Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS
The American Health Information Management Association Standards of Ethical Coding includes new and updated information and guidance as of December 2016. This is a must-have resource for any health information management coding professional.
The standards now include definitions which provide terminology consistency and clarity without needless repetition in the standard itself.
For example, the section on coding-related activities includes selection, research, and completion of code assignment, querying, other health record data abstraction, data analytics and reporting with codes, coding audits, remote coding, and coding educational activities and functions.
In addition, the portion on data includes all healthcare data elements including clinical, demographic, and financial.
There are 11 key ethical coding principles:
- Apply accurate, complete, and consistent coding practices that yield quality data.
- Gather and report all data required for internal and external reporting, in accordance with applicable requirements and data set definitions.
- Assign and report, in any format, only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, and requirements.
- Query and/or consult as needed with the provider for clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices.
- Refuse to participate in, support, or change reported data and/or narrative titles, billing data, clinical documentation practices, or any coding-related activities intended to skew or misrepresent data and their meaning that do not comply with requirements.
- Facilitate, advocate, and collaborate with healthcare professionals in the pursuit of accurate, complete, and reliable coded data and in situations that support ethical coding practices.
- Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements.
- Maintain the confidentiality of protected health information in accordance with the Code of Ethics.
- Refuse to participate in the development of coding and coding-related technology that is not designed in accordance with requirements.
- Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
- Refuse to participate in and/or conceal unethical coding, data abstraction, query practices, or any inappropriate activities related to coding and address any perceived unethical coding-related practices.
The ninth principle is a new addition with this version of the standards: “Refuse to participate in the development of coding and coding related technology that is not designed in accordance with requirement.” This is of particular importance as technology continues to advance and more tools are being utilized related to coding, including electronic health records and beyond.
Included in the standards is a section of “Shall” and “Shall Nots” with examples to help explain the principles and guide professionals further. HIM professionals should consider bringing a copy of the standards to their next staff meeting for review and discussion. The 2016 version of the American Health Information Management Association Standards of Ethical Coding is available online in AHIMA’s HIM Body of Knowledge, available at http://bok.ahima.org/PdfView?oid=301963.
Gloryanne Bryant is the national director, coding quality, education, systems and support, national revenue cycle for a large healthcare organization.