Ethics, Independence, and Professional Conduct
Ethics, Independence, and Professional Conduct tests whether an auditor can remain objective, confidential, competent, and resistant to pressure while producing accurate work.
Core rules
- Independence means independence in fact and appearance. Do not audit your own coding, billing, or management work; disclose any relationship that could influence judgment.
- Objectivity requires conclusions based on sufficient evidence and stated criteria, not on the provider’s revenue value, seniority, or personal relationship with the auditor.
- Confidentiality: protect PHI and audit workpapers, use minimum necessary access, and avoid discussing findings in public areas or unapproved channels.
- Competence and due care: know the code set, payer rules, and sampling limits; obtain expert review when outside your scope; do not guess at a standard.
- Report accurately. Never delete a valid finding, backdate a workpaper, or alter a record. Escalate pressure to change a finding through the compliance chain.
Worked example
A medical director asks an auditor to remove a confirmed modifier 25 finding because the physician is a top revenue producer and “everyone does it.” The auditor declines, documents the request and date, keeps the original workpaper, and escalates to the compliance officer. The report includes the finding and the management response. Removing it would impair independence and could create a false compliance picture.
Traps
- Becoming an advocate for the auditee rather than an independent reviewer.
- Accepting gifts, meals, or favors from an audited area.
- Using “professional judgment” to override written criteria without documentation.
- Discussing PHI or findings with unauthorized staff.
- Failing to disclose a prior coding role in the same practice.