Ethics can look easy on paper, but the working world offers some complex situations. In the April print issue writer Mark Crawford explores three scenarios that illustrate the kinds of difficult situations that HIM professionals can find themselves facing.

“Some behaviors are clearly unethical—fraud is an extreme example,” Crawford writes, “but many are less clear and occur in complex situations. The most complicated situations often involve colleagues who witness what is, or appears to be, unethical behavior and are unsure how to respond—especially if job security is on the line.”

The following scenario, reprinted from the story, is a good example. What do you think? What leads to situations like this, and what options does the coder have? Are HIM professionals in all roles (not just coders) facing greater pressures to commit or condone questionable or unethical behavior? Discuss it by commenting at the end of the scenario.

* * *

Scenario 1: Pressure to Upcode

In a large, for-profit, multi-specialty clinic, strong emphasis is placed on optimizing revenue opportunities for private-payer patients. The coding supervisor, who holds RHIT and CCS credentials, has informed the coding staff they must consistently assign E&M codes at a higher level than documentation supports.

One of the coders, also CCS-credentialed, has expressed her concerns about the appropriateness of this direction. The supervisor has indicated these comments are unwelcome and implied the coder should perhaps seek employment elsewhere if she has concerns. However, this is the only healthcare facility within the community, and the coder is a single parent with financial responsibilities for her family.

“The ethical concern here is the coding supervisor’s pressure to increase revenue at the expense of actual documentation to support the codes assigned,” notes Dana C. McWay, RHIA, JD, a clerk of the United States Bankruptcy Court for the Eastern District of Missouri in St. Louis. “She clearly does not value the coding staff’s input, as evidenced by her comment that criticism is unwelcome and the implication of seeking another job.”

It seems clear the supervisor’s instructions are intentional and designed to increase financial gain for the clinic.

This, of course, puts the coder in a difficult situation, especially with the hint of termination. Any liability for incorrect coding will likely be assigned to the coder and the clinic.

If the supervisor’s instructions are carried out, the clinic risks “financial and reputational harm, possibly resulting in sanctions by external forces,” says McWay. “Damage is also done to individual coders who are asked to sacrifice correct coding standards to comply with this inappropriate request. There is also harm to AHIMA because both the supervisor and coder are credentialed and represent the association’s ethical standards.”

The scenario contains multiple violations of AHIMA’s code of ethics, especially principle II, which instructs members to conduct their work in an honorable way. The supervisor also is violating principle IV, which calls for refusal to participate in unethical practices or procedures. Guideline 4.6 has also been broken, which states HIM professionals will not perpetuate dishonesty, fraud, or deception.

Probable violations of AHIMA Standards of Ethical Coding include standards 1 and 3 (accurate coding practices) and standards 6, 9, and 11 (not committing fraudulent or unethical practices).

The choice the coder makes may depend on the corporate culture. Does the culture encourage the reporting of violations? Will the company protect the coder if she informs another supervisor about the situation?

“I’d suggest she seek advice from a trusted HIM professional, just to be sure the direction given is indeed inappropriate,” says McWay. “If so, she needs to learn what process is available for voicing her concern to a higher level. Some organizations have an ombudsman or similarly situated individual who can help in situations like this.”