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AAPC Committed to Ethical Standards

Members can rely on AAPC’s Ethics Committee to uphold honesty and excellence.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO

To help members remain ethical throughout their career, AAPC has established an Ethics Committee as a standalone entity responsible for evaluating alleged violations of the AAPC Code of Ethics and, when necessary, determining appropriate sanctions. AAPC’s Ethics Committee is comprised of eight members: Four from the Legal Advisory Board, two from the National Advisory Board, and two from the AAPC Chapter Association board. Ethics Committee members are selected by their respective boards.

Ethics Committee Working for You

When a complaint is submitted to the committee, a Legal Advisory Board member is appointed to investigate the complaint, gather information, and when necessary, refer the case to the other committee members for a determination. After the investigating member refers a case, the remaining members review the submitted information, which includes the complaint, any response from the member involved, and other investigatory information. The remaining seven members of the committee then vote as to whether a violation of the AAPC Code of Ethics occurred and, if so, determine the appropriate sanction to impose.

Cases Show What Crosses the Line of Ethics

To provide you with a better understanding of the Ethics Committee’s role in serving you, here are actual cases the committee has evaluated. They do not represent all cases, but will show you the types of cases we address. The cases have been stripped of identifying factors to protect members from embarrassment. To deter members from ethical misconduct, use these cases to educate yourself and other members of the type of conduct that’s contrary to the AAPC Code of Ethics.

Case No. 1

A test proctor inappropriately opened an extra examination booklet and was not completely forthcoming to the committee when responding to the Notice of Complaint.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. The sanction was a letter of reprimand and permanent preclusion from serving as a test proctor.

Mitigating factors: No prior ethics related issues, expression of remorse and embarrassment, and no evidence that exam information was further disclosed.

Case No. 2

A member falsely represented possession of both AAPC and non-AAPC credentials.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials.

Mitigating factors: No prior ethics related issues.

Aggravating factors: Member did not respond to the committee and took no action to correct the misrepresentations, once notified.

Case No. 3

A member falsely represented possession of a Certified Professional Coder (CPC®) credential in the signature block of email correspondence, falsified credential verification results from the AAPC website, and made multiple false statements to employer indicating possession of the CPC® credential.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was a 12-month suspension of membership and credentials.

Mitigating factors: No prior ethics related issues, and member sat for and passed the CPC® exam (having already passed a specialty examination) within weeks of misconduct.

Case No. 4

An AAPC curriculum instructor improperly obtained copies of the CPC® examination while serving as proctor, and created a study guide containing actual exam questions and answers. The instructor provided the study guide to students, allowing students to compete unfairly on the CPC® examination.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials and loss of license to provide AAPC-approved curriculum instruction.

 

Mitigating factors:No prior ethics related issues and member was forthcoming to committee in response to Notice of Complaint.

Aggravating factors: The violation was considered especially egregious because the instructor was in a position to influence future members regarding ethical obligations as professional coders. The member’s actions compromised the integrity of the CPC® examination and devalued the CPC® credential by causing potentially unqualified individuals to obtain the CPC® credential, thereby justifying the imposed sanction.

Case No. 5

A coding instructor improperly obtained copies of CPC® and specialty examinations while serving as proctor. Copies of the examinations were allegedly provided to students, who then sat for the exams, completed them, and passed their respective CPC® and/or specialty examination in approximately three hours.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials.

Mitigating factors: No prior ethics related issues.

Aggravating factors: Member was not forthcoming in the response to the Notice of Complaint submitted to the Ethics Committee. Member also interfered with the investigation by responding on behalf of the students. The violation was considered especially egregious because the instructor was in a position to influence future members regarding ethical obligations as professional coders. The member’s actions compromised the integrity of the CPC® and specialty examinations and devalued AAPC credentials by causing potentially unqualified individuals to obtain the CPC® or specialty credential, justifying the imposed sanction.

Case No. 6

A member misrepresented possessing a number of specialty certifications, as well as falsely having status as an “AAPC Approved Online Education Provider” on a publicly accessible development Web page.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was a letter of reprimand and instruction to remove inaccurate statements from the development page on the website.

Mitigating factors: No prior ethics related issues, forthright response, and committee determined there was no intent to deceive the public.

Considering the size of our membership, the incidence of improper conduct is extremely small. This suggests the vast majority of AAPC members are committed to upholding the ethical standards of our profession. Of the cases reported, the most common cases pertain to misrepresentation of credentials or experience needed to obtain removal of apprentice status; however, the recent cases involving improper conduct by instructors (and potentially students) involving AAPC examinations are the most disturbing. Those who are tempted to accept dishonest help should consider that cheating on an exam may get you a credential, but it doesn’t mean you have the skills needed to perform the job.

Instructors and proctors must understand that obtaining an exam and providing it to students doesn’t help the students. It may result in a high pass rate, but it does not mean the person is a good instructor.

Speak Up! Your Reputation Is on the Line

The AAPC Code of Ethics imposes a duty to report unethical conduct by another member. Silent acquiescence enables such conduct, and diminishes the credibility of all who have earned AAPC credentials.

If you want to file a complaint, but are concerned about retribution, know that the committee takes great pains to keep the identity of the complainant anonymous, when anonymity is requested. If you are aware of ethical misconduct, report it to the Ethics Committee via email at: ethics@aapc.com.

The Ethics Committee needs the help of all members in upholding the ethical standards of our profession by not tolerating unethical conduct.

Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, serves on AAPC’s National Advisory Board, Legal Advisory Board, and is chair of the AAPC Ethics Committee. He has over 20 years of experience in healthcare coding and over 16 years as a compliance expert, forensic coding expert, and consultant. Miscoe has provided expert analysis and testimony on a wide range of coding and compliance issues in civil and criminal cases and his law practice concentrates exclusively on representation of healthcare providers in post-payment audits as well as with responding to HIPAA OCR issues. He speaks and is published on the national level, addressing a variety of coding, compliance, and health law topics. Miscoe is a member of the Johnstown, Pa., local chapter.

October 1st, 2014

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Debunking ICD-10 Myths

In an age of urban legends and conspiracy theories, it’s no surprise that some have popped up about ICD-10, prompting the Centers for Medicare & Medicaid Services (CMS) to post Medicare Learning Network (MLN) pages on “ICD-10-CM/PCS Myths and Facts.

Sadly, none are as intriguing as the urban myths we usually hear, but CMS feels too many people believe them at a time when ICD-10 is close to implementation.  CMS uses the document to quash misinformation that’s making the transition more difficult for providers, facilities, and coders.  Some of the information CMS wants you to know includes the following:

  • ICD-10-CM and PCS will be implemented on October 1, 2015.
  • State Medicaid programs will be required to use ICD-10.
  • ICD-10 was developed with significant clinical input.
  • ICD-10-CM and ICD-10-PCS books will be available after implementation.
  • ICD-10 is current, having been updated several times since introduction.
  • ICD-10 won’t require unnecessary documentation when implemented as most of the necessary information is already the medical record.

There are plenty other truths in the MLN document that will help calm nerves and make the ICD-10 implementation a little easier to swallow.

September 29th, 2014

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ICD-10 Monitor: Talk Ten Tuesday

In the most recent episode of the Talk Ten Tuesdays podcast, Betty Hovey, CPC, CPMA, CPC-I, CCS-P, CPC-H, CPCD reported on the 2nd Code-a-Thon held sept 15th.  The event was hosted by CMS and AAPC in an effort to ensure health care providers and other industry professionals are preparing for the transition to ICD-10.

“AAPC’s ICD-10 expert coders including myself, Peggy Stilley, [Jacqueline] Stack, and—of course—Rhonda [Buckholtz], answered ICD-10 coding questions for three hours by live stream.” said Betty Hovey. “We looked at more than 600 questions on ICD-10-CM and PCS…a lot of good information was shared with the attendees.”

The September 2014 Code-a-Thon transcripts are available for download.

September 26th, 2014

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2014 CMS-AAPC Code-a-Thon Recap

On Monday, September 15, 2014  CMS collaborated with AAPC to host live three-hour Q&A “Code-a-Thon”. ICD-10 trainers from AAPC made themselves available to help industry leaders and providers prepare for the ICD-10 code set compliance date of October 1, 2015.

Materials from the webinar are available below:

[Code-a-Thon Q&A transcript]

[Code-a-Thon audio transcript]

September 25th, 2014

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Document “Unlisted” Procedures Thoroughly to Ease Payment

Providers hear over and over again how important their documentation is to ensuring proper code selection and, ultimately, optimal compliant reimbursement. But the documentation stakes are even higher when there isn’t an appropriate code to describe the procedure or service performed.           

You should never report a code that “almost” describes the procedure or service performed. Instead, the CPT® codebook includes unlisted procedure codes to allow you to submit claims for services that have no specific CPT® descriptor assigned to them. Insurers consider claims for unlisted-procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Here are a few documentation pointers for providers to ensure that such claims do, indeed, gain payment.

Describe the Procedure in Plain English: Any time you file a claim using an unlisted-procedure code, include a separate report that explains, in simple, straightforward language, exactly what you did. You might also include diagrams or photographs to better help the insurer understand the procedure. Some practices recommend highlighting, or making notes on the operative report, to indicate where the provider describes the unlisted procedure.

Don’t forgetdocumentation of medical necessity to back up the decision to perform the procedure. Some practices include copies of articles in medical journals supporting the reasonableness of the procedure, such as clinical trials and medical indications.

Include a cover letter: When submitting an unlisted-procedure claim, your documentation should also include an explanatory cover letter.

Example: A young child requires a post-fistula tracheotomy tube change. The child is restless and unruly and will not submit to the procedure in the physician’s office. Therefore, the doctor elects to perform the procedure in the operating room with the patient under anesthesia. In this case, your best code choice is 31899 Unlisted procedure, trachea, bronchi. Your documentation might state

I performed the procedure under anesthesia in the OR rather than in the office because the patient was a young child who could not be safely restrained in the office setting. This was the best method to ensure a positive outcome and prevent any undue harm to the patient. CPT® does not contain a code to describe a procedure of this type, and therefore we are submitting an unlisted procedure code.

Compare the Procedure: An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.Rather than leave it up to the insurer to determine which code is the “next closest,” you should explicitly make reference to the nearest equivalent listed procedure.

Also, note the specific ways that the unlisted procedure differs from the next-closest procedure listed in CPT®. This explanation will help relate the procedure performed to an existing procedure as support for reimbursement. Explain how your procedure differs to show why you didn’t choose the existing code. Basing your fee on a similar procedure is helpful in claims processing, but isn’t mandatory.

If you’re submitting an unlisted procedure code for a particular service, often, consider meeting with the payer’s medical director to discuss how you might be paid for the service without documenting the service so extensively for each claim. The payer may create a dummy code for the procedure, or set a fee for the unlisted codes, facilitating automatically adjudication.

September 24th, 2014

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