentialed nonmembers interpret the 12 principles.

Preamble

The ACDIS Code of Ethics serves as a guide for the professional behavior of its members and nonmembers who hold the certified clinical documentation specialist (CCDS) credential. This code of ethical standards for members of ACDIS strives to promote and maintain the highest standard of professional service and conduct among its members. Adherence to these standards assures public confidence in the integrity and service of all members of ACDIS.

The ethical obligations of the clinical documentation improvement specialist include:

• the proper use of medical records and the documentation contained therein for quality and reimbursement purposes
• the protection of patient privacy and confidential information, and disclosure of information.

Both handwritten and computerized medical health records contain many sacred clinical stories—stories that must be protected on behalf of the individual and the aggregate community served in the healthcare system. Healthcare consumers are increasingly concerned about the loss of privacy and the inability to control the dissemination of their protected information. Core health information concerns include:

• what information should be collected
• how the information should be handled
• who should have access to the information
• under what conditions the information should be disclosed

Ethical obligations are central to the clinical documentation improvement professional's responsibilities, regardless of the employment site or the method of collection, storage, and security of health information. Sensitive information (genetic, adoption, drug, alcohol, sexual, and behavioral information) requires special attention to prevent misuse.

Values

All ACDIS members and credentialed nonmembers agree to maintain the highest standard of personal and professional conduct. Members and credentialed nonmembers shall respect the rights of patients, clients, employers, and all other colleagues. ACDIS is committed to recognizing the intrinsic worth of each member.

ACDIS members and credentialed nonmembers define professional values as:

• honesty
• acting in an manner which brings honor to self, peers and profession
• committing to continuing education and lifelong learning
• performing association duties honorably
• strengthening professional membership
• representing the profession to the public
• promoting and participating in research

These professional values require balancing competing interests and obligations of those who seek access to health information and require an understanding of ethical decision-making.

Purpose

The ACDIS Code of Ethics serves five purposes:

1. Identifies core values on which ACDIS is based.
2. Summarizes broad ethical principles that reflect the profession's core values and establishes a set of ethical principles to guide decision-making and actions.
3. Helps CDI professionals identify relevant considerations when professional obligations conflict or ethical uncertainties arise.
4. Orients practitioners new to the field to ACDIS’ mission, values, and ethical principles.
5. Articulates a set of guidelines that the CDI professional can use to assess whether they have engaged in unethical conduct.

Application of the Code of Ethics

The ACDIS Code of Ethics outlines aspirational principles and guidelines. It reflects the commitment of all individuals, agencies, organizations, and bodies allied with the association to uphold the profession's values.

The Code of Ethics does not provide a set of rules that prescribe how to act in all situations. Specific applications of the code must take into account the context in which it is being considered and the possibility of conflicts among the code's values, principles, and guidelines. Ethical responsibilities flow from all human relationships, from the personal and familial to the social and professional. Further, the ACDIS Code of Ethics does not specify which values, principles, and guidelines are the most important and ought to outweigh others in instances when they conflict.

Ethical Principles

The following ethical principles are based on the core values of ACDIS, the American Health Information Management Association (AHIMA), and the American Academy of Professional Coders (AAPC). They apply to all ACDIS members and nonmembers who hold the CCDS credential.

Clinical Documentation Improvement Specialists shall:

1. Advocate, uphold, and defend the individual’s right to privacy and the doctrine of confidentiality in the use and disclosure of information.

2. Use only legal and ethical means in all professional dealings and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive or illegal acts.

3. Put service and the health and welfare of persons before self-interest, and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the clinical documentation improvement profession.

4. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations.

5. Refuse to participate in or conceal unethical practices or procedures.

6. Advance their specialty knowledge and practice through continuing education, research, publications, and presentations.

7. Recruit and mentor students, peers, and colleagues to develop and strengthen the professional workforce.

8. Perform responsibilities of the ACDIS honorably, whether those responsibilities relate to appointed or elected positions, and preserve the confidentiality of any privileged information made known in any official capacity.

9. State truthfully and accurately their credentials, professional education, and experiences.

10. Facilitate interdisciplinary collaboration in situations supporting clinical documentation improvement practice.

11. Respect the inherent dignity and worth of every person.

12. Avoid participation in, condone, or be associated with dishonesty, fraud and abuse, or deception.

How to Interpret the Code of Ethics

The following ethical principles represent the core values of ACDIS, AHIMA, and the AAPC. Guidelines included for each ethical principle are a non-inclusive list of behaviors and situations that can help to clarify the principle. They are not a comprehensive list of all situations that can occur.

1. Advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information.

Clinical Documentation Improvement professionals shall:

i. Protect the confidentiality of all information obtained in the course of professional service or otherwise. Disclose only information directly relevant or necessary to achieve the purpose of disclosure.

2. Use only legal and ethical means in all professional dealings and shall refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive or illegal acts.

Clinical Documentation Improvement professionals shall:

i. Refuse to participate in, or conceal unethical practices or procedures
ii. Act in a professional and ethical manner at all times
iii. Be knowledgeable about organizational policies and procedures for handling concerns about colleagues’ unethical behavior
iv. Strive to maintain and enhance the dignity, status, competence, and standards of ethical clinical documentation practice

Clinical Documentation Improvement professionals shall not:

i. Participate in, condone, or be associated with dishonesty, fraud and abuse, or deception

3. Put service and the health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the clinical documentation improvement profession.

Clinical Documentation Improvement professionals shall:

i. Act with integrity, behave in an honest, trustworthy manner, abiding by ethical principles, elevate service to others above self-interest, and promote high standards of practice in every setting.
ii. Ensure that the working environment is consistent, avoids any conflict of interest, and encourages compliance with the ACDIS Code of Ethics, taking reasonable steps to eliminate any conditions in their organizations that violate, interfere with, or discourage compliance with the code.

4. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations.

Clinical Documentation Improvement professionals shall:

i. Protect the confidentiality of patients' written and electronic records and other sensitive information. Take reasonable steps to ensure that patients' records are stored in a secure location and that patients' records are not available to unauthorized personnel.

5. Refuse to participate in or conceal unethical practices or procedures.

Clinical Documentation Improvement professionals shall:

i. Act in a professional and ethical manner at all times.
ii. Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues.
iii. Be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. These include policies and procedures created by ACDIS, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations.
iv. Seek resolution if they believe that a colleague has acted unethically or exhibits incompetent or impaired behavior. This includes discussing these concerns with the colleague when feasible and when such discussion is likely to be productive. Take additional action through appropriate formal channels, such as contacting an accreditation or regulatory body and/ or the ACDIS Professional Ethics Committee.
v. Consult with a colleague when feasible and assist the colleague in taking remedial action when there is direct knowledge of a colleague’s incompetence or impairment.

6. Advance their specialty knowledge and practice through continuing education, research, publications, and presentations.

Clinical Documentation Improvement professionals shall:

i. Develop and enhance continually their professional expertise, knowledge, and skills (including appropriate education, research, training, consultation, and supervision). Contribute to the knowledge base of clinical documentation improvement specialists and share knowledge related to practice, research, and ethics.
ii. Base practice decisions on recognized knowledge, including empirically based knowledge relevant to clinical documentation improvement and clinical documentation improvement ethics.
iii. Contribute time and professional expertise to activities that promote respect for the value, integrity, and competence of the clinical documentation improvement profession. These may include, but are not limited to:

• mentoring colleagues
• assisting with research
• participating in professional organizations or other activities that contribute to the profession’s body of knowledge

iv. Take reasonable steps to provide or arrange for continuing education and staff development, addressing current knowledge and emerging developments related to health information management practice and ethics.

7. Recruit and mentor students, peers and colleagues to develop and strengthen the professional workforce.

Clinical Documentation Improvement professionals shall:

i. Evaluate new CDI professional’s performance in a manner that is fair and respectful when functioning as mentors or supervisors.
ii. Assist students, peers and new clinical documentation Improvement professionals to develop and strengthen skills.
iii. Provide directed practice opportunities for new clinical documentation improvement professionals.

8. Perform honorably ACDIS responsibilities, either appointed or elected, and preserve the confidentiality of any privileged information made known in any official capacity.

Clinical Documentation Improvement professionals shall:

i. Resign from an Association position if unable to perform the assigned responsibilities with competence.
ii. Speak on behalf of ACDIS, accurately representing the official and authorized positions of the organizations.

9. State truthfully and accurately their credentials, professional education, and experiences.

Clinical Documentation Improvement professionals shall:

i. Make clear distinctions between statements made and actions engaged in as a private individual and as a representative of the clinical documentation improvement profession, a professional health information organization, or the clinical documentation improvement professional’s employer.
ii. Claim and ensure that their representations to patients, agencies, and the public of professional qualifications, credentials, education, competence, affiliations, services provided, training, certification, consultation received, supervised experience, other relevant professional experience are accurate.
iii. Claim only those relevant professional credentials actually possessed and correct any inaccuracies occurring regarding credentials.

10. Facilitate interdisciplinary collaboration in situations supporting health information practice.

Clinical Documentation Improvement professionals shall:

i. Participate in and contribute to decisions that affect the well-being of patients by drawing on the perspectives, values, and experiences of those involved in decisions related to patients. Clearly establish professional and ethical obligations of the interdisciplinary team as a whole and of its individual members.

11. Respect the inherent dignity and worth of every person.

Clinical Documentation Improvement professionals shall:

i. Treat each person in a respectful fashion, being mindful of individual differences and cultural and ethnic diversity.
ii. Promote the value of self-determination for each individual.

12. Avoid participation in, condone, or be associated with dishonesty, fraud and abuse, or deception.

Clinical Documentation Improvement professionals shall not:

i. Promote patterns of retrospective documentation to avoid suspension of, or increases to, reimbursement
ii. Assign diagnostic related groups (DRGs) or diagnoses without physician documentation
iii. Encourage or support coding when documentation does not justify the billed procedures
iv. Encourage or support coding an inappropriate level of service
v. Promote miscoding to avoid conflict with others
vi. Engage in negligent documentation or coding practices including misstating or misusing official coding guidelines
vii. Hide or ignore review outcomes, such as performance data
viii. Misuse sensitive information about a competitor
ix. Violate the privacy of individuals

Acknowledgements

• Adapted with permission from the Code of Ethics of the American Health Information Management Association (AHIMA), AHIMA, Code of Ethics, 1998.
• Adapted with permission from the Code of Ethics of the American Academy of Professional Coders, AAPC, Medical Coding Code of Ethics.