Code Of Ethics and Practice Standards

Introduction:

The Establishment Committee of the Clinical Coders’ Society of Australia has developed a Code of Ethics and Practice Standards to define the principles governing the conduct of its members.

Every member of the Clinical Coders’ Society of Australia shall abide by the Code of Ethics and Practice Standards and shall strive to promote the objectives of the Clinical Coders’ Society of Australia at all times.

Code of Ethics:

Members of the Clinical Coders’ Society of Australia shall:

1. Not misrepresent or falsify their education, qualifications or experience, and not make determinations outside their realm of knowledge.

2. Refuse to participate in illegal or unethical acts and will report the illegal or unethical acts of others to the appropriate authorities.

3. Legitimately code to optimise casemix group weight (ensure all codes used accurately reflect care) but will not code to maximise casemix group weight (add or alter codes which are not substantiated by documentation).

4. Assist managers and clinicians in guidelines and practices that support ethical coding.

5. Protect the confidentiality of health records and administrative records of health institutions in accordance with legal and management policy requirements unless compelled to do otherwise by statutory requirements.

6. Participate in ongoing education in order to maintain and improve coding competence and support the objectives of the Clinical Coders’ Society of Australia.

7. Liaise with other professional bodies in order to strive for the advancement of quality health care.

8. Discharge honourably the responsibilities of any national or state association positions and preserve the confidentiality of any privileged information obtained whilst acting in an official capacity.

9. Maintain the integrity of the Clinical Coders’ Society of Australia and not make unsanctioned representations on behalf of the Society.

Practice Standards:

Members of the Clinical Coders’ Society of Australia will strive to observe and abide by the following practice standards:

1. 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.

2. Use documentation in that episode of care or encounter to support the diagnoses and procedures selected for coding.

3. Use definitions of the National Health Data Dictionary to select, code and sequence diagnoses and procedures.

4. Use their skills and knowledge of the current Australian coding system, the Australian Coding Standards and any other available resources, including clinician consultation, to select, sequence and code diagnoses and procedures.

5. Not code diagnoses or procedures that are not substantiated by documentation within the medical record.

6. Initiate and maintain communication with other health care professionals and relevant organisations to improve the quality of documentation and accuracy of coding.

7. Participate in quality improvement activities to ensure the quality of coding is maintained.

8. Ensure coding accuracy is maintained in accordance with work experience accuracy rates.