The Case of the Coding Dilemma

The Case of the Coding Dilemma

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Background: Coding is the process of assigning a billing code to a patient diagnosis. The billing code comes from a standardized code book. Each code represents a specific diagnosis and a designated amount of reimbursement by government and private insurers. Entering a higher code than is warranted will result in overpayment for the patient’s particular diagnosis. Entering a lower code than is warranted will result in underpayment for the patient’s particular diagnosis. All diagnoses are coded and billed by the assigned code regardless of how the bill will be paid.

The Situation: Joe Brown is a long-time patient of the clinic with a chronic condition. Joe recently lost his job and subsequently his health insurance. Although Joe is looking for a job, he was uninsured at the time of his most recent visit to the clinic. Joe’s visit was a follow up visit for his existing chronic condition for which he has been receiving care. At his last visit as an insured patient, the visit code entered matched directly with the diagnosis for the visit. The current uninsured visit, although for the same condition, was coded with a different code that resulted in a lower charge for the visit. This type of coding variation is a typical practice within the clinic when an uninsured patient is seen. Suzy Staff, a newly appointed member of the Corporate Compliance Committee, called the “downcoding” practice to the attention of the Corporate Compliance Committee who undertook an investigation.

Using information from this week’s required studies and at least two articles from outside healthcare research, write a 4-page case analysis to answer the following:

What are the ethical principles that relate to this case?

How does the case relate to the concept of Stewardship?

How does the case relate to the concept of Justice?

How does the case relate to the GAAP principles required by SOX of accuracy, transparency, comparability, and consistency?

What is the role of a compliance audit in this situation?