Medical Coding Ethics Ethical Concerns in Health Care Delivery: Focus on Medical Coding and Billing Practices

The objective of this study is to examine ethical concerns medical coding and billing in the physician office. Medical coding and billing has become very complex in light of health care reform. Recently, Christopher Gregory Wayne, reported to be "dubbed the Rock Doc" was arrested on a dozen charges of Medicare fraud" when he was accused of fraudulently billing for "physical therapy procedures, such as massages and electrical stimulation, that were not necessary or in some instances had been provided at his prior medical practice in Miami." (Weaver, 2013, p.1) It appears that where this doctor failed is billing for physical therapy when his staff was not properly accredited for providing these treatments.

Health Care Coding and Billing Changes

It was reported by Gunderman (2013) that October 1, 2014 is the deadline on implementing the ICD-10 system for classification of diseases. The World Health Organization developed the predecessor of ICD-10 and specifically ICD-9 which has been utilized since the latter part of the 1970s. There are at least 13,000 billable codes listed including "such exotic diagnoses as "injury from fall while occupying spacecraft" and "exposure to fireball effects of nuclear weapon." (Gunderson, 2013, p. 1) The new system, ICD-10 will have approximately 68,000 codes reported to be "emblematic of a plague of complexification sweeping across healthcare." (Gunderson, 2013, p. 1) Gunderson reports that health care is "becoming more bureaucratic, and the rate of bureaucratization seems to be increasing exponentially." (2013, p.1)

II. Medical Billing and Coding Ethics

Medical coding and billing principles are reported to include the following: (1) only those individuals who have the necessary background and training should perform the medical coding function; (2) It is necessary that those performing medical coding and billing tasks receive training and education that is ongoing and continuing, respectively, on an annual basis; (3) National guidelines govern coding and are in place for the specific setting for the performance of function coding; (4) Coding is also governed by state law where it is applicable; (5) Only information documented in the medical record should be coded; (6) professional coders do not take part in coding practices that are unethical. (Weil and Regan, p. 233) The False Claims act is violated is the individual "knowingly applies incorrect codes for a higher reimbursement" or in the event they assign a code that is incorrect to get a claim paid. Penalties that the provider may suffer include the following: (1) Three times the damage amount sustained by the government; (2) Civil penalties no less than $5,000 and no more than $10,000; and (3) Possibility of being excluded from participating in government health care programs such as Medicare and Medi-Cal. ( )

III. AAPC Audit Findings & Challenges Ahead

AAPC is reported to have recently audited records according to the rigorous specification of ICD-10-CM and reports that after having audited 20,000 records, "Only 63% of providers' current physician documentation is sufficient…This lack of specific enough documentation could have a major negative impact on revenue if not corrected before implementation, with coders relying on less specific default codes. Findings state that insufficient documentation is often comprised by a large percentage "of at-risk revenue compared with what was properly documented as facilities." (APC Insider, 2013, p.1) In fact, it is reported that at one facility, there were seven diagnostic codes that were used the most and that represented 93% of the revenue for the facility. Therefore, making sure that documentation is valid on a very few codes could greatly affect the bottom line for the facility. The study also indicated that the sufficiency of documentation for ICD-10 was differentiated by specialty in that "Gastroenterology practices had the lowest percent of complete documentation at just 48%. Plastic surgery, meanwhile, boasted the highest at 98%." (APC Insider, 2013, p.1) Providers however, are aware of the problem but have less than 12 months left before implementation. There should have already been an assessment of documentation by providers in order to ensure that they comprehend the conditions...

It is necessary that every individual in the revenue cycle is well versed in what will be required to ensure reimbursement. (APC Insider, 2013, paraphrased)
Ethical principles for coding based on the American Health Information Management Association and the AHIMA Code of Ethics which apply to all coding professional are stated to include the following stated ethical principles: Medical coding personnel will (1) Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data. Coding professionals and those who manage coded data shall: (A) Support selection of appropriate diagnostic, procedure and other types of health service related codes (e.g. present on admission indicator, discharge status); (B) Develop and comply with comprehensive internal coding policies and procedures that are consistent with official coding rules and guidelines, reimbursement regulations and policies and prohibit coding practices that misrepresent the patient's medical conditions and treatment provided or are not supported by the health record documentation; (2) Code assignment resulting in misrepresentation of facts carries significant consequences: (A) Participate in the development of institutional coding policies and ensure that coding policies complement, and do not conflict with, official coding rules and guidelines; and (B) Foster an environment that supports honest and ethical coding practices resulting in accurate and reliable data. (3) Coding professionals shall not: Participate in improper preparation, alteration, or suppression of coded information; (4) Coding professionals shall report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, public data reporting, quality and patient safety measurement, research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines; and (5) Adhere to the ICD coding conventions, official coding guidelines approved by the Cooperating Parties, the CPT rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets; and (6) utilize appropriate resource tools that assist coding professionals with proper sequencing and reporting to stay in compliance with existing reporting requirements are available and used; (7) make selection and sequencing diagnosis and procedure codes in accordance with the definitions of required data sets for applicable healthcare settings; (7) Comply with AHIMA's standards governing data reporting practices, including health record documentation and clinician query standards; (8) Assign and report only the codes that are clearly and consistently supported by health record documentation in accordance with applicable code set conventions, rules, and guidelines. (AHIMA House of Delegates, 2008, p. 1) Coding professionals are additionally require to apply their skills and their knowledge concerning current mandates in coding and classification systems and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services)." (AHIMA House of Delegates, 2008, p. 1) It is considered unethical to confirm the code for a clinical condition that is not indexed in the classification or to report a code for the convenience of that report or to "affect reporting for a desired effects on the results." (AHIMA House of Delegates, 2008, p. 1) In addition, the medical coding personnel is responsible to "query provider for clarification ad other additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element It is reported that coding professionals 'shall not' "Change the description for a diagnosis or procedure code or other reported data element so that it does not accurately reflect the official definition of that code" and further should refuse to take…