Make ethics the top of your operating set of principles

By Brian Murphy 

 

ACDIS recently updated its Code of Ethics. It’s worth reading; I’ve linked to it below. 

 

Even if you’re an industry old-timer I recommend a refresher, to remind yourself what should be at the top of your operating set of principles.

 

We can debate the finer points of ethics as it relates to CDI and coding. I think the most important aspect is: 

 

Does the diagnosis exist, and is it being treated in some manner?

 

If yes, apply the Official Guidelines. If not, don’t report it.

 

It seems easy, but ethics is a moving target. For at least two reasons:

• Technology

• Human weakness.

 

Let’s examine further.

• Technology

 

Technology has opened the door to the use of prior medical records, including as evidence for query. This practice used to be verboten, but updated guidance allows it. Ignoring historical records in the age of the EHR and ready access to vast stores of information is foolish and impractical. Moreover, not using prior records leads to utilization distortions including ordering extraneous tests, i.e., an echogram solely to code/capture CHF. Which results in unnecessary costs.

 

However, the use of prior medical records introduced “mining” for old diagnoses that no longer have any relevance on the current stay. Now we are seeing UnitedHealth accused of utilization for dollars through the use of a medical device to screen people for artery disease, allowing for the capture of peripheral artery disease and billions in additional questionable HCC revenues (see STAT article below).

• Human weakness

 

Ethics will also remain a forever battle due to the conflicts within the human heart, fueled by organizational pressures.

 

There are your truly egregious cases. A private practice physician reporting a level 5 E/M or applying modifier -59 on every code because they know it will jack up reimbursement. But I’m not really talking about these crass levels of fraud. 

 

Many hospitals are fighting for their existence. Capturing borderline codes is one way to shift the bottom line from red to black and keep the doors open. You can see how this would happen, and someone succumbs. 

 

All of this makes a north star a must, and a coherent definition of integrity. 

 

Here’s one I like: 

 

Do the right thing, even when no one is watching.

 

(Often attributed to C.S. Lewis, though that may be apocryphal).

 

We don’t always operate with integrity. We know what’s right, we know how we should act with integrity, but pressures make us waver. We succumb to weakness, and act outside the lines. 

 

That doesn’t mean we don’t forgive. 

 

FYI, I’ve failed. I’ve done things that I’m embarrassed by that I knew were dumb and dishonorable at the time.

 

But I pick myself up. And keep walking on the path of integrity.

 

Because it means… well, everything.

 

Resources

 

• ACDIS, Code of Ethics.

 

• STAT, How UnitedHealth turned a questionable artery-screening program into a gold mine.