Medical Coding Ethics
Ethical Concerns in Health Care Delivery: Focus on Medical Coding and Billing Practices
The objective of this study is to examine ethical concerns medical coding and billing in the physician office. Medical coding and billing has become very complex in light of health care reform. Recently, Christopher Gregory Wayne, reported to be "dubbed the Rock Doc" was arrested on a dozen charges of Medicare fraud" when he was accused of fraudulently billing for "physical therapy procedures, such as massages and electrical stimulation, that were not necessary or in some instances had been provided at his prior medical practice in Miami." (Weaver, 2013, p.1) It appears that where this doctor failed is billing for physical therapy when his staff was not properly accredited for providing these treatments.
Health Care Coding and Billing Changes
It was reported by Gunderman (2013) that October 1, 2014 is the deadline on implementing the ICD-10 system for classification of diseases. The World Health Organization developed the predecessor of ICD-10 and specifically ICD-9 which has been utilized since the latter part of the 1970s. There are at least 13,000 billable codes listed including "such exotic diagnoses as "injury from fall while occupying spacecraft" and "exposure to fireball effects of nuclear weapon." (Gunderson, 2013, p. 1) The new system, ICD-10 will have approximately 68,000 codes reported to be "emblematic of a plague of complexification sweeping across healthcare." (Gunderson, 2013, p. 1) Gunderson reports that health care is "becoming more bureaucratic, and the rate of bureaucratization seems to be increasing exponentially." (2013, p.1)
II. Medical Billing and Coding Ethics
Medical coding and billing principles are reported to include the following: (1) only those individuals who have the necessary background and training should perform the medical coding function; (2) It is necessary that those performing medical coding and billing tasks receive training and education that is ongoing and continuing, respectively, on an annual basis; (3) National guidelines govern coding and are in place for the specific setting for the performance of function coding; (4) Coding is also governed by state law where it is applicable; (5) Only information documented in the medical record should be coded; (6) professional coders do not take part in coding practices that are unethical. (Weil and Regan, p. 233) The False Claims act is violated is the individual "knowingly applies incorrect codes for a higher reimbursement" or in the event they assign a code that is incorrect to get a claim paid. Penalties that the provider may suffer include the following: (1) Three times the damage amount sustained by the government; (2) Civil penalties no less than $5,000 and no more than $10,000; and (3) Possibility of being excluded from participating in government health care programs such as Medicare and Medi-Cal. ( )
III. AAPC Audit Findings & Challenges Ahead
AAPC is reported to have recently audited records according to the rigorous specification of ICD-10-CM and reports that after having audited 20,000 records, "Only 63% of providers' current physician documentation is sufficient…This lack of specific enough documentation could have a major negative impact on revenue if not corrected before implementation, with coders relying on less specific default codes. Findings state that insufficient documentation is often comprised by a large percentage "of at-risk revenue compared with what was properly documented as facilities." (APC Insider, 2013, p.1) In fact, it is reported that at one facility, there were seven diagnostic codes that were used the most and that represented 93% of the revenue for the facility. Therefore, making sure that documentation is valid on a very few codes could greatly affect the bottom line for the facility. The study also indicated that the sufficiency of documentation for ICD-10 was differentiated by specialty in that "Gastroenterology practices had the lowest percent of complete documentation at just 48%. Plastic surgery, meanwhile, boasted the highest at 98%." (APC Insider, 2013, p.1) Providers however, are aware of the problem but have less than 12 months left before implementation. There should have already been an assessment of documentation by providers in order to ensure that they comprehend the conditions...
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