As a certified coder, the AAPC expects you to maintain and enhance the dignity, status, integrity, competence and standards of the profession. So what do you do when you work for a provider who remains dishonest after multiple warnings and violates coding ethics?

For coders who are new to the vocation, this is a common problem which must be taken seriously. There are a myriad of rules to follow so keeping up with federal, state, and local laws is important for a coder and it is important to keep our providers informed as well.

Medical Coding Ethics: The Reality

But let’s face it. In the real world, not every coding scenario is going to replicate a question in your textbook. There will be challenges. There will also be providers who want to code it right. There are others who will want to maximize their collections at any cost and keep their fingers crossed that no one will catch on.

Let’s take Dr. Norman Smith, a family practitioner who practices in the Boston area. Dr. Smith codes every patient with a level four or five E/M visit, even if the patient is seen for a B-12 injection. No matter how many times the physician is warned, he ignores his staff and continues to choose high level codes. If the patient complains that he received a bill because his insurance did not cover a particular service, Dr. Smith will tell the staff to appeal the claim to match the patient’s benefits. Ethical? Absolutely not!

Dr. Martin is an internist who runs blood tests, cardiac studies and stress tests prior to seeing patients for a physical exam. He likes to create a baseline for new patients and monitor his established patients annually. Many of the tests he provides are only covered when medical necessity is evident. Dr. Martin does not have patients sign Advance Beneficiary Notices or discuss financial liability prior to seeing the patient.

One day a member of his staff had her husband make an appointment with the doctor. He had all the tests performed prior to his exam and genuinely liked the way Dr. Martin practiced medicine. So what was the problem? The coder for the practice walked up to the other staff member and offered her condolences. “I had no idea John had so many health problems,” she said. The woman looked over the paperwork Dr. Martin had given the coder. Dr. Martin had listed Congestive Heart Failure and Coronary Artery Disease as her husband’s diagnosis codes. When the physician was questioned, his response was, “If I don’t code it this way, your insurance will not pay.” Needless to say, her husband’s claim went out as an adult physical and he paid for the tests out of pocket. When the staff began auditing Dr. Martin’s charts, something they had never done before, they discovered that he did not have a sub-specialty in cardiology and that almost every patient who was given these tests was listed with a cardiac problem that didn’t exist.

Many doctors under code, regardless of the complexity of the visit, for fear of being audited. This practice is just as wrong.

Coders must adhere to standards, even if it means walking away from a job. Our profession demands a high standard of coding ethics.

The above stories are a glimpse into what a coder may face in their profession. Failure to adhere to these standards may result in the loss of credentials and AAPC membership, as well as questioning by governmental authorities for fraud and abuse. Most providers want feedback on their documentation and prefer maximizing their revenue ethically, but for the doctors who are questionable – stay clear!

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