ETHICS ISSUE 4: Ethical Practices in Business and Management—Business Integrity 2. Ethical 3. Ethical Standard 4. Best Ethics 5. Metric 5. Current 1. Ethics Issue Standard Description(s) with Practice Ethics Practice Source(s) Exclusions “Should” “Is” Coding staff are not American Health Health information Coding staff should Numerator: routinely consulting Information management professionals ensure accurate physicians to clarify Management shall not participate in, coding by reviewing conflicting or Association Code condone, or be associated conflicting or ambiguous of Ethics with dishonesty, fraud and ambiguous documentation in the abuse, or deception documentation with VHA Handbook including: the physician of patient’s electronic health record, and 1907.03 Health Assigning codes without record. therefore enter Information physician documentation inaccurate Management Coding when information. Clinical Coding documentation does not __________________ Program justify the procedures Denominator: Procedures that have been billed Coding an inappropriate level of service Miscoding to avoid conflict with others VHA policy states that when Method: there is conflicting or ambiguous documentation in the the patient’s record, Sample size: physician(s) must patient’s be consulted for clarification. Time frame for data collection: Exclusion(s): None MODULE 3 MODULE 4 MODULE 2
ETHICS ISSUE 4: Ethical Practices in Business and Management—Business Integrity 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 5. Current Ethics Practice “Is” Coding staff are not routinely consulting physicians to clarify conflicting or ambiguous documentation in the patient’s electronic health record, and therefore enter inaccurate information. American Health Information Management Association Code of Ethics VHA Handbook 1907.03 Health Information Management Clinical Coding Program Procedures Health information management professionals shall not participate in, condone, or be associated with dishonesty, fraud and abuse, or deception including: Assigning codes without physician documentation Coding when documentation does not justify the procedures that have been billed Coding an inappropriate level of service Miscoding to avoid conflict with others VHA policy states that when there is conflicting or ambiguous documentation in the patient’s record, the patient’s physician(s) must be consulted for clarification. Exclusion(s): None Coding staff should ensure accurate coding by reviewing conflicting or ambiguous documentation with the physician of record. Numerator: __________________ Denominator: Method: Sample size: Time frame for data collection: MODULE 2 MODULE 3 MODULE 4