Over the past decade, the term fraud has been brought to the forefront of coding and billing practices. Upcoding, unbundling or billing for services that are not documented are serious concerns for practices and payers. In a release from the Centers for Medicaid and Medicare Services, it was revealed that up to 30% of claims paid contained errors. Almost half of these were due to insufficient documentation (Prophet & Hammen, 1998).
Ethics plays a big role in every aspect of health care, especially in medical coding and billing. The American Health Information Management Association, or AHIMA, has developed Standards of Ethical Coding that are the foundation for every coding department in the United States ("Standards," 2015).
Departmental …show more content…
This certification can be obtained through a reputable organization such as American Academy of Professional Coders. Coding and billing regulations change periodically so employees must receive continuing education to keep up-to-date with these changes. Not only is formal continuing education a requirement, but understanding payer requirements is important as well. Many insurance companies publish monthly or quarterly bulletins that outline their payment policies. Coding employees should have an understanding of the payer requirements to ensure that they are providing the appropriate information to the payer (Prophet & Hammen, …show more content…
In other words, they must not upcode a claim in order to be reimbursed at a better rate. This could also change reporting data to outside agencies, misrepresenting patient case mix ("Standards," 2015).
All employees, including physicians, should have a clear understanding of what information is required at the time the record is coded. Physicians are ultimately responsible for the documentation so knowing what is necessary and the timeline for coding is important (Prophet & Hammen, 1998). This could reduce the number of queries that are made by the coding department.
There may be situations that are not explicitly addressed in the Code of Conduct or policy and procedure manual, so employees must have guidelines for what to do if this occurs. Having a liaison between the coding department and the physician may be beneficial as the liaison can act as an advisor when these situations occur (Prophet & Hammen, 1998).
Review of Standards and Corrective
Ethics plays a big role in every aspect of health care, especially in medical coding and billing. The American Health Information Management Association, or AHIMA, has developed Standards of Ethical Coding that are the foundation for every coding department in the United States ("Standards," 2015).
Departmental …show more content…
This certification can be obtained through a reputable organization such as American Academy of Professional Coders. Coding and billing regulations change periodically so employees must receive continuing education to keep up-to-date with these changes. Not only is formal continuing education a requirement, but understanding payer requirements is important as well. Many insurance companies publish monthly or quarterly bulletins that outline their payment policies. Coding employees should have an understanding of the payer requirements to ensure that they are providing the appropriate information to the payer (Prophet & Hammen, …show more content…
In other words, they must not upcode a claim in order to be reimbursed at a better rate. This could also change reporting data to outside agencies, misrepresenting patient case mix ("Standards," 2015).
All employees, including physicians, should have a clear understanding of what information is required at the time the record is coded. Physicians are ultimately responsible for the documentation so knowing what is necessary and the timeline for coding is important (Prophet & Hammen, 1998). This could reduce the number of queries that are made by the coding department.
There may be situations that are not explicitly addressed in the Code of Conduct or policy and procedure manual, so employees must have guidelines for what to do if this occurs. Having a liaison between the coding department and the physician may be beneficial as the liaison can act as an advisor when these situations occur (Prophet & Hammen, 1998).
Review of Standards and Corrective