Encourage staff to complain loud and often
The alternative could be a whistleblower action
Overseeing quality monitoring processes that are in place with coding functions becomes an important part of your job in quality assurance, whether your future role includes functioning as a compliance officer or not.
What should you do if a member of the coding staff comes to you with an ethical dilemma? Perhaps the staffer doesn’t feel comfortable entering certain information; somehow, the staffer says, it doesn’t seem right.
The answer is: Listen closely, get details, and deal with the problem. If you don’t, you’re asking for trouble and encouraging the employee to take his or her grievance elsewhere maybe even to federal investigators.
"Most qui tam, or whistleblower, plaintiffs come forward not looking for a bonanza under the whistleblower provisions of the federal False Claims Act," says Ernest L. Tsoules Jr., JD, a Wayne, PA, attorney, "but rather because of a sense of frustration." Disgrunted staff typically have tried several times to report a complaint internally, and no one would listen. Only after multiple attempts to get a problem straightened out internally being told to ignore the problem or undergoing retaliation or termination did they go to the government and file the qui tam action.
Avoid even the appearance of fraud
Honest mistakes can be wrongly construed, and the last thing you want is to provoke a federal investigation. The billing manager has always instructed the billing staff to maximize reimbursement, and they can continue to do so. But it may now be your job to provide them with tools so they can avoid at all costs even the appearance of fraud that can be created by improper coding.
The following standards for ethical coding were developed by the American Health Information Management Association (AHIMA) in Chicago. They are sanctioned by the American Hospital Association, the American Health Information Management Association, the Health Care Financing Administration, and the National Center for Health Statistics, and should be followed in all facilities, regardless of payment source.
1. Diagnoses that are present on admission or diagnoses and procedures that occur during the current encounter are to be abstracted after a thorough review of the entire medical record. Those diagnoses not applicable to the current encounter should not be abstracted. Also, diagnoses that would not be abstracted if they did not influence payment should not be included.
2. Selection of the principal diagnosis and procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set.
3. Assessment must be made of the documentation in the chart to ensure that it is adequate and appropriate to support the diagnoses and procedures selected to be abstracted.
4. Medical record coders should use their skills, their knowledge of ICD-9-CM and CPT, and any available resources to select diagnostic and procedural codes.
5. Medical record coders should not change codes or narratives of codes so that the meanings are misrepresented. Nor should diagnoses or procedures be included or excluded because the payment will be affected. Statistical clinical data is an important result of coding, and maintaining a quality database should be a conscientious goal.
6. Physicians should be consulted for clarification when they enter conflicting or ambiguous documentation in the chart.
7. The medical record coder is a member of the health care team and, as such, should assist physicians who are unfamiliar with ICD-9-CM, CPT or DRG methodology by suggesting resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the occurrence of events during the encounter.
8. The medical record coder is expected to strive for the optimal payment to which the facility is legally entitled, but it is unethical and illegal to maximize payment by means that contradict regulatory guidelines.
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