The purpose of The Association's Ethical Code is to promote an ethical culture in the clinical coding profession.
A Definition of Clinical Coding
Clinical Coding is the translation of medical terminology describing the reason for a patient's encounter; such as a patient's complaint, problem, diagnosis, treatment or other reason for medical attention; into statistical code to support both statistical and clinical uses.
An Ethical Code is necessary and appropriate for the clinical coding profession, which is founded on the trust placed in its objective and accurate translation of clinical terminology. The Association's Ethical Code extends beyond the definition of clinical coding to include three essential components:
- Principles that are relevant to the profession and practice of clinical coding;
- Rules of Conduct that describe behaviour norms expected of clinical coders. These rules are an aid to interpreting the Principles into Practice Standards
- Practice Standards, which are practical applications and are intended to guide the ethical conduct of clinical coding practitioners
The Ethical Code represents The Association's Framework for Professional Practice that together with other relevant Association statements provide guidance to clinical coders. The term 'clinical coders' refers to Association members and those who provide clinical coding services within the definition of clinical coding.
Applicability and Enforcement
This Ethical Code applies to both individuals and entities that provide clinical coding services. For Association members, breaches of the Ethical Code will be evaluated and administered according to The Association's Disciplinary Procedures. The fact that a particular conduct is not mentioned in the Rules of Conduct does not prevent it from being unacceptable or discreditable, and therefore, the member liable to disciplinary action.
Clinical coders are expected to apply and uphold the following principles:
- Integrity: The integrity of clinical coders establishes trust and accordingly provides the basis for reliance on their judgment.
- Objectivity: Clinical coders exhibit the highest level of professional objectivity in gathering/retrieving, analysing, evaluating, translating and communicating information. Clinical coders make a balanced assessment of all relevant appropriate information and are not unduly influenced by their own interests or by others in forming coded judgments.
- Confidentiality: Clinical coders respect the value and ownership of information they receive and do not disclose information without the appropriate authority unless there is a legal or professional obligation to do so.
- Competency: Clinical coders apply the knowledge, skills and experience required in the performance of clinical coding services. (See Practice Standards)
2. Rules of Conduct
- Shall perform their work with honesty, attentiveness and responsibility.
- Shall observe the law and make only those disclosures required by the law and the profession.
- Shall not knowingly be a party to any illegal activity, or engage in acts that are discreditable to the clinical coding profession, to the Association or to their employing organisation.
- Shall ensure all codes assigned accurately reflect care but will not fraudulently code to maximise casemix weight by the addition or alteration of codes, which are not substantiated by documentation.
- Shall not misrepresent or falsify their education, qualifications or experience.
- Shall respect and contribute to the legitimate and ethical objectives of the Association and their employing organisation.
- Shall not make unsanctioned representations on behalf of the Association.
- Shall not participate in any activity or relationship that may impair or be presumed to impair their unbiased assessment. This participation includes those activities or relationships that may be in conflict with the interests of the Association and/or their employing organisation.
- Shall not accept anything that may impair or be presumed to impair their professional judgment.
- Shall be prudent in the use and protection of information acquired in the course of their duties.
- Shall not use information for any personal gain or in any manner that would be contrary to the law or detrimental to the legitimate and ethical objectives of the Association and/or their employing organisation.
- Shall engage only in those clinical coding services for which they have the necessary knowledge, skills and/or experience.
- Shall perform clinical coding services in accordance with the Practice Standards.
- Shall continually enhance their knowledge, skills, and other competencies through continuing professional development.
3. Practice Standards
Members of the Professional Association of Clinical Coders - UK shall endeavour to observe and abide by the following practice standards:
- In order to assign codes for a particular patient episode of care or encounter, carry out a thorough review of documentation in the clinical record pertinent to that episode or encounter.
- Use documentation in that episode of care or encounter to support the diagnoses and procedures selected for code assignment.
- Use those standards and definitions described as National Standards to assign codes and sequence diagnoses and procedures.
- Use their skills and knowledge of the current mandated UK coding schemes, the National Standards for clinical coding and any other available resources, including clinician consultation, to assign codes and sequence diagnoses and procedures.
- Do not code diagnoses or procedures that are not substantiated by documentation within the medical record.
- Initiate and/or maintain those communications with other health care professionals and relevant organisations required to improve the quality of source documentation and accuracy of clinical coding.
- Take part in data quality improvement activities to ensure that coded data quality is maintained.