1. Ethics Issue 2. Ethical 3. Ethical Standard 4. Best Ethics Practice Standard Source(s) Description(s) with “Should” Exclusions Coding staff are not routinely American Health Information Health information Coding staff should ensure consulting physicians to clarify Management Association Code management professionals accurate coding by reviewing conflicting or ambiguous of Ethics shall not participate in, conflicting or ambiguous documentation in the condone, or be associated with documentation with the patient’s electronic health record, and dishonesty, fraud and abuse, physician of record. VHA Handbook 1907.03 therefore enter inaccurate or deception including: Health Information information. Assigning codes without Management Clinical Coding physician documentation Program Procedures 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 when there is conflicting or ambiguous documentation in the patient’s electronic health record, the physician(s) must be patient’s consulted for clarification. Exclusion(s): None MODULE 2 MODULE 3
1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 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 when there is conflicting or ambiguous documentation in the patient’s electronic health 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. MODULE 2 MODULE 3
PE_BtB_Mod3_Handouts_final.docx