Ethical dilemmas require proactive approach

Dilemmas can cause tension among staff. Coders may feel trapped between what supervisors tell them to do and what they know is the ethical practice of their profession. Who wants to be in that situation? No one.

Ethical dilemmas can creep in at any time during a coder’s average workday. However, one might be hard pressed to find a coder who will openly acknowledge this, says Brad Hart, MBA, MS, CMPE, CPC, COBGC, president of Reproductive Medicine Administrative Consulting, Inc., in West Orange, N.J.

 

Hart, who is also the author of Ethics in Medical Coding: Theory and Practice, often provides specialty-specific ethics training for coders working primarily in clinics owned and operated by larger hospitals or health systems. Hart says he doesn’t hear about ethical dilemmas unless he attends a conference and interacts with coders who confide in him privately. “Can I personally say that I’ve heard about a lot of [dilemmas] when I speak at conferences about ethics? No, but I’m completely convinced that they exist,” he says.

 

For example, some coders may feel overt or covert pressure from their supervisors to code everything in the record even when conditions aren’t treated, or when they’re documented only once or twice, says Hart.

 

They may also feel pressure to increase a patient’s level of severity by reporting a CC or MCC that may not be justified, he says. Hypertension is a common example. If it’s mentioned only once in the record-or a ­physician documents “history of hypertension” with no current ­treatment-then coders shouldn’t report it.

 

Some clinical documentation improvement (CDI) programs contribute to these pressures, says Kathy DeVault, RHIA, CCS, CCS-P, director of HIM solutions at AHIMA in Chicago. Coders become uncomfortable when programs focus on MS-DRG optimization rather than on enhancing quality of documentation and capturing patient severity independent of reimbursement, she says.

 

Coding for the sake of increasing reimbursement goes against every coder’s ethical backbone, says DeVault. The AHIMA Standards of Ethical Coding also prohibit this practice. Some coders don’t even feel comfortable implying that a physician may have omitted a diagnosis when clinical indicators are present in the record, she says. ­Although they can’t submit leading queries, coders can and should query physicians when information in the record justifies doing so.

 

Medical necessity poses another challenge. “Some coders have told me about their lack of comfort with being asked to make decisions about medical necessity,” says Hart. “That’s, in effect, what’s happening when they’re being asked to select codes [or sequence ­diagnoses] that determine whether a service [or admission] is necessary.”

 

The Standards of Ethical Coding state that coders may not “misrepresent the patient’s clinical picture through intentional incorrect coding or omission of diagnosis or procedure codes, or the addition of diagnosis or ­procedure codes unsupported by health record documentation, to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or qualify for insurance policy coverage benefits.”

 

For example, coders can’t report a salpingectomy rather than a tubal ligation when the narrative descriptions of both the diagnosis and procedures reflect a tubal ligation, but only a salpingectomy will meet medical necessity requirements.

 

Coders also cannot suppress coded information. The Standards of Ethical Coding, which were last updated in 2008, state coders may not “inappropriately exclude diagnosis or procedure codes to misrepresent the quality of care provided.” For example, coders can’t omit a code for a surgical complication when a patient acquires an infection after surgery due to a break in sterile procedure.

 

Organizations that promote or tolerate the omission of adverse outcomes are violating coding ethics, says DeVault. “With the onset of HACs [hospital-acquired conditions] and the POA [present on admission], there is this whole new notion of omitting codes. This just goes against everything we know,” she says. “Saying that you’re not going to report anything that negatively affects your reimbursement is wrong and unethical.”

Ethics should be on every coder’s mind the moment a record is opened and throughout the coding process, says DeVault. Pressure to reduce the discharges not final billed and capture as much revenue as possible may put those ethics to the test, but coders should never compromise their values, she says.

 

Hospitals must develop ethics policies that include specific coding-related scenarios and how staff should handle them, says Hart. “I prefer to see coding discussed in specific terms because it’s such a breeding ground for potential ethical problems.”

 

Educating senior leadership may also help. Part of the problem could be that chief financial officers or the finance department don’t understand that coding professionals have a code of ethics, says DeVault. “We’re obligated to make sure that senior leadership understand that we have a code of ethics. We don’t just randomly pick what we’re going to code and not going to code.”

 

The Standards of Ethical Coding also require coders to take action to discourage, prevent, expose, and correct the unethical conduct of colleagues. This means that ­coders who witness unethical behavior may need to involve a manager or other director within the organization or contact the AHIMA Professional Ethics Committee.

 

Coders who witness unethical coding or documentation should notify a direct supervisor. If the supervisor doesn’t take action, consider speaking with the HIM director, a compliance officer, or someone from senior leadership. Physician champions may also be helpful, and speaking with the medical staff’s ethics group may be worthwhile, says DeVault. “I would hope that at some point in the chain of command, you would encounter someone who has the moral compass to say ‘this is not right,’ “ she says.

 

Coders are in an ideal position to identify ethical challenges and start conversations to address them, says Hart. “Because coders have the knowledge and ­training-and because AAPC and AHIMA have such strong ethical foundations-I think coders are the ones who should take the lead in this respect.”

 

Wait for a pattern of unethical coding or documentation to emerge so that you have data to support your argument, says Hart. Voice your concerns, but also propose a solution, even if it’s something as simple as suggesting that a chart could use a closer look.

 

“If the coder initiates the discussion, they’re in a greater position of power than if they’re doing it reactively,” he says.

 

However, discussing ethics is easier said than done. Coders may find themselves stuck between a rock and a hard place when an immediate supervisor advises them to violate policy established by the compliance department, says Hart.

 

Ultimately, coders can refuse to code a record until an unethical practice is resolved or addressed. “As coders, we need to be able to step up and say, ‘I’m following the guidelines or Coding Clinic, and I won’t change something just to get the bill paid. That’s against my code of ethics,’” says DeVault. “You might get to this point where the ­ethics of the organization doesn’t match your own, and it might be time to move on.”

 

Ethical dilemmas certainly won’t disappear as hospitals implement technologies designed to assist with code selection, says Hart.

 

“EHRs do facilitate much better recordkeeping, but they also facilitate overproduction of notes and overstatement of documentation. The depth of treatment being provided is overstated via the copy and paste ­function,” says Hart.

 

DeVault agrees. Documentation that’s copied and pasted may include diagnoses that aren’t even treated during a patient’s current stay, she says. “A lot of the struggles that we have with ethics now really goes back to documentation. It’s not necessarily the coder-it’s the documentation that’s causing the problem.”

 

At some point, physicians must be held accountable for their contributions to these ethical dilemmas, says Hart. He has audited charts at clinics where every examination is identical and maps to the highest level of E/M service possible. “This is unethical physician behavior, but then the coder gets stuck with it. When I see workshops and webcasts being produced, all of them talk about how to enhance reimbursement. I don’t see any discussion of ethical considerations in that reimbursement,” he says.

 

Computer-assisted coding (CAC) may also pose ethical challenges if coders simply accept the codes that the technology suggests without verifying their accuracy, says DeVault. “CAC is very literal in terms of looking at documentation and assigning codes, so you’d think that it would drive ethical coding,” she says. “The key to that then becomes the audit function. There still needs to be a human element involved.”

 

ICD-10 can also pose ethical challenges for coders. “I think ICD-10-PCS might pose more challenges because of the specificity. We need to resist the urge to make any assumptions in order to complete and bill the account,” says DeVault.

 

Although coders may infer certain information to assign a, ICD-10- PCS code, they certainly can’t invent information that was never documented simply to complete the code, she says. “The [ICD-10] coding guidelines give us permission [to infer], but it’s easy to cross over into assuming. We need to be careful of this,” she says.

 

For example, when a physician documents “partial resection,” a coder may independently correlate this to the root operation “excision” without querying for clarification. However, coders may not make assumptions about any other aspect of the procedure (e.g., the approach or the device).