Professionalism and Ethics in Medical Billing and Coding

A career in medical billing and coding offers a meaningful way to support patient care from the administrative side of the healthcare team. Medical billers and coders ensure that care is accurately documented and correctly billed, which impacts everything from insurance reimbursement to patient outcomes. Even behind the scenes, your work as a coder carries real responsibilities—errors or unethical choices can affect patient care, insurance processing, and trust in the system.

Below, we’ll walk through the standards certified medical coding professionals are expected to follow, from HIPAA and patient data confidentiality in billing to examples of unethical billing practices and how to avoid them.

What Is Professionalism in Healthcare?

Professionalism in healthcare refers to certain standards that healthcare professionals are expected to uphold. These standards, such as integrity, continued improvement, compassion, and excellence, help prevent dishonest behavior or practices among healthcare professionals while also protecting the safety and confidentiality of those in their care. Medical billing and coding specialists are integral to the healthcare field, making it essential for them to consistently demonstrate a high degree of professionalism. While they may not be directly involved with hands-on patient care, their commitment to ethics and professionalism helps ensure patient safety and privacy.

Why Healthcare Professionalism Is Important

Healthcare professionalism is essential for protecting patients and keeping their information safe. Professionalism among medical workers also improves the likelihood of positive health outcomes for patients. For example, physicians and nurses upholding professional standards can make informed and ethical decisions regarding how to provide patients with the best care. For medical billers and coders, professionalism helps ensure that patient documentation has the correct codes, so patients receive proper and timely care.

Ethical Behavior and Professionalism in Medical Billing and Coding

Working in medical billing and coding involves being familiar with the standards of professionalism and ethical behavior expected in this kind of healthcare job. Medical billing and coding specialists have access to confidential and highly sensitive patient information, making a commitment to professionalism essential. The following are some of the standards that those working in medical billing and coding should follow at all times.

Data Gathering

The way data is gathered through coding practices can become an ethical issue. Medical billing and coding specialists should always use accurate and consistent practices to gather data. All data needed for coding should be reported to ensure accuracy. Healthcare workers should follow all internal coding policies and procedures on data gathering and reporting, and avoid altering or suppressing any coded information.

Accuracy

Medical coders are expected to always be accurate when coding. This means avoiding entering codes for medical services, procedures, diagnoses, or treatments that haven't been provided. Maintaining a high level of accuracy is one of the most important standards of professionalism for medical billers and coders. Not adhering to this standard can put these healthcare workers at risk of being accused of fraud and potentially compromise patient safety, such as if the wrong treatment or diagnosis is coded.

Misrepresenting or Changing Data

Those who work in medical billing and coding should never change or misrepresent data when coding a patient's procedure, diagnosis, service, or treatment. If a patient or physician asks for changes to be made that do not match the clinical documentation, such as when a patient wants to make sure their insurance will cover a procedure, medical billers and coders should refuse to do so. This includes intentionally entering incorrect codes or adding codes that are not part of the patient's documentation.

Over-Billing

Over-billing can lead to higher medical bills for patients and the possibility of having insurance companies deny reimbursement. Medical billing and coding specialists should avoid billing for services, treatments, or procedures that aren't considered billable. Those who aren't sure should go over the details of a patient's care with physicians to ensure accurate billing and coding. For example, not every part of a procedure is considered billable unless the physician states otherwise. Clarifying these complex situations with physicians helps reduce the risk of over-billing.

Bad Coding

When working on medical billing and coding, specialists should work hard to avoid making errors or other mistakes that result in bad coding. This also includes avoiding upcoding or undercoding, such as coding for a more expensive service than the one provided. Medical billing and coding specialists should avoid unbundling as well, which involves using several individual codes rather than a single code for an entire group of procedures or treatments.

Maintaining Professional Values

Medical billing and coding specialists are expected to maintain professional values and encourage colleagues to do so as well. This might involve exposing unethical behavior that a colleague has participated in or discouraging colleagues from behaving unethically. As part of maintaining professional values, medical billers and coders should be knowledgeable about the standards of professionalism as they apply to them. Medical billers and coders should also know the correct procedures and policies for reporting unethical behavior.

Patient Confidentiality

The Health Insurance Portability and Accountability Act (HIPAA) legally requires healthcare workers and providers to maintain patient confidentiality. In addition to this legality, protecting patients' information is an ethical matter. Medical billing and coding specialists can see sensitive information on patients' records, which should be kept confidential at all times. These workers should also avoid accessing any medical information that isn't relevant to the treatment, service, or procedure they're handling in medical billing and coding.

Honesty and Integrity

Honesty and integrity are important parts of medical professionalism. Medical billing and coding professionals should always act with honesty and integrity. This means refusing to engage in unethical practices or behaviors in coding, such as misrepresenting data or breaching patient confidentiality by looking up irrelevant patient information. Acting with honesty and integrity involves always making ethical choices on the job and maintaining high standards of professionalism, even when faced with pressure to act unethically.

Explore Medical Billing and Coding at CHCP

Ready to take the next step toward a career in medical billing and coding? CHCP’s Medical Billing and Coding Certificate Program—available both on-campus and online—centers on career-focused knowledge and hands-on training to help you build a strong foundation in the field. You’ll have the opportunity to explore critical topics like medical law, patient confidentiality, informed consent, and professional liability, so you’re prepared to pursue entry-level roles with integrity and confidence.

Want to learn more? Connect with CHCP today. We’re here to answer your questions and help you move forward with your goals.