J Sullivan was admitted to General Hospital with chest pain, had a cardiac cath done, which revealed significant blockage, unsent bypass, and numerous post-op complications that necessitated multiple visits to the operating room. He also had a CVA, which caused dysphagia, pneumonia, and respiratory failure that necessitated ventilator support.

He was discharged from the hospital’s intensive care unit and admitted to the skilled nursing unit for rehabilitation. His account had over $400000 in charges. Hospital coders are under a lot of pressure to keep unmilled inpatient accounts under $750000. Prior to discharge, Mr. Sullivan’s account was $925000, and when discharged, it was over a million dollars.

Carma, the coding supervisor, called to arrange a meeting with the CFO. He told her that the Sullivan account would be coded and billed by the end of the day because it was a critical financial time for the facility. She assured him that she would handle it personally.

Carma was aware of the financial situation at the facility. Weekly accounts receivable analysis had been replaced by daily analysis and midday reporting of coding productivity. Layoff rumors were circulating, and Carma, as a lower-level manager, was constantly concerned that her position would be eliminated. She felt compelled not only to code the account but also to demonstrate her abilities and value to the organization to the CFO. She went straight to the chart after her meeting. Due to all of the procedures and complicated diagnoses, it would take her the majority of the day to code the chart, especially if it had not been properly assembled and analyzed first.

J Sullivan was readmitted to the hospital that morning with a dissecting abdominal aortic aneurism that necessitated emergency surgery.

Later that afternoon, the CFO called Carma to inquire about the status of the account. Carma informed him of the situation, but he was unconcerned and insisted on her staying at work until the account was billed.

Due to additional complications, the patient was referred to additional specialists. Carma made several attempts to obtain the record and was willing to work in an ICU area. She went to see the CFO about the situation, only to be told that it was not his problem how she completed the chart and that he expected that account to be billed before the end of the day.

In the ICU Carma was confronted by a physician who was enraged by her interference with the patient record and told her that financial obligations should not be allowed to interfere with patient care needs. Carma went back to her office and was summoned to her director’s office. The Director informed her that she had received a call from the ICU nursing supervisor about her interfering with patient care in order to obtain a chart for coding. Carma explained the situation to the director, including how the CFO insisted on the record being coded by the end of the day. The director informed Karma that she would speak with the CFO and handle the situation.

The director met with the CFO and explained that due to the patient’s health situation, all physicians needed immediate access to the health record without interference for administrative and financial reasons. The director had expected a sympathetic response from the CFO. The CFO informed her that the financial situation had reached the point where a full-time equivalent (FTE) reduction was required, and that if the account was not coded and billed by the end of the day, she would be required to eliminate Carma’s position.

1. What internal and external forces are at work in this case?

2. What legal issues are addressed in this case?

3. What ethical issues are raised in this case?

4. How does the American Health Information Management Association Code of Ethics address the ethical issues in this case?

Question 5: Is there anything Carma could have done differently in this situation?

Question 6: What should the director say in response to the CFO’s final statement?

7th question Using the case method, evaluate possible actions to be taken and choose the best one.

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