How to Maintain Your Integrity and Keep Your Medical Coding and Billing Job

By Karen Smiley from Medical Billing and Coding For Dummies

As a medical coder and biller, clients and employers trust you not only with their patients’ personal and private information, but they also trust you to code accurately, fairly, and legally. To be worthy of this trust, you must maintain your integrity as a medical biller/coder.

However, you may find yourself faced with a client, patient, fellow employee, or payer representative who asks you to ignore your own professional standards. In these cases, your integrity must take priority over getting your client paid. By protecting your professional integrity and coding in a way that upholds professional coding standards, you can rest assured that you are doing the best job you can.

When you become a certified coder and biller, you receive instruction in correct coding and claim submission procedures and rules. From that point on and throughout your coding career, you’re responsible for observing and promoting those rules.

“But, I have a boss!” you say. Yep, you sure do — probably a coding manager, an office manager, or perhaps the healthcare provider. This person may sign your paychecks, but the onus for correct coding is on you, especially when your boss is unaware of or unconcerned about correct coding rules. Even some managers, despite being aware of coding rules, may ignore them.

Superiors asking you to fudge the coding

Having an office manager challenge the coding of claims when reimbursement is low isn’t uncommon, and it puts you in a tough situation. For example, some office managers may want you to use modifiers as a tool to increase reimbursement rather than a tool to increase specificity when reporting services.

In cases where a superior wants you to fudge the coding, rely on your coding books for backup. The NCCI edits are a good place to start. If you stick to your correct coding guidelines, you have the facts you need to make coding decisions that maintain your professional integrity.

Physicians asking you to submit codes the record doesn’t support

Some physicians may want to submit procedural codes that the record doesn’t support. In this case, you may need to review the code description with the physician and ask for clarification as to why he feels the code is justified. You may discover that he failed to fully document the procedure that was performed.

If, however, you are certain that you correctly abstracted the codes from the record, you can request an independent audit, in which another coder reviews the record and notes which codes he feels are supported by the documentation.

If the audit supports your position, you’ve secured the necessary documentation and you can submit the claim as you coded it originally. If the audit indicates that you are under-billing the claims, you must be willing to alter the way you code. The good news here is that you get the opportunity to make the record right — and you now know how to code more accurately in the future.

If you find yourself in an office that demands coding that is contrary to correct coding standards, despite the results of an independent audit, then it’s time to find another job. You should always code and bill ethically. If the employer’s business philosophy contradicts those ethics and your integrity, then leave.

Acquiescing to unethical standards can get you into big trouble. When (or if) your employer is subject to a request for payment refund, an audit, or accusations of fraudulent billing, not only will those events not look good on your resume; the possibility exists that you will be considered an accomplice.