Medical Coding Ethics: The Reality

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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4 thoughts on “Medical Coding Ethics: The Reality”

    • Thank you, Laureen. The coding scenarios I presented were actual clients of mine. I had no choice but to terminate our business relationships. In fact, these stories are only two out of many that I have encountered over the years. There is nothing worse than being investigated by Health and Human Services and the FBI until proven innocent. Following the Officer of the Inspector General (OIG) guidelines is the best advice I can give. I had every incident documented and it helped me 100%. Fortunately, most providers choose to be ethical – for that we can be grateful!

    • Not sure if you’re still monitoring these posts, I’m obviously late to the rodeo. We are stepping out of general contracts in which we reported service encounters, but did not submit actual billing. As this is changing and we’re expanding into the commercial market I’m wondering about ethical considerations for a billing/coding department to change codes that are mistakes. (Mistakes only, I’m not talking about upcoding, or fraudulent coding to increase reimbursement. Unfortunately, until we upgrade our EHR it is possible for a provider to complete a service encounter in an inaccurate–solely by clicking an incorrect code.) I’ve done some research and I haven’t found a clear answer. Can it be a simple query? Once the clarification is made, what is the best way to document that the provider authorized a change? Thanks in advance for any input you have.

      • Hi Bryan – we do try to monitor them – thanks for stopping by. The bottom line is since the providers are essentially signing off on what bills are sent out they need to be the ones to ok changes being made for obvious errors. I personally would like to get some sort of confirmation that it was ok to make the change. I’d ask your EHR rep what they suggest for their system. You might also want to join our forum to see if other members have had similar challenges –Laureen


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