Standards of Ethical Medical Coding: Part 3


Healthcare Insurance industry requires stringent guidelines and ethical practices for the protection of patient information. The field of medical coding and billing falls under the same ethical guidelines as any other part of the medical industry.

Coding is one of the core functions, and due to the complex regulatory requirements affecting the health information coding process, coding professionals are frequently faced with ethical challenges. Following are the set of guidelines recognized by AHIMA for ethical medical coding. With these series of tutorials, we have tried to bring together the important information about the standards of ethical medical coding which included elements like confidentiality, Accuracy and Consistency. This part will cover the professional integrity needs to be demonstrated during the coding process.

Professional Integrity

Medical billers and coders shall maintain objectivity and integrity while performing their duty. It is not always easy to choose between keeping a clinic profitable and work professionally, in the current healthcare scenario. The amount of loopholes in the coding and billing guidelines makes it easier to consider alternative methods to maintain collections.

But the benefits of professional Integrity in Medical Billing can never be undermined with more vigilant authorities, the trend of monitoring claims and sophisticated presence of data that validates collections in specific specialties and practices.

Here are certain points that support your decision to maintain highest level of Professional Integrity:

a)  Medical billers and coders should refrain to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or by reporting better performance  by means that do not comply with federal and state statutes, regulations and official rules and guidelines. Having a week moment and allowing the following practices may be detrimental in the long run for your practice and career:

  • Allowing inappropriate patterns of retrospective documentation to avoid suspension or increase reimbursement
  • Assigning codes without supporting provider (physician or other qualified healthcare practitioner) documentation
  • Coding when documentation does not justify the diagnoses and/or procedures that have been billed
  • Adding, deleting, and altering health record documentation

b) They should 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.

  • Failure to research or confirm the appropriate code for a clinical condition not indexed in the classification, or reporting a code for the sake of convenience or to affect reporting for a desired effect on the results, is considered unethical.

Generally factors that help in maintaining Professional ethical coding standards:

  • Being knowledgeable about established policies and procedures for handling concerns about colleagues’ unethical behavior.
  • Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
  • Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues.
  • Consult with a colleague when feasible and assist the colleague in taking remedial action when there is direct knowledge of a health information management colleague’s incompetence or impairment.
  • Assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, and re-sequence or include diagnoses or procedures when needed to more accurately reflect the acuity, severity, and the occurrence of events.

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