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ACDIS Code of Ethics

The Association of Clinical Documentation Improvement Specialists (ACDIS) Code of Ethics is based on core values and broad ethical principles that professionals can aspire to and use when making a decision or choosing a course of action. It helps clinical documentation improvement (CDI) professionals identify relevant considerations when professional obligations conflict with ethical standards or when ethical uncertainties arise. It also serves to orient new CDI practitioners to CDI’s mission, values, and ethical principles. This document articulates a set of guidelines that CDI professionals can use to assess whether they have engaged in unethical conduct.

The ACDIS Code of Ethics serves as a guide for the professional behavior of its members and nonmembers who hold the Certified Clinical Documentation Specialist (CCDS) credential. This code of ethical standards strives to promote and maintain the highest level of professional service and conduct among ACDIS members. Adherence to these standards ensures public confidence in the integrity and service of the association.

The ACDIS Code of Ethics is intended to assist in decision-making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate CDI professionals’ commitment to integrity. The standards set forth are relevant to all CDI professionals and those who manage the CDI function, regardless of the healthcare setting in which they work, or whether they are ACDIS members or nonmembers.

Ethical obligations are central to CDI professionals’ responsibilities, regardless of the employment site or the method of collection, storage, and security of health information. Sensitive information (genetic, adoption, drug, alcohol, sexual, and behavioral information) requires special attention to prevent misuse.

Values

All ACDIS members and CCDS-credentialed nonmembers agree to maintain the highest standard of personal and professional conduct. CDI professionals (including ACDIS members and anyone holding the CCDS credential) shall respect the rights of patients, clients, employers, and all other colleagues. CDI professional values are:

  • Honesty and integrity
  • Acting in an manner that brings honor to self, peers, and profession
  • Committing to continuing education and lifelong learning

Ethical Principles

Clinical documentation improvement professionals shall:

  1. Advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations.
  2. Use only legal and ethical means in all professional dealings, and refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive, or illegal acts.
  3. Put service and the health and welfare of persons before self-interest, and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and the CDI profession.
  4. Support the reporting of all healthcare data elements (e.g., diagnosis and procedure codes, present on admission indicators) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety, measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.
  5. Refuse to participate in or conceal unethical practices or procedures.
  6. Advance their specialty knowledge and practice through continuing education, research, publications, and presentations.
  7. Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality healthcare data.
  8. Facilitate interdisciplinary collaboration in situations supporting CDI practice.
  9. Respect the inherent dignity and worth of every person.
  10. Avoid participation in, condone, or be associated with dishonesty, fraud and abuse, or deception.
  11. Manage CDI departments and practices collaboratively and honestly, avoiding engagement in unethical practice and ensuring thoughtful decision-making processes.

How to Interpret the Code of Ethics

The following ethical principles represent the core values of ACDIS and the ACDIS Code of Ethics and apply to all CDI professionals. Guidelines included for each ethical principle provide behaviors and situations that can help to clarify the principle. They are not a comprehensive list of all situations that can occur.

1. Advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations.

Clinical documentation improvement professionals shall:

i. Act in a professional and ethical manner at all times

ii. Follow Health Insurance Portability and Accountability Act (HIPAA) guidelines to compliantly secure patient information in every form (written, verbal, electronic, etc.)

iii. Ensure patient-related communication is compliant with protection of protected health information in every form (written, verbal, electronic, etc.)

iv. Follow organizational policies and procedures related to patient confidentiality

v. Take reasonable steps to ensure that patients’ records are stored in a secure location and that they are not available to unauthorized personnel

vi. Protect the confidentiality of all information obtained in the course of professional service or otherwise

vii. Disclose only information directly relevant or necessary to achieve the purpose of disclosure

2. Use only legal and ethical means in all professional dealings, and refuse to cooperate with, or condone by silence, the actions of those who engage in fraudulent, deceptive, or illegal acts.

Clinical documentation improvement professionals shall:

i. Refuse to participate in or conceal unethical practices or procedures

ii. Act in a professional and ethical manner at all times

iii. Be knowledgeable about organizational policies and procedures for handling concerns about colleagues’ unethical behavior

iv. Strive to maintain and enhance the dignity, status, competence, and standards of ethical clinical documentation practice

v. Always conduct their work in a manner that supports and encourages clinicians to use their clinical judgment in identifying the most appropriate diagnoses

Clinical documentation improvement professionals shall not:

i. Participate in, condone, or be associated with dishonesty, fraud and abuse, or deception

ii. Condone or participate in directing physicians to document only specific diagnoses and/or to always avoid specific diagnoses, based solely on financial impact

3. Put service and the health and welfare of persons before self-interest, and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and the CDI profession.

Clinical documentation improvement professionals shall:

i. Act with integrity; behave in an honest, trustworthy manner; abide by ethical principles; elevate service to others above self-interest; and promote high standards of practice in every setting

ii. Ensure that the working environment is consistent, avoids any conflict of interest, and encourages compliance with the ACDIS Code of Ethics, taking reasonable steps to eliminate any conditions in their organizations that violate, interfere with, or discourage compliance with the code

4. Support the reporting of all healthcare data elements (e.g., diagnosis and procedure codes, present on admission indicators) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety, measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.

Clinical documentation improvement professionals shall:

i. Adhere to the official coding guidelines approved by the Cooperating Parties, the CPT rules established by the AMA, and any other official coding rules and guidelines established for use with mandated standard code sets

ii. Comply with AHIMA’s standards governing data reporting practices, including health record documentation and clinician query standards

iii. Query the provider (i.e., physician or other qualified healthcare practitioner) for clarification and additional documentation when there is illegible, unclear, imprecise, conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator)

iv. Participate in the development of query policies that support documentation improvement, comply with the ACDIS-AHIMA Physician Query Practice Brief "Guidelines for Achieving a Compliant Query Pracitce," and meet regulatory, legal, and ethical standards for coding and reporting

v. Use queries as a communication tool to improve the quality of health record documentation, not to inappropriately increase reimbursement or misrepresent quality of care

vi. Ensure adequate clinical evidence and/or supportive documentation is noted within the medical record and presented within the associated query

vii. Follow organizational guidelines and/or current industry and clinical practice guidelines to identify clinical criteria for support of queries

Clinical documentation improvement professionals shall not:

i. Query the provider when there is no clinical information in the health record prompting the need for a query

ii. Query the provider without identifying and presenting the supporting clinical evidence related to the associated condition within the query

5. Refuse to participate in or conceal unethical practices or procedures.

Clinical documentation improvement professionals shall:

i. Act in a professional and ethical manner at all times

ii. Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues

iii. Be knowledgeable about established policies and procedures for handling concerns about colleagues' unethical behavior. These include policies and procedures created by ACDIS, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations

iv. Seek resolution if they believe that a colleague has acted unethically or is exhibiting incompetent or impaired behavior. This includes discussing these concerns with the colleague when feasible and when such discussion is likely to be productive. Take additional action through appropriate formal channels, such as contacting an accreditation or regulatory body and/or the ACDIS Advisory Board.

v. Consult with a colleague when feasible and assist the colleague in taking remedial action when there is direct knowledge of another colleague’s incompetence or impairment

6. Advance their specialty knowledge and practice through continuing education, research, publications, and presentations.

Clinical documentation improvement professionals shall:

i. Develop and continually enhance their professional expertise, knowledge, and skills through appropriate education, research, training, consultation, and supervision.

ii. Base practice decisions on recognized knowledge, including empirically based knowledge relevant to CDI and CDI ethics.

iii. Contribute time and professional expertise to activities that promote respect for the value, integrity, and competence of the CDI profession. These may include, but are not limited to:

  1. Mentoring colleagues
  2. Assisting with research
  3. Participating in professional organizations or other activities that contribute to the profession’s body of knowledge

iv. Take reasonable steps to provide or arrange for continuing education and staff development, addressing current knowledge and emerging developments related to health information management practice and ethics.

7. Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality healthcare data.

Clinical documentation improvement professionals shall:

i. Facilitate documentation for the reporting of appropriate diagnoses and procedures as well as other types of healthcare documentation (e.g., present on admission indicators)

ii. Develop and comply with comprehensive internal reporting policies and procedures that are consistent with official coding rules and guidelines as well as reimbursement regulations and policies; these policies and procedures should also prohibit documentation practices that misrepresent the patient's medical conditions and treatment provided

iii. Foster an environment that supports honest and ethical reporting practices, resulting in accurate and reliable data

iv. Ensure practices that support accurate coding, without undercoding or overcoding

Clinical documentation specialists shall not:

i. Participate in alteration, suppression, or improper preparation of health record information

ii. Participate in CDI practices that result in either undercoding or overcoding

8. Facilitate interdisciplinary collaboration in situations supporting CDI practice.

Clinical documentation improvement professionals shall:

i. Participate in and contribute to decisions that affect the well-being of patients by drawing on the perspectives, values, and experiences of those involved in decisions related to patients

ii. Clearly establish professional and ethical obligations of the interdisciplinary team as a whole and of its individual members

9. Respect the inherent dignity and worth of every person.

Clinical documentation improvement professionals shall:

i. Treat each person in a respectful fashion, being mindful of individual differences and cultural and ethnic diversity

ii. Promote the value of self-determination for each individual

10. Avoid participation in, condone, or be associated with dishonesty, fraud and abuse, or deception.

Clinical documentation improvement professionals shall not:

i. Promote patterns of retrospective documentation to avoid suspension of, or increases to, reimbursement

ii. Assign diagnostic related groups (DRG) or diagnoses without physician documentation

iii. Encourage or support coding when documentation does not justify the billed procedures

iv. Encourage or support coding an inappropriate level of service

v. Promote miscoding to avoid conflict with others

vi. Engage in negligent documentation or coding practices, including misstating or misusing official coding guidelines

vii. Hide or ignore review outcomes, such as performance data

viii. Misuse sensitive information about a competitor

ix. Violate the privacy of individuals

11. Manage CDI departments and practices collaboratively and honestly, avoiding engagement in unethical practice and ensuring thoughtful decision-making processes.

Clinical documentation improvement leadership professionals shall:

i. Appropriately research and establish reasonable individual and team performance metrics and key performance indicators (KPI)

ii. Make every effort to create and maintain equitable workload distribution among CDI staff according to current departmental and organizational conditions and circumstances

iii. Regularly monitor team and individual performance and provide meaningful feedback

iv. Establish a process for ongoing evaluation of individual and team performance metrics and KPIs to validate ongoing appropriateness given current conditions and circumstances

v. Monitor and evaluate departmental and individual performance based on organizational guidelines, given current circumstances, in a professional and honest manner

vi. Ensure that the CDI department effectively collaborates with other related organizational departments

vii. Use recommendations and feedback from third parties (including vendors and consultants) only after careful consideration of the current status of the department, consultation with appropriate organizational experts, and reflection on organizational standards, compliant practice, and alignment with overall goals

viii. Establish processes and procedures in compliance with industry standards applicable to CDI practice, including the query process, query compliance and escalation, etc.

ix. Ensure availability of adequate training and ongoing education to CDI staff to ensure that they understand current industry standards as well as organizational and departmental standards

Clinical documentation improvement leadership professionals shall not:

i. Promote unethical query practice to inflate outcomes or results

ii. Promote a KPI, performance metric, and/or workload distribution scheme that disproportionately impacts certain CDI specialists

iii. Hide or ignore review outcomes, such as performance data

iv. Take recommendations from a third party (including vendors and consultants) at face value without appropriate evaluation and reflection on organizational policies, professional best practice, and coding, compliance, and CDI practice standards

v. Establish processes that do not provide adequate training for CDI professionals

Application of the Code of Ethics

The ACDIS Code of Ethics outlines aspirational principles and guidelines. It reflects the commitment of all individuals, agencies, organizations, and bodies allied with the association to uphold the profession's values.

The Code of Ethics does not provide a set of rules prescribing how to act in all situations. Specific applications of the code must take into account the context in which it is being considered and the possibility of conflicts among the code's values, principles, and guidelines. Ethical responsibilities flow from all human relationships, from the personal and familial to the social and professional. Further, the ACDIS Code of Ethics does not specify which values, principles, and guidelines are the most important and ought to outweigh others in instances when they conflict.

Acknowledgments

  • ACDIS and AHIMA Guidelines for Achieving a Compliant Query Practice: http://www.hcpro.com/content/289883.pdf
  • ICD-10-CM Official Guidelines for Coding and Reporting
  • ICD-10-PCS Official Guidelines for Coding and Reporting
  • Adapted with permission from the American Health Information Management Association (AHIMA):
    • AHIMA Code of Ethics
    • AHIMA Standards of Ethical Coding
    • AHIMA's position statement on Quality Health Data and Information
    • AHIMA's position statement on Data Stewardship
  • Adapted with permission from the American Academy of Professional Coders (AAPC) Code of Ethics

Appendices

Scenarios/Questions Regarding Application of Ethical Principles

1. When creating a concurrent query on an inpatient case, a CDI specialist includes existing documentation from the current acute encounter of “low EF” and “chronic BLE 2+ pitting edema.” The CDI specialist notes that the patient takes Lasix PO at home, as well as a BNP 450, IV Lasix, and an RN assessment of “LS-rales.” The CDI professional also notes in the query notation from PT that “patient normally not able to walk more than 100 feet without SOB.” After posing a question regarding further clarification of an applicable diagnosis related to the noted signs, symptoms, clinical indicators, and treatment, the CDI specialist adds several options for diagnoses: “Acute on chronic systolic heart failure; acute on chronic diastolic heart failure; chronic systolic heart failure; chronic diastolic heart failure; volume overload only; other, unable to determine.” Is there an ethical concern related to this query construction practice?

Apply Ethical Principle #4

There is not a concern related to this query construction. There is supportive clinical evidence of a potential missed diagnosis, which is included in the construction of the query. Be sure that this practice follows organizational standards/policies. In line with the Code of Ethics, CDI staff should participate in the creation of compliant query processes and practices to ensure that the practice is compliant with current AHIMA-ACDIS physician query practice briefs, guidelines noted by the Cooperating Parties, CPT rules established by the AMA, and any other official coding rules and guidelines established for use with mandated standard code sets. CDI departments should ensure that they have established query compliance policies and procedures to make sure all queries have appropriate clinical evidence to support them.

2. Given the expansion of Medicare Advantage programs and the use of HCC capture in identification of expected financial expenditure for patient care, CDI programs are now focusing on MCC, CC, and HCC capture. Is there an ethical concern related to this program focus?

Apply Ethical Principles #4 and #7

There is no compliance concern related to this practice. Given that the initial scope of most CDI programs is to focus on the highest-impact populations (i.e., those with associated financial impact), and given the focus of CMS on the proper coding and reimbursement of MS-DRG payers, this practice may be practical and appropriate. Best practice is to ensure that the longterm plan for a CDI department is to expand from a purely financial focus to overall accuracy of all provider documentation, regardless of whether reimbursement is affected, within the identified departmental and organizational scope. Regardless of the focus of its department, in line with the Code of Ethics, CDI staff should participate in the creation of compliant query processes and practices to ensure that the practice is compliant with current AHIMA-ACDIS physician query practice briefs, guidelines noted by the Cooperating Parties, CPT rules established by the AMA, and any other official coding rules and guidelines established for use with mandated standard code sets.

3. A CDI specialist identifies unclear documentation in a medical record. The CDI specialist discovers that the potential query will have a negative impact on the severity of illness (SOI) and risk of mortality (ROM) of the case. The staff member decides not to submit the query due to the potential negative outcomes, even though the documentation requires additional clarification. Is there an ethical concern related to this decision?

Apply Ethical Principles #4 and #7

There is an ethical concern related to this practice. CDI policies should be designed to promote complete documentation regardless of whether reimbursement is affected. The goal of CDI work is to promote accurate documentation and subsequent coding. Queries should be submitted to the provider to clarify when documentation in the health record that impacts an externally reportable data element is illegible, incomplete, unclear, inconsistent, or imprecise; query submission should occur regardless of SOI/ROM impact.

4. An employee performs CDI functions in addition to case management and utilization review functions. The staff member is asked to utilize the payer coverage decisions to ask the provider for different documentation to ensure coverage. Is there an ethical concern related to this practice?

Apply Ethical Principles #2, #8, #10, and #11

There is a potential ethical concern related to this practice. The role and responsibilities of CDI should be clearly defined and outlined in internal policies to ensure there is no conflict of interest with different expectations. Combining CDI and case management/utilization roles is not inherently unethical; however, the organization should consider the appropriateness of applying clinical assessment responsibilities to the CDI role as there is no patient care or assessment completed within CDI responsibilities. Organizations should also consider the ethical implications of combining referral, payer communications, and/or other outside responsibilities with a role like CDI, which has a deep understanding of coding and reimbursement rules. CDI processes should be designed to promote complete documentation and coding in compliance with official coding guidelines approved by the Cooperating Parties, the CPT rules established by the AMA, and any other official coding rules and guidelines established for use with mandated standard code sets.

5. A CDI specialist identifies a process within the organization in which physicians who do not directly care for patients receive documentation clarifications and respond to CDI queries. The staff member is concerned about the compliance of this practice and is considering expressing this concern to leadership. Is there an ethical concern related to this practice?

Apply Ethical Principles #4, #5, #7, and #8

There is an ethical concern related to this practice. According to the Official Guidelines for Coding and Reporting, the term provider is defined as a “physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.” The “medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not” (p. 97 of 107). Additionally, the guidelines state that “issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.” Furthermore, according to the CMS State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, “§482.24(c)(1) - All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.”

6. A CDI specialist is asked to order nutrition consults and wound nurse consults based solely on the CDI review, prior to submitting any queries to the providers. The staff member is concerned about the compliance of this practice and is considering expressing this concern to leadership. Is there an ethical concern related to this practice?

Apply Ethical Principles #2, #4, #8, and #11

There is a potential ethical concern related to this practice. CDI roles and responsibilities should be clearly defined and outlined in internal policies to ensure there is no conflict of interest with different expectations. The organization should consider the appropriateness of applying clinical assessment responsibilities to the CDI role as there is no patient care or assessment completed within CDI responsibilities. Organizations should also consider the ethical implications of combining referral, payer communications, and/or other outside responsibilities with a role that has such deep understanding of coding and reimbursement rules for each patient. CDI processes should be designed to promote complete documentation and coding in compliance with official coding guidelines approved by the Cooperating Parties, the CPT rules established by the AMA, and any other official coding rules and guidelines established for use with mandated standard code sets.

7. A CDI manager captures the CDI department’s overall financial impact, as well as each CDI specialist’s individual impact, as part of the metrics monitored. The manager distributes the CDI workload by floor, with some CDI specialists covering only medical cases and some covering only surgical cases. Some CDI specialists have “financial impact” as a part of their performance reviews. Is there an ethical concern related to this practice?

Apply Ethical Principles #4, #10, and #11

There may be a potential concern/risk related to this practice due to the possibility of CDI specialists asking inappropriate queries to ensure that they meet prescribed financial goals. Due to the variation between units, this workload distribution may not allow each CDI specialist to have the same opportunity to impact a MS-DRG change and create a financial impact. All CDI professionals should promote accurate documentation and avoid issuing queries solely to meet financial expectations. In order for an organization to ensure the success of CDI, an effective monitoring process must be established, along with department-specific KPIs. Each department’s established KPIs may routinely need to be reevaluated or revised due to specific variable changes (for example, the number of years a CDI program has been in existence, levels of experience amongst its staff, facility size, and assignment of coverage). In addition, all performance metrics and expectations should be applied consistently throughout the department, not to just some CDI specialists.

8. A CDI department has a query rate goal for each CDI specialist and for the team as a whole. The workload is divided by service line, and each CDI specialist is assigned to both surgical and medical service lines, with all members of the team helping when there is high census in a certain area. The CDI specialists are provided with ongoing performance feedback, including compliance of queries submitted, missed query opportunities, and coding queries sent on their cases. Overall documentation is monitored through these reports on an annual basis to evaluate current documentation trends and missed query opportunities. Is there an ethical concern related to this practice?

Apply Ethical Principles #4, #10, and #11

There is no concern/risk related to this practice. Leadership has established metrics based on current need and provides ongoing feedback to staff on performance as well as ongoing monitoring of the appropriateness of the metric. Leadership is also working to create as equal a workload distribution as possible.

9. A CDI specialist works for a hospital in which external CDI educators issue blanket requirements to query in every instance of certain borderline clinical indicators (for example, NA+ 134, querying for sepsis in every instance of a patient that meets two criteria for SIRS, and querying for encephalopathy in every instance of a patient with altered mental status that resolved shortly after admittance to the hospital). Is there an ethical concern related to this practice?

Apply Ethical Principles #2, #4, #5, and #10

There may be a potential concern/risk related to this practice. CDI specialists must issue queries based on a review of the entirety of the supporting medical record of each individual patient. In addition, CDI specialists must ensure that adequate clinical evidence and/or supportive documentation is noted within the medical record and presented within the associated query. CDI specialists must follow organizational guidelines and/or current industry and clinical practice guidelines to identify clinical criteria for support of queries. Per the 2013 ACDIS/AHIMA query practice brief Guidelines for Achieving a Compliant Query Practice, “Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions. A query should include the clinical indicators, as discussed above, and should not indicate the impact on reimbursement. A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.”

How Do I Address Ethical Concerns?

Reference industry information and/or resources from reliable organizations related to your concern: AHIMA, ACDIS, AHRQ, AAPC, AMA, etc.

Approach your departmental leadership with your concern and ask for clarification regarding any associated processes or procedures.

Follow your organizational process for escalating any concerns within your organization. Some departments/contacts that may be helpful include compliance, privacy, HIM/coding, and quality and patient safety.