Ethics Are Critical to the Billing and Coding Profession

By Karen Smiley from Medical Billing and Coding For Dummies

As a medical biller or coder, you must consistently do the right thing at work, especially related to providers, payers, and patients. By virtue of your position, you are privy to sensitive information and have an impact on the financial well-being of all the people who rely on you to do your job.

These are some of the most egregious of the ethical and legal violations that can land you in hot water if you ever stray from the straight and narrow.

Honesty is the best coding and billing policy

Certified medical coders are trained to abstract billable procedures from the medical record. A true-blue coder respects the rules of coding. The biggest rule is that all the procedures you submit must be documented in the record, not just mentioned in the heading.

Therefore, resist the temptation to submit codes that are only implied or that are not documented by medical necessity. Don’t unbundle codes for the sake of additional reimbursement and don’t choose a procedural code that is “like” the actual service performed. Code honestly, code accurately, and you’ll do just fine.

Shift the blame for bad coding

You have nothing to gain by shifting the blame of inaccurate coding on to others. If you work in an environment with a department for each step of the coding cycle, ask for clarification as to how much leeway you have to facilitate.

If you notice that claims are not being submitted in a timely manner, for example, and nothing in the documentation explains the reason for the delay, bring the matter to the attention of the appropriate party.

If the entire revenue cycle is your job, then take responsibility to ensure that the claims are moving as they should through the cycle. To maintain your integrity and the respect of your superiors and co-workers, be a team player and stay focused on the bottom line: revenue for your provider or client.

To bill more than is documented is a no-no

Physicians often dictate every step of a procedure, but that does not mean that each step is actually billable. To be eligible for separate reimbursement, the procedure must have required additional work and skill by the physician. If the documentation is ambiguous, take the time to clarify what occurred with the physician.

Break patient confidentiality at your peril

As the coder, you have access to both the patient’s clinical information and his or her personal demographic information, such as Social Security number, date of birth, address, and so on. It goes without saying that you need to guard this information as you would your own. Otherwise, you are violating the Health Insurance Portability and Accountability Act (HIPAA). HIPAA violators may be subject to steep fines and the possibility of imprisonment.

Don’t follow the lead of an unscrupulous manager

Most coding managers know about and adhere to correct coding processes and expect you to follow those processes as well. Unfortunately, you may encounter a manager who is less aware of correct coding rules or who, if cognizant of the rules, tends to bend or overlook them.

These coding managers may see modifiers as a tool to increase reimbursement rather than a tool to increase specificity when reporting services, for example, and may challenge the coding of claims when reimbursement is low.

If your manager or other superior encourages you to code out of bounds, don’t. Instead, do what you think is right and report the incident to an office leader who can follow up on the matter. You may get on the shady manager’s bad side, but you’ll be able to sleep much better at night!