Ethical Dilemmas in Billing and Coding
By Lacey Peters and Susannah York
Published November 2023 in the ISHA Voice
Ethical billing and coding practices are important to help maintain trust between the clinician and their patients/families, administrators, colleagues and third-party payors. Inaccurate use of ICD-10 codes, diagnosis codes or therapeutic intervention time can misrepresent the client's disorder, plan of care, services delivered, and reimbursement amounts due. Below are a few common misconceptions or ethical dilemmas when it comes to billing and code practices.
Scenario 1:
My client needs therapy and the family has expressed financial difficulty with paying their portion. Is it ok to change diagnostic or billing codes for coverage through insurance because I am helping the family?
It can be frustrating and disheartening when a family’s insurance plan denies coverage. It is a violation of a provider/company’s contract with an insurance company to change ICD-10 codes that are appropriate to a client’s diagnosis to another code, for the purposes of reimbursement. In these scenarios, it is important that a provider has done a comprehensive benefits verification and/or supported a client in verifying their benefits and coverage. In the cases of denial, it is also important to involve clients and families in advocacy such as calling their insurance company, contacting their HR department for guidance, and initiating appeals.
Scenario 2:
I have a client who misses appointments on occasion. They have told me they are ok with me billing their insurance because their out-of-pocket has been met, and so I can still get paid even when they cancel or do not show up.
Always check your contract with a payor about procedures for billing missed sessions/no show sessions. Many payers explicitly state that charges for these situations are non-billable. Providers/companies often have the ability to charge clients in these situations, though this is also payor specific. It is prudent to establish a known cancellation policy that is explained and signed by the client to minimize financial loss to a provider. Providers who do not directly bill payers are encouraged to discuss these policies with their supervisors to ensure ethical billing practices are being followed.
Scenario 3:
When I was hired, I was told that I did not need to know about billing or coding because my workplace has a billing department that handles all billing and coding for all therapists in the group.
As an evaluating and/or treating therapist, you will use your clinical skills and judgment to determine what diagnostic codes will be applicable to specific cases. Medical billers, for example, do not have the knowledge, skills, or training to determine whether specific diagnostic codes are appropriate for your clients. It is important to educate yourself about these codes. Fortunately, ASHA has developed a number of resources for clinicians to learn more about ICD-10 codes and their uses in different clinical settings and cases. The rendering provider's name and National Provider Identifier (NPI) number are on claim forms; if your company engages in fraudulent billing practices you may be facing criminal and/or civil charges.
Navigating ethical billing and coding can be a challenging undertaking. The following resources are available to help clinicians and administrators navigate billing and coding methods while maintaining sound ethical practices.
Lacey Peters, M.A. CCC-SLP holds a B.S. in Communication Sciences and Disorders from Northern Illinois University and a M. A. in Speech-Language Pathology from University of Illinois at Urbana-Champaign. Lacey is currently the Owner, President and Clinical Director of Midwest Speech Therapy in Bloomingdale, IL. Lacey is an active member of ISHA and has served as a member of the Billing and Reimbursement Committee since 2021.
Susannah York is a bilingual speech-language pathologist and the owner of York Bilingual Speech Services in Chicago. Susannah has been a speech-language pathologist since 2006, and she currently provides home and school-based services to pediatric clients with a wide range of communication needs. Her areas of interest include bilingual speech-language development and disorders, speech sound disorders and childhood apraxia of speech, as well as the intersection of language and early literacy.
